By Dr. Kenneth L. Scott Jr., DO, CMD
“Medical directors? They’re just a necessary evil.”
Over the years as a certified medical director of nursing homes, I have heard that phrase more times than I can shake a stethoscope at. I’ve also heard the following sentiment countless times, explicitly and implicitly stated by directors of nursing:
“Doctor, you need to understand that nursing homes are called nursing homes because nurses run them, not doctors.”
I quoted this response once in front of several hundred nursing home administrators and immediately felt their indignation that I would even repeat that statement to them. After all, they ran their nursing homes. While I am a physician and medical director, I still understood the sentiment well since I started working in nursing homes back in the day when doctors were rarely present in such facilities—a fact that is, regrettably, still true in many facilities today.
That common DON refrain has often been in response to my suggestion that the facility could be set up in a more efficient way that would help make a physician more productive. DONs don’t make that statement as a direct challenge to the authority or leadership of the administrator. Most DONs are clear, by word and action, as to what their responsibilities are and what the responsibilities of the administrator are.
In an efficient nursing home, after all, these two leaders typically work well together. The response is really more directed at me, the “newcomer” on the team of post-acute and long-term care. What my responsibilities were as a part of the team is usually not nearly as clear to either the DON or the administrator—and neither of them were totally to blame.
Let’s look at how the government has made medical directors responsible for the quality of care at their facilities, how their roles are often sidetracked in the shuffle of paperwork, and how they can break down barriers and improve communication with facility administrators and nursing staff.
Medical Directors Responsible for Quality of Care
Although the government has required that a physician be appointed as the medical director to ensure the quality of care in a nursing home for close to 20 years, few physicians appointed to the role seemed to be actively involved or “hands-on” when it comes to improving systems such as workflow or team interactions. In reality, even today, most do not spend enough time inside the facility to understand inefficiencies, workflow difficulties, or communication issues, such as patient hand-offs between nursing shifts or organizational structure. Thus, the mere fact that I would attempt to enter that discussion seems out of place to most directors of nursing.
Prior to 1974, there was no requirement for a nursing home to have a medical director. As the American Medical Directors Association reports, “In 1974, in response to perceived quality-of-care problems, Medicare regulations, for the first time, required that a physician serve as medical director in skilled nursing facilities and be responsible for the medical care provided in those facilities.” The Omnibus Budget Reconciliation Act of 1987 (OBRA-1987) extended this requirement to all nursing homes.
The introduction of a medical director as a requirement for a nursing home began to solidify the understanding of the government and society that the nursing home, rather than just a form of housing for elderly people, was a legitimate health care institution where medical care was delivered. Medicare established the sentiment that if Medicare dollars were to be allocated to nursing homes as a needed level of care for vulnerable patients, then a certain standard had to be expected. Significant to that was that a doctor had to oversee the quality of care in the facility.
The fact that the government ruled that nursing homes must have a medical director did not ingratiate doctors to nursing homes. Instead, it was seen more as a new tax—a cost of doing business that did not necessarily change how business was to be conducted but added an additional “encumbrance” to getting the job done.
With time, however, the ruling was seen as something more positive. Patients who formerly could not afford a room in a nursing home now had a payment source—thus, the market size increased. Furthermore, over time, nursing homes realized that doctors were a good source of referrals, and they began to seek the nearby primary care doctor with the largest practice to be their medical director, hoping that would make for a better referral source. This seemed like a good rationale, especially early on when there was no specific training for doctors to educate them on how to be good medical directors.
Even geriatric residency programs were more focused on how to run a geriatric practice and how to do geriatric hospital consults than how to provide service to a nursing home. Thus, how was a facility to judge who would make a good medical director?
Medical Director’s Role Often Lost in Paperwork Shuffle
Coming from the background of a hospitalist, I was well aware of the workflow in multiple hospitals, all of which were more or less designed to help me be efficient. After all, the hospital needed the doctor’s notes daily on the chart to justify the insurance or Medicare payment for the continued hospital stay.
The nursing home, on the other hand, was paid more like a room rent that did not depend on daily physician visits. In many nursing homes, physicians showed up once a month—or once a week, if the facility was fortunate. Medical directors would time their visit to coincide with certain meetings, such as quality assurance, so they could listen in and sign off on reports as required by the title. Nurses were used to working and caring for patients in the absence of the doctor, not knowing when he or she would be back in the building.
It was unusual for a doctor to show up as often as I did, let alone attempt to insert themself, as I did, in any way into daily operations. Thus, the surprised responses from DONs to my suggestions on inefficiencies that might need to be addressed. After all, the most important thing was the efficiency of the nurses who carried up to 20 or more patients per nurse, compared to the hospital, where nurses were individually responsible for six to seven patients at most.
Adding to the frustration, the doctor’s understanding of their role as the medical director was an issue. The doctor understood patient care and what was needed to provide excellent service. Making visits was not the issue. Understanding the flow of the facility and how to improve quality outcomes, however, was not only a challenge but also fraught with danger, not knowing when or if one would step on a land mine and lose a limb. The administrator and DON’s inability to help define the role or describe what was needed did not help.
In many cases, the role was seen as more of a paperwork shuffle. As long as the medical director signed off on needed paperwork to prove that the facility had a legitimate doctor in that role, that was perceived as sufficient for the cause. After all, the most important thing to many administrators was to legitimize the payments the facility was receiving from the federal government.
Unfortunately, many doctors bought into that mindset. When being sold on my first medical director position, I was told by another physician that it would be the easiest money I would ever make. All I had to do was show up at the facility, attend a few meetings, and pick up my check.
For many medical directors, that behavior was reinforced by positive accolades for showing up and negative or neutral responses to suggestions for improvement or change. For a medical director with the desire to be involved, figuring out how to engage and affect change was a challenge outside of the scope of their formal training. Implied or stated biases to each other’s role in leadership was also an issue.
Early on, in a meeting with leadership, I spoke up with a recommendation that I felt would improve the facility both financially and operationally. My suggestion that day had little to do with quality of care and more to do with business. My comment temporarily silenced the room. Then the president spoke up and said, “Well, you are a weird doctor that you understand and could come up with that.”
In other words, the best compliment I could receive was that the operations team never expected me to understand anything about their jobs or the potential outcomes of any decision I would make while at the facility.
Breaking Down Barriers and Improving Communication
On the other side of the fence, it’s clear that many physicians hold preconceived ideas about administration and nursing. The most common assumption from the physician standpoint is that administrators only care about the bottom line and that nurses fall in line with what administrators want since they have the ability to climb the corporate ladder as employees of the corporation.
Unfortunately, many of these thoughts remain embedded in the culture of post-acute and long-term care just as they do in the thoughts of the health care industry as a whole. Although the rhetoric is not as blatant as laid out here, the inferences show up in discussions every day across the country.
The question remains how to break down these barriers and improve communication across the industry in order to improve the quality of care and, as a result, financial viability. For a start, I would make the following suggestions:
- Get to know the other team leaders personally. That doesn’t mean learning the intimate details of their lives. It does mean asking about them as human beings, finding out what they like and do with their spare time and generally showing interest in them as people. Health care workers tend to shy away from this because it is time-consuming and seems inefficient. However, it is easier to extend leeway to someone you know personally and understand where they are coming from than to someone you have no connection with. Furthermore, the time you waste in resentment against someone whom you misunderstand will be a lot less efficient than the time you take to get to know and understand them on a more basic level.
- Learn to speak clearly. Mean what you say and say what you mean—but make sure that others understand what you truly mean to say. Misunderstandings lead to wasted time and forfeited opportunities. Clarity leads to good team dynamics and better outcomes. At one point, I was asked to address a state’s health care committee and agreed to do so. After preparing my thoughts, I asked to meet with the company’s legal team to go over my argument. The lawyers agreed with the general discussion points; however, they asked me to change several specific words in the presentation. They understood what I meant but felt that the politicians would interpret those words differently since they were not versed in health care. My presentation went well, in part because I took their advice and was able to convey meanings clearly.
- Ask questions. In health care, we think we are saving time because we assume we know exactly what someone means when they speak to us. Assumptions, however, can lead to poor results because we assumed something that wasn’t correct. Always ask that extra question or more if you need further elaboration.
Getting to know your leadership team better will help forge better working relationships and develop efficiencies that improve the working environment as well as the morale and culture at the facility. When that occurs, improvements in quality of care and, subsequently, financial viability can more easily be achieved.
