Article Figures & Data
Figures
- Figure 1.
Conceptual Framework: What Makes The Quality Of Health Care Exceptional?
Tables
- Table 1.
Physician and Practice Characteristics Self-Reported by Study Participants, (n = 20)
Question Response N (%) Do you consider yourself a primary care physician? Yes 20 (100) No 0 Within the past 12 months have you had an active medical license? Yes 20 (100) No 0 Are you board certified in Family Medicine or Internal Medicine? Yes - Family medicine 7 (35) Yes - Internal medicine 11 (55) No 2 (10) How many physicians are in your practice? 1–14 (small) 9 (45) 15 (large) 11 (55) How many years have you been practicing after residency? 1–4 3 (15) 5-9 5 (25) 10–14 1 (5) 15–19 5 (25) ≥20 6 (30) How would you define your practice setting? Urban 9 (45) Suburban 6 (30) Rural 5 (25) In what region of the United States do you practice? Mid-Atlantic or Northeast 2 (10) Midwest 3 (15) Northwest 5 (25) 2 (10) West 8 (40) What percent of your patients are covered by Medicare Part B? 0–19 1 (5) 2 (10) 30–39 10 (50) 40–49 4 (20) ≥50 3 (15) What percent of your patients do you think suffer from financial challenges such as housing, utility, or food instability? 0 1 (5) 1–9 6 (30) 10–19 3 (15) 20–29 2 (10) 30–-39 2 (10) 40–49 1 (5) ≥50 5 (25) How large is your personal panel of patients? <1000 9 (45) 1000–1499 3 (15) 1500–1999 2 (10) 2000–2499 1 (5) ≥2500 5 (25) How are you primarily compensated? Fee for service 9 (45) Capitation 2 (10) Salary 9 (45) What percent of your practice's income comes from fee-for-service payments? 0 1 (5) 1–24 3 (15) 25–49 1 (5) 50–74 2 (10) 75–99 9 (45) 100 3 (15) Not sure 1 (5) Do you have staff on hand to help manage quality of care? Yes 17 (85) No 3 (15) Did you or your group participate in the Physician Quality Reporting System (PQRS)? Yes 12 (60) No 6 (30) I don't know 2 (10) - Table 2.
List of Study Themes, Associated Study Sub-Themes, and Relevant Institute of Medicine Domains
Study Themes Study Sub-themes Relevant IOM Domain Evidence-based care that is safe Providing recommended health maintenance Effective Controlling chronic diseases Effective Knowing and following current recommendations Effective Making accurate diagnoses; not missing diagnoses Safe Delivering efficient care (not too much and not too little) Efficient Patient-centered care Providing personalized care Patient-centered Providing well-coordinated care Patient-centered Spending enough time with patients Patient-centered Responsiveness to patient concerns Patient-centered Being an advocate for patients Patient-centered Understanding social needs Patient-centered Helping patients achieve their goals Patient-centered Prioritizing quality of life Patient-centered Listening to patients Patient-centered Educating patients Patient-centered Establishing trust and long-term relationships Patient-centered Demonstrating compassion Patient-centered Providing timely care Timely IOM, Institute of Medicine.
Note: Participants did not mention the concept of equity, which is one of 6 IOM Domains of the quality of healthcare.
Box 1: Key questions for study participants.
What do you consider to be “good” quality of care? What does it “look” like?
What is exceptional quality of care, and how is it different than good quality of care?
What is low quality care, and how is it different than good quality of care?
What kinds of things can a primary care physician do to ensure he/she is providing exceptional quality of care?
