Ezekiel Emanuel: Keys for High-Performing Hospitals

He underscored the importance of quality measurement and old-fashioned competition in encouraging doctors to use best practices.

At the Mayo Clinic Center for Innovation’s annual Transform meeting in Rochester, Minnesota, Healthcare Analytics News™ caught up with outspoken doctor, author, and speaker Ezekiel Emanuel, MD. Emanuel was founding chair of the Department of Bioethics at the National Institutes of Health and is currently vice provost for global initiatives at the University of Pennsylvania.

In this section of the conversation, we asked Dr. Emanuel to detail some tips for how hospitals can improve outcomes, a topic on which he has recently written a book. He pointed to several key concepts, and underscored the importance of quality measurement and old-fashioned competition in encouraging doctors to use best practices.


I'm Ezekiel Emanuel, I'm chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, I've also just completed a book: Prescription for the Future about 12 transformational practices for highly effective medical organizations. They range everything from how you schedule patients and make sure that they come in on the same day to actually how you room patients, how you take a patient from the waiting room to the exam room and the things you can do to actually dramatically improve quality just in that short period of time.

We then looked at things like chronic care coordination and behavioral and mental health, especially for the chronically ill.

We don't expect every healthcare organization can adopt all 12 right away, no one can. As a matter of fact, none of the organizations we looked at actually had all 12 implemented, so even at the top of American healthcare there's room for substantial improvement. We do think that things like changing how you schedule, chronic care coordination, standardization and performance evaluation so doctors and nurse practitioners and others in the healthcare system know actually how well they're doing compared to their peers, and selectively directing patients towards very efficient providers…those are probably the key first four steps that are necessary to transform a healthcare system.

One of the transformational practices we identified was performance measurement and feedback: absolutely critical. I put it in one of the top four that every organization ought to institute.

Do we have perfect quality measures? Absolutely not. Do we have good enough quality measures to begin the process of performance evaluation and feedback? Yes. Does performance evaluation and feedback always work? No, not always, but there are some secrets that people have identified that do improve performance. Getting doctors to buy into the metrics, any PCP doesn’t have any argument that having a hemoglobin a1c under 7% is good, or having a blood pressure in the normal range is critical, those are serious substantive outcomes. I think you get agreement on that, then you measure patients.

You can risk adjust patients, you give the information back to doctors, and almost every place that does it well that gives it back identified. That means the doctor's name is there, but his or her colleagues are also identified, so they know how they're doing compared to their peers. The important thing about that is, first of all, it does fuel the competitive juices of doctors, but the second, and probably even more important thing, is it actually allows doctors to go to other physicians who are doing well and to find out what they're doing better: ‘How do you get more of your patients to have blood pressure under control, or to get the hemoglobin a1c down?’

That process of asking your peer what they're doing that's allowing them to excel turns out to be very important. I think there is a process here, places that do it well know works, and we need to use the data collection on how physicians are performing and give it back to them and encourage them to ask their peers how to improve.