Practicing Excellence

Excellence is a habit, not a single act. We are what we do repeatedly. — Aristotle

Excellence in medical practice today goes beyond the comparison with pornography: I know it when I see it. Sure, a great patient visit or disease outcome gives the impression of excellence. But repeated and consistent excellence in medical practice is rare, even among the best physicians.

What constitutes practice excellence? There are at least three dimensions. First, the patient must feel as if they received excellent care. The patient satisfaction score is all the way to the top. Secondly, what was done for the patient matches the highest current standards of care. Current best practice was delivered. Thirdly, the outcome of the care was optimal, given all realistic possibilities. Best outcomes are derived from consistently repeated best practice.

How do we achieve such an ideal in medical practice? Is excellence a realistic goal and a consistently achievable outcome? Yes, according to Steve Beeson, Sharp-Rees Stealy physician leader of the Sharp Experience and author of Practicing Excellence: A Physician’s Manual to Exceptional Health Care (1). His article in this issue tells the story of the Sharp Experience from the physician perspective. Steve Beeson does not just talk the talk of excellence. He walks the walk, both for himself in full-time practice and for his group.

Steve Beeson’s book is a wonderful read, and I recommend it highly to all physicians, regardless of specialty. After making the case for excellence, everything from improving patient compliance, building patient loyalty to reducing malpractice risk, he dissects the clinical encounter into detail most of us have never thought about. Did you know there are eight parts to each visit? They are:

1. The First Impression
2. Exam Room Preparedness
3. Techniques in History Taking
4. The Physician Exam
5. Providing Patient Information
6. Patient/Physician Collaboration
7. Patient Follow-up
8. Effective Appointment Closure

Each of these has room for error or inadequate performance. Beeson gives pointers for excellence with each of these steps. He then provides pointers for difficult patient situations.

The book then goes beyond the individual physician and staff to the medical group. How does an entire group achieve excellence? Beeson provides nine steps that were used at Sharp Rees-Stealy to accomplish their amazing turnaround.

Steve Beeson was the keynote speaker at the Sharp Primary Care Conference in Hawaii. Fifteen of his colleagues were present. I enjoyed listening to the early skeptics, for example, the urgent care and occupational medicine physicians, who felt that they were doing as well as they could under difficult circumstances. They are now doing incredibly better and look back on their past performance as an earlier time of substandard practice.

Converting to consistent excellent practice is not easy. Physician coaching is often necessary, not something we in a traditionally autonomous profession are inclined to admit that we need. Finding and developing coaches is an important and challenging process, but one that is necessary for group-wide excellence. Other companies known for consistent excellent service, like Nordstrom or Starbucks, use coaching and development continuously. We need to also, and not just for our office staff.

Steve Beeson’s keynote presentation highlighted nine essential elements of practice excellence. Everyone must be present for a group to sustain excellence. I find a list of nine things intimidating, and I quickly wondered how realistic that could be. They are: Vision, Leadership, Passion, Relentlessness, Ownership, Recognition, Accountability, Measurement, and Execution. I could not think of any one of these to remove and still have excellence.

It has been five years since I became the director of the San Diego Center for Patient Safety, an organization that is no longer active due to lack of funding. Benchmarks of quality of care in San Diego County revealed lots of gaps. One study on several common conditions even put us in the bottom 25 percent of major metropolitan areas! A lot has happened here since that time. I am convinced that San Diego County is now in the top 25 percent nationally. Every major hospital and medical group has had dedicated efforts to improve quality, as this issue of San Diego Physician describes. Sharp’s recent Malcolm Baldridge Award is a crowning achievement. Steven Beeson has emerged as a major champion of physician excellence. We would all do well by following his teachings and example.

Reference:

1. Beeson SC. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. Gulf Breeze, FL: Fire Starter Publishing (Studer Group), 2006.