Theme Sub-Theme Delivering evidence-based care that is safe Providing recommended health maintenance “I believe that there are certain elements of providing care that are standard of care and that are proven to be beneficial to patients. Flu vaccine, pneumonia vaccine, vaccines in general, cancer screenings, like breast screening, colon cancer screening, cervical cancer screening.” (P4) “To deliver high-quality healthcare, first you have to talk about annual screening.” (P2) “For example, you have to make sure that patients are screened for colon cancer appropriately, for breast cancer, cervical cancer, that they're getting their vaccinations, that they are meeting the blood pressure goals.” (P6) Controlling chronic diseases “When people have certain chronic diseases there are certain measures that are just proven, like having an A1C that's as close to normal, having blood pressure at certain levels, having cholesterol--being on certain medications when you have certain chronic diseases--I think those things are quality to me.” (P4) “When a physician is taking care of a patient with diabetes… the patient should come in at 1 month, then 3 months, then 6-month intervals. [The physician] should know what blood work they're getting at that interval. At every visit, [the physician] should take off their shoes and socks, check monofilaments on them, make sure that the medications are reconciled, and that this information is communicated with the patient's other physicians. This should be a set protocol.” (P12) Knowing and following current recommendations “I think good quality care has to be evidence-based. That's considered the standard of care.” (P3) “Lifelong learning and staying engaged with the latest literature, guidelines, and evidence-based recommendations [can help physicians provide high-quality healthcare].” (P16) “Do the basics really well. Like getting everyone who has diabetes to have an A1C less than 9%, people's blood pressure less than 140/90, just the things that you--except for the small number of cases--you should be able to help patients to get to.” (P15) “I would say that practices making every effort to ensure that they are meeting the standard of care as put forth from well-established bodies such as US Preventive Services Task Force, from CMS, and from our own organizations such as the American Academy of Family Physicians.” (P6) Making accurate diagnoses “Part of the key to being a good doctor is making the right diagnosis.” (P7) “Everybody can do checklist medicine and check [a hemoglobin A1C] twice this calendar year. [On the other hand,] when you have a patient with a difficult diagnosis which you establish and come up with an effective treatment for--now that's good care.” (P11) “If you ever come up with a diagnosis that someone else had missed, I think that's when I think high-quality care.” (P7) Delivering efficient care (not too much or too little) “High-quality care is medical care that's a universal standard, done in an efficient way that minimizes costs.” (P12) “My grandma was a very wealthy person, and she was very demanding. Basically, she would want you to forget about standards in healthcare and spend every healthcare dollar on her and waste everything on her to get every test possible, which is absolutely not right.” (P12) “What I learned is that quality equals appropriateness times the combination of outcomes and service and then dividing that by waste. I kind of like thinking about it as an equation-based definition.” (P15) Delivering patient-centered care Providing personalized care “I think I include the patient in all the decision-making. I present it to them like a buffet, where they get to pick and choose. I'll say, 'You know, at this age, I would love for you to have these three screening tests.' Then, they may say, 'I don't want to have a colonoscopy. What are my options? Can I have a stool test?' I would say that incorporating them into the decision-making is all about establishing a good relationship.” (P1) “Quality of care is all the care you need and none of the care that you don't need, delivered in a personalized way…working within the flow of patients' lives.” (P16) Providing well-coordinated care “About 20% of our patients are non-English speaking….So, also making sure that care is coordinated well so that all pieces of the care get accomplished and get coordinated in a way that it's doable for the patients and also provides a good health outcome is challenging.” (P9) “I think developing systems as an individual or with teams in your clinic to ensure good follow-up for patients. So, seeing patients and tracking patients over time--Looking across your panel…and trying to be systematic and proactive about having patients come back in or refer to sites of care expeditiously and effectively.” (P16) “I can see records on a lot of different systems. So that kind of coordination of care is really important, in terms of making sure that we know what's going on with our patients….It requires a little bit of diligence, just making sure that your support staff, your medical assistants, whoever it is that's tracking down records, that they're doing that.” (P19) “I was very satisfied with the process because we're fortunate enough to have a referral team within our clinic so that I could get him to this study, then get the biopsy, the pathologist's report, and get him into the oncologist's office so that he was being treated within 5 days of the original study.” (P20) “You have to connect all the dots for the patients so that they have less to think about and less to worry about.” (P12) Providing timely care “I personally give my patients my email address so they can directly contact me with any concerns without being filtered by my staff. I try to have good hours, leave slots for urgent care, essentially have them be able to access me so that they can get care.” (P1) “It's more and more incumbent on doctors to manage your staff… so that if someone calls and they have a reason they need to get in, we need to do everything we can do to get them in.” (P5) Spending enough time with patients “There are some primary care physicians who are seeing outrageous numbers of patients a day. 30, 40, and I'm doing about half that at most….I have time to review everything while I'm there. So, for example, if they're there for a hypertension visit and I'm adjusting their medications, I can also say, 'Ok, let me make sure you're up-to-date with your mammogram, with your colonoscopy, and I'll take a look at your vaccinations.'” (P6) “I think a good doctor has to spend enough time with the patient. Doctors shouldn't overbook themselves, and that means they have to be choosey about what insurances they accept.” (P7) “The key for most