Research your group (HOSPITAL ADMINISTRATIVE EXECUTIVE COMMITTEE) and describe t

Question

Research your group (HOSPITAL ADMINISTRATIVE EXECUTIVE COMMITTEE) and describe the primary role(s) of your group and reporting relationships vis a vis the other groups.

2. From a Human Resources Management perspective, describe the three most significant HRM issues that, given your role, you need to address in the short term.

3. Identify two long term HRM issues that your group needs to address to ensure that this scenario does not happen again.

4. Develop a specific strategy and objectives that will address each short term issue and long term issues. Your objectives should describe the metrics you will use to measure your progress and performance.

5. Describe your “fall-back” or alternative strategy if events change or your primary strategy does not work.

1 How to Mend a Broken Heart Program A Case Study 2

Introduction This case is based on a heart program in a mid-sized Midwestern community at a 480 bed community hospital. Special gratitude is expressed to Dr. G, the Senior Vice President of Medical Affairs, during the critical years of this case. Many persons contributed countless hours to improve a program that had for various reasons had spun out of control. A review of the literature and conversations with many clinicians and administrators documents that cases like this occur far too frequently. Many circumstances are never reported, but are included in the raw number of reports like To Err is Human. Less frequently we have accounts such as Dr. Michael Swango, which was documented in Blind Eye: The Terrifying Story of a Doctor Who Got Away With Murder. The New York Department of Health has been reporting cardiac surgery outcomes by hospitals and by physicians since 1989. One of the reports included the following: “Choosing the best surgeon and hospital for coronary artery bypass surgery on the basis of these published outcomes data can significantly improve your chance of survival. Did the 216 CABG patients treated by Doctor Cunningham at Maimonides Hospital between 1998 and 2000 know that their risk-adjusted chance of dying was 9 times greater than if they had received treatment from Doctor Marvasti at Saint Joseph's Hospital Health Center? They would have, if they had looked at these data.” A final ‘positive’ resolution in this case would not have been possible without many professionals, from various disciplines, contributing their expertise in the interest of all patients who deserve quality care in a safe environment. A special word of appreciation is extended to David, who served as Board Chair during these trying times and who made, or supported, difficult decisions by doing the right things for the right reasons even though the decisions were not easy or popular. Every effort was made to accurately (and objectively) report the facts of this case study as they occurred. Dr. G, a key player as the case unfolded, reviewed and edited the case to give a second perspective of accuracy. Some of the names and locations were changed to assure no peer review or confidentiality agreements were violated. History of Open Heart Surgery Open heart or open cardiac surgery was refined throughout the 1950’s, notably by Owen Wangenstein at the University of Minnesota, and by John Kirklin at Minnesota’s Mayo Clinic. Rene G. Favalaro introduced (modern) coronary artery bypass surgery in 1967 at the Cleveland Clinic. Since the 1950’s and the 1960’s coronary artery bypass graft (CABG) procedures have become common at hundreds of hospitals throughout the United States and the rest of the world. According to the American Heart Association, 467,000 bypass (cardiac revascularization) procedures were performed in 2003. Jeanette Regional Medical Center: As open heart surgery proliferated, throughout the U.S. and the world, more hospitals assembled resources to initiate an open heart program. Jeanette Regional Medical Center 3 (JRMC), in Centerville, Indiana an institution which began its open heart surgery program in 1988 with a consulting surgeon from the University of Louisville-School of Medicine and one newly recruited full-time “cardiac surgeon.” The full-time surgeon was Dr. Whitecoat, a general surgeon who received additional training in cardiovascular surgery, but was never board certified in cardiac surgery. JRMC was a 480 bed, not-for-profit 501(c) (3) hospital serving a community of 100,000 and a region of approximately 250,000 residents. JRMC functions as the regional trauma center with one of the highest emergency department volumes in the state. Dr. Whitecoat, who was in his mid-fifties, recognized the difficulty of covering a program by himself, and therefore began the recruitment of a second cardiovascular surgeon. Dr. Savemed, a foreign medical graduate, who was not board-certified, allegedly due to political instability in his home country, joined Dr. Whitecoat in 1990. JRMC’s open heart program grew to an annual volume of 150-200 cases in the program’s first 5-6 years. Even though the volume did not justify three surgeons, a third surgeon joined the program in 1993. This physician was a native of Kentucky, who completed his medical training at the University of Indiana School of Medicine. Dr. Pathey was board eligible and passed his board examination on his first attempt. I came to JRMC in 1994 as the Chief Operating Officer just after Dr. Pathey joined the medical staff. Within a year of my arrival, the CEO of JRMC was presented an opportunity to return to his home town of St. Louis as the CEO of St. John’s Medical Center. With his support I was promoted to CEO. During this transitional time the boards of JRMC and the local Presbyterian Hospital had entered into serious merger discussions. Although the merger was approved in the summer of 1995 (by the Justice Department) and began as a legal entity on October 1, 1995 it was not a major factor in this case study on cardiac surgery. The merger did impact me as the first CEO of the new Jeanette Regional Medical Center (JRMC) from the perspective of the amount of time that was required to integrate two culturally different institutions. Issues Between the Cardiovascular Surgeons For reasons I was not aware at the time, Dr. Pathey decided to disassociate from the other two cardiac surgeons and practice on his own. Dr. Savemed also decided to leave Dr. Whitecoat to join Dr. Pathey. This sudden chain of events forced Dr. Whitecoat to begin the recruitment of a new associate as a result of a bitter separation. Clearly, JRMC did not have the volume to support four cardiac surgeons, but Dr. Whitecoat needed coverage for call and began to recruit a new associate due to the caustic relationship with his former associates. Shortly after Dr. Pathey left the practice headed by Dr. Whitecoat some of Dr. Pathey’s patients or patient’s families began to receive anonymous letters alleging poor care by Dr. Pathey. Two or three of the letters alleged Dr. Pathey was responsible for the death of patients. Coincidentally, family members of Dr. Savemed’s patients started receiving letters making similar allegations. As CEO I called a special meeting of the Joint Conference Committee (members of the Medical Executive Committee (MEC) and the Executive Committee of the Board of Directors). The sole agenda item was to inform board members and the MEC members of the events surrounding our cardiac surgery program. One of my management rules is ‘no surprises.’ In addition to the anonymous letters alleging poor care, other letters were sent to the local newspaper and to the FBI alleging Dr. Pathey and Dr. Savemed were guilty of over billing 4 patients. Specifically, the allegation was that both physicians were charging a fee to assist the other during open heart surgery cases, when in fact they were not present long enough to warrant a fee. Inferences were made by multiple persons that Dr. Whitecoat was in some way involved in the anonymous letters and the billing complaint. Due to the gravity of the allegations the hospital contracted with a former FBI agent, who was now a private investigator, in an attempt to identify the source of the anonymous allegations. The conclusions of the private investigator pointed in the direction of Dr. Whitecoat. However, many of the people interviewed would not speak on the record. Therefore we did not pursue any further investigation. Fourth Surgeon Recruited As all of these events unfolded Dr. Whitecoat actively worked to recruit a new associate. One candidate expressed a high level of interest, but decided on another opportunity in the state of Louisiana. After a few short months in Louisiana, the physician, Dr. Walters, is back in Centerville because the deal he was “promised” in Louisiana did not work out. Dr. Whitecoat offered Dr. Walters a contract and energetically began the process of getting Dr. Walters credentialed. In the process of credentialing Dr. Walters, the chair of the credentials committee, Dr. Neil Nelson, tells me the credentials committee approved Dr. Walters, but they should not have, based on some information the credentials committee discovered regarding Dr. Walters when he was in Tennessee. After a few phone calls I discovered Dr. Walters had been charged with verbal harassment and physical assault of a nurse in Bristol, Tennessee. As a result of the charges his privileges had been temporarily suspended and he pleaded no contest to Class B misdemeanor assault charges. A long standing practice at JRMC was for the CEO to grant temporary privileges to a physician once the credentials committee had approved a candidate’s application, which would then go to the Medical Executive Committee and then on to the Board of Directors. The reason for the CEO to grant temporary privileges was due to the fact that the credentials committee made its’ recommendation to the MEC on the first Monday of the month and the Board did not meet until the third Monday of the month. In this situation, based on the “tip” I received from Dr. Neil Nelson, I refused to authorize temporary privileges, which created a huge backlash from Dr. Whitecoat and Dr. Walters. Keep in mind that credentialing information is ‘confidential and protected by peer review’ so I was not in a position to explain why I would not authorize temporary privileges. As a result Dr. Whitecoat and Dr. Walters initiated a campaign with individual board members to secure privileges for Dr. Walters. At the next Board meeting the Board asked me for my recommendation and I said I would not recommend approval for Dr. Walter’s application. After much deliberation the Board in split vote, by a margin of one vote, approved Dr. Walters with the caveat that they would ‘watch his behavior closely’. John Horty, who heads the law firm of Horty, Springer and Mattern, in Pittsburgh, counsels boards that the burden is on the applicant to demonstrate he/she is worthy of being credentialed and the board has no obligation to feel pressured into credentialing any candidate. Our board learned this lesson the hard way. The key players are now in place for what transpired over the next few years. In the interest of brevity I will summarize some of the key events that transpired. 5 Complaints from the Staff & High Mortality Within a month of Dr. Walters being credentialed I began to receive complaints from nurses in the ICU regarding the behavior of Dr. Walters. Some of the complaints constituted sexual harassment, others did not. As CEO I asked the nurses to put their complaints in writing addressed to the appropriate medical committee with a copy to the chair of credentials, Dr. Nelson. These events were also reported to Dr. Burns Bradley, head of the “Impaired Physicians Program” in Indiana, who Dr. Walters had to report to on a regular basis due to his assault charges in Tennessee. If the indications regarding the behavioral problems with Dr. Walters was not enough of a concern, I was informed by the quality department that Dr. Walters had three deaths in his first 14 cases for a raw mortality of 21.42%. The national average is between 2-3% and declining. Dr. Walters had a fourth mortality in one of his next 8-9 cases. Additionally, the complaints from staff members regarding inappropriate behavior by Dr. Walters continued. External Review As a result of the high mortality rate I met with the MEC and we determined an external review of the cases by Dr. Walters should be initiated as soon as possible. I contacted the executive director of the American Legal Foundation (AMF) and she arranged for Dr. Sid Lavin, the director of cardiac surgery at the Harvard School of Medicine and Dr. John Cornell, director of cardiac surgery at the Texas Heart Institute in Houston, Texas to conduct a chart review of Dr. Walter’s cases, focusing on the four deaths. Dr. Cornell has since left Texas Heart to accept the position of Dean of the School of Medicine at Yale. Drs. Lavin and Cornell, while raising serious concerns regarding the performance of Dr. Walters were not able to draw any definitive conclusions from the chart reviews. Drs. Lavin and Cornell recommended a comprehensive review of the entire cardiac program, including the invasive and non-invasive cardiology programs. In addition to reviewing the cardiac surgery and cardiology programs the review also examined the delivery of cardiac anesthesia and the treatment of cardiac patients in the ICU. Physicians are contracted through the AMF to review the entire cardiac program. In addition to the review by the AMF recommended physicians, a group of cardiologists requested the hospital contract with Dr. Michael Pine, an independent cardiologist who is working closely with Anthem/Blue Cross to develop a statewide Coronary Care Network. As a result of the analysis by Anthem in the state of Ohio, the “state’s most highly regarded coronary unit, at Ohio State University Medical Center”, ranked among the worst performers in the first Anthem study, released in 1995. After its ouster from the Anthem system in 1995, the Columbus, Ohio institution reassigned some surgeons, revamped its program and improved its results. The cardiologists’ motivation to bring in Dr. Pine was a direct reaction to the events at Ohio State University Medical Center. As part of Dr. Pine’s agreement to consult and review our program he included his associate, Dr. Thomas Williams, the cardiac surgeon who ‘cleaned up’ the program at Ohio State. As outside consultants were trying to develop a clear picture of whether or not we had problems, and if so where, the hospital was collecting data through the normal committee process under the direction of Dr. G. By analyzing data from the Society of Thoracic Surgeons (STS), the Anthem