Fixing the Four Ring Problem: Driving Uniformity and Mediocrity

So do non-physician leaders and executives really know how to drive quality in the health care system?  Is the focus correct and do they really understand patient care?  The premise here at HCR is that most do not.  This is not an elitist stance.  It is just impossible to manage something so complicated without ever having done it.  A recent example follows.

A health care organization noted that it had an issue with patients getting timely access to the physicians.  There are some conditions that require urgent but not emergent care.  And from a business aspect if a patient can’t get a timely appointment with a physician then they may end up at a competitors place of business.  The problem is an important one.  The problem of access to physician care is complicated and there are multiple layers.  The administrative fix is a four ring rule.  If a patient calls a physicians office and does not get a person and an appointment in four rings then the call will get forwarded to a call center where a call center person will insert that patient into a slot in some physician’s template somewhere.

The first issue to get off the table is that, like in all occupations, there are physicians who simply want to do the least amount of work and collect the highest possible salary. has acknowledged the importance of physicians taking responsibility for restoring the profession of medicine (see: “Nobility Obliges” and “Guilty as Charged”).  The first place to look is always into the mirror.

The problems and issues that affect timely access to physicians are not uniform.  It is likely that there are four groups.  The first group (Group 1) are physicians who have built practices that realize the importance of getting patients into the office quickly and have the people and processes in place to make that happen.  The second group (Group 2) are physicians who realize the importance of timely access but do not have the people or processes in place to allow for it to happen.  The third group (Group 3) are physicians who don’t currently recognize how important timely access is but can be educated and are willing to change.  The fourth group (Group 4) are physicians who don’t acknowledge the importance of timely access and likely never will and are resistant to change.  One could obtain the distribution of the groups with the appropriate data mining.  The optimal fix for the access problem would in fact be four separate fixes.  Complicated but precise.

The alternative is a generic, universal fix applied to all physician offices.  A centralized call center and a rigid physician template.  All calls not answered on the fourth ring to a physician’s office would then be forwarded to a 100 person call center where a person who likely has no medical training will answer the phone.  The call center person will likely listen for key words from the caller-patient and then insert them into one of thousands of physicians templates that have been created.  It’s the M.B.A. fix.  It looks great on paper.  But it will only partially correct the problem of patients not being seen in a timely manner.  And at what cost?

The problem with this or any generic fix is the unintended consequences.  And also, these generic and universal fixes usually result in uniformity and mediocrity rather than the ultimate goal of best practice management.  Have the following issues been considered?

1) The physicians who are now performing well with respect to patient access are potentially penalized.  What if these physicians get most but not all calls on the fourth ring?  And what if the patients who gets a recording are called back very promptly?  Those patients who would have been called back are now likely to be inserted into another physicians template.  This could adversely affect the physician’s practice.  Even though the patient was accepting of the process.

2) Patients are often referred to a certain specialist based on a referring physician developing a level of trust with the specialist.  That trust is based on the specialist providing quality care and maintaining communication with the referring physician.  The incentive to do so by the specialist will be diminished and the previously invested hard work becomes negated.

3) Physicians have become specialized and sub-specialized.  Can an untrained person in a call center really connect a patient with the best person to provide best care within the larger group of physicians?  And if a bad outcome occurs because of an inappropriate referral is it justified because the four ring metric was hit?

4) And honestly, will this generic fix do anything to make the unmotivated physician be more receptive to change?

Applying a one-size fits all fix to problem is never the well thought about fix.  Does it make sense to break down practices that may be working fine to help others that are broken? Uniformity and mediocrity or best practices?  Four rings of the phone or quality outcomes?  Fixing health care is much more complicated than four rings of the phone.

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