primary care doctors I believe is generally spending enough time, being responsive, and being accessible.” (P3) Responsiveness to patient concerns “Sometimes the difference between a good outcome and a bad outcome is just someone who is really paying attention.” (P4) “I think we want to provide healthcare for each individual, and we want to provide healthcare that addresses their needs.” (P17) “For me, good quality care is really trying to hear the patient out…Do they have any new or active issues that need to be addressed and then if so, properly addressing them.” (P1) Being an advocate for patients “When I think of a doctor who is exceptional, I think of someone who is an awesome patient advocate who makes sure that patients get what they need.” (P4) “I had a patient who was scheduled for a 15-minute visit on Saturday for a red swollen leg. [After getting a lower extremity ultrasound and a chest CT that were both positive for clots done from clinic], we directly admitted her from clinic. The patient was really grateful. It's not often that I get to deliver really good care like that but I definitely felt like it was high-quality because we bypassed the ED. She didn't have to go sit there for hours before being seen.” (P15) Understanding social needs “Our population of patients have [poorly reimbursing insurance], don't speak English, don't have stable housing, and have been to jail. So, we definitely think about [food and housing security] first before we are able to get them their blood pressure medication and that sort of stuff.” (P17) “When I have patients who have certain socioeconomic challenges, it may be that they're homeless and it doesn't make sense to have them on nine medications a day for their heart failure, because there's no way they can possibly be compliant with it.” (P5) Helping patients achieve their goals “Having a person or system or team that is able to meet individual [needs and concerns], that's exceptional care.” (P17) “I think our job as doctors is to help patients achieve their life goals, their health-related life goals. So for me, that's what quality is about….At the end of the day, if I'm achieving perfect scores [on quality measures] but not meeting the patients' goals, helping advance what they want, I'm not doing a good job.” (P5) Prioritizing quality of life “You have to keep the patient happy. I mean, they should be productive and happy and carrying on their daily living.” (P2) “The goal is to help patients achieve a better quality of life, and that is basically having people be as active as they want to be, having people be productive members of society, having them enjoy going for a walk.” (P10) “A lot of time it's balancing quality of life versus longevity and frequently we will opt for a shared decision-making process to focus more on quality of life, which may mean foregoing many recommended treatments, including certain ones that would achieve higher quality measure scores.” (P5) Listening to patients “I think the patients are looking for someone who will listen, someone who seems to be interested in the problems that they're presenting….Obviously, they want you to be knowledgeable and compassionate and timely and everything else. But I think patients want to be listened to and taken more seriously than anything else.” (P20) “I think the important thing about patient care is about hearing people and really listening, letting them know that you're there.” (P1) Educating patients “It comes down not only to making an accurate diagnosis but also making sure that the patient understands [the rationale with the care plan] and is on board with it--and that's frankly one of the more difficult things to do these days.” (P11) “The patient population we serve here--We have to hold them by the hands….You hold them by their hands and you educate them. They're going to be like, 'Why do I have to take my blood pressure medication when I feel okay?' So, it's all about education, education, education.” (P13) Establishing trust and long-term relationships “Any time I see a patient, they're my number one priority. We are engaged and so, their perception of my time with them…whether I spend two minutes with them or 10 minutes with them, they always thought I spent enough time….So then what happens when people are satisfied is they go around and they tell their neighbors and they tell the family and so I have more patients coming in to be established and so on.” (P10) “What people don't get is that if patients go to the person that they trust, they're more likely to be adherent to their medication or adherent to whatever regimen, if they know and trust the physician. I just think that's not there with virtual medicine or Uber docs or whatever.” (P1) “The quality movement has been perverted to a kind of big data enterprise now and really, I think the focus of primary care is actually about relationships and building sort of meaningful relationships with people over time….My quality metric--definition of quality is really much more around interpersonal relationships.” (P18) Demonstrating compassion “There was this patent who just passed with severe COPD and she lived to be 86 with a disease that should have potentially taken her--in my mind, she should have gone 10 years ago. But you know, we kept in close contact. There's this human component that's hard to measure, the connection that people feel with their primary care doctor for those who feel connected.” (P10) “I think that you have to be aware, first and foremost, for meeting a quality standard for all your patients but you also have to make sure that you have a heart for them as well. There is real truth to the statement that there is an art form in addition to the hard, basic science.” (P6) Participant number Practice size Practice setting Compensation Region Patient Panel Size P1 Large Urban Salary West 2500 or more P2 Small Urban Capitation West 2000-2499 P3 Small Suburban Fee-for-service West <1000 P4 Large Urban Fee-for-service West <1000 P5 Large Urban Salary West <1000 P6 Small Urban Capitation West 1000-1499 P7 Small Suburban Fee-for-service West 2500 or more P8 Small Rural Fee-for-service Midwest 1500-1999 P9 Small Rural Salary West <1000 P10 Large Suburban Fee-for-service Midatlantic or Northeast 2500 or more P11 Large Suburban Fee-for-service Midwest 2500 or more P12 Large Urban Salary South Midatlantic or Northeast <1000 P13 Small Rural Fee-for-service South <1000 P14 Small Rural Fee-for-service South 2500 or more P15 Large Urban Salary Northwest 1000-1499 P16 Large Suburban Salary Northwest <1000 P17 Large Urban Salary Northwest <1000 P18 Large Urban Salary Northwest <1000 P19 Small Suburban Salary Northwest 1000-1499 P20 Large Rural Fee-for-service West 1500-1999
