The health care system promotes physician authority to the pinnacle of the decision making when it comes to determining what is best for a patient. In rehabilitation hospitals, the physician is responsible for diagnosing and obviating the sequelae of illness or injury and restoring a patient to a level of ability consistent with the pathophysiology and prognosis of each patient’s condition. Under his guidance, the teams of multidisciplinary clinical professionals stand ready to follow his lead in coordinated synchrony to deliver and execute a plan of care to effectively manage impairment and limit disability and handicap. If this sounds a bit like command and control of a military operation it should; for this is war and winning is each patient’s quality outcome. And the physician is in charge.
What motivates the person in charge? Money, fame or prestige? Maybe, doing the best in each case and realizing patient and family goals are most likely high on each physician’s list of what brings him/her to work each day. But where is the quality? And should he/she be compensated accordingly? These questions are the issues to be addressed as our healthcare system undergoes its transformation.
Quality is defined by the expectations set. Written, communicated and measured; and as most leaders will attest, quality occurs only after all the problems have been resolved. But the work required, gathering intelligence, identifying objectives, planning strategy, procuring resources, deploying personnel and coordinating actions required to execute the plan, assessing results and modifying tactics all happen under the leaders command.
Sound extreme? Think about your patient care unit, rehab team or program and the work it does to evaluate and admit each patient. Who is in charge? Who reviews the intelligence gathered by team members and prioritizes the patient’s problems? Who integrates this information into a comprehensive interdisciplinary goal-directed plan of care? Who continuously monitors and adjusts the strategy and tactics to optimize the effectiveness of the team’s interventions? CMS says it is the physician and is looking for this level of evidence in each patient record. For now, this is the CMS expectation. Soon, auditors will look at the care delivery process and will measure the degree to which these expectations are met. The report of quality will then follow.
In medical rehabilitation the physician’s role remains at the head of the therapeutic process. However, his or her ability to command and control the cadre of clinicians to effectively achieve quality in process and outcome is being questioned. Each physician must be provided with the required intelligence to plan and execute care strategy and tactics. This influence is required to be in evidence throughout the length of stay and recorded in the clinical record. For the time being, this is a requirement for Medicare payment. Next, it will be reported as a quality measure for inpatient hospital rehabilitation and the degree to which this requirement is met, will rank hospitals across the country.