Coronary Services Network (Dr. Pine’s data), data from Health Grades, and 6 other sources, we were compiling a convincing case that we had serious problems with cardiac mortality. The national average for CABG mortality, before being risk adjusted, is approximately 2-3%, with excellent programs below 1.5 or even 1%. Results for the four surgeons at JRMC for the years 1993-1998 were as follows: (Note that all four surgeons did not practice all of the years recorded.) Physician A: For the years 1993-1998, surgeon A had an observed mortality of 6.0% and a predicted mortality of 3.4% for an O/E ratio of 1.76. This surgeon had a high mortality of 10% in 1995 and a low mortality of 3.1% in 1998. Physician B: For the years 1993-1998, surgeon B had an observed mortality of 2.3% and a predicted mortality of 3.4% for an O/E ratio of .676. This surgeon had a high mortality of 5.2% in 1994 and a low mortality of 0% in 1993. Physician C: For the years 1993-1998, surgeon C had an observed mortality of 7.2% and a predicted mortality of 3.5% for an O/E ratio of 2.05. This surgeon had a high mortality of 20.0% in 1998 and a low mortality of 2.9% in 1996. Physician D: For the years 1997-1998, surgeon D had an observed mortality of 12.8% and a predicted mortality of 4.7% for an O/E ratio of 2.72. This surgeon had a high mortality of 23.1% in 1997 and a low mortality of 8.8% in 1998. An O/E ratio of less than one is an indication the surgeon is performing better than predicted or expected. An O/E ratio of greater than one is an indication the surgeon is performing worse than predicted. An interesting development was the cardiologists’ desire not to be linked with the high profile external audit of the Open Heart Surgery Program. Based on the recommendations of Drs. Pine and Williams I approached the Chair of Cardiac Services regarding the need to establish minimum standards in light of the outcomes and all of the publicity focused on Cardiac Surgery. There was no response to the recommendations of Drs. Pine and Williams. For a lay administrator to become actively involved in clinical activities can be a career limiting move. However, when a number of key physician leaders acknowledged they were either unable or unwilling to take on the quality issues I felt I had do something in light of mortality rates that were much higher than national averages. This reality was reinforced when over half of the twenty board members had privately directed me to be sure they or their spouse would be sent out of town if they needed open heart surgery. During this period of time the board continued to “re-credential” some of the questionable surgeons. I believe the board members were well intentioned and were “hoping” the problem would resolve itself. I have often stated that “hoping” is not a good management strategy. Working to “fix” a major clinical problem in cardiac surgery is a mammoth task in and of itself. The task became even more daunting when I received a call from the AMF cardiologists who were brought in to review the performance of our cardiologists. Their presence was based on a recommendation made by Drs. Lavin and Cornell to conduct a comprehensive review of cardiology. They reasoned that it made sense to review our entire cardiac program to get a better perspective of how the cardiac surgery program interacted with our diagnostic and interventional cardiology program. Three nationally recognized cardiologists were selected by the AMF to review all aspects of our cardiology program. One was from Stanford, one was from the University of Pittsburgh School of Medicine and the third was from Oschner, a nationally recognized teaching facility in 7 Louisiana. Prior to their arrival our staff in the departments of medical records, utilization review, and the department of cardiology were directed to assemble medical records, videotapes of cardiac catherizations and related data on each of the cardiologists. The AMF cardiologists would review at least 10-20 cases of patients from each of our cardiologists. Although our local cardiologists were not eager to have their clinical decisions and outcomes reviewed, they found it difficult to argue with the logic of the nationally renowned surgeons from the AMF or even our own MEC and the newly formed cardiac services committee, which was comprised of their peers from the OMHS medical staff. The AMF cardiologists were brought in to review our cardiology program in May of 1999. They arrived on a Thursday with plans to work all day on Friday, Saturday and Sunday morning, with plans to return to leave Centerville late Sunday. I was scheduled to be in Indianapolis that weekend for a swim meet for our sons. They had asked for my cell phone number and indicated they would like to talk to me around noon on Sunday to give me a verbal summary of their findings. The call I received was one I will never forget. All three of the “consulting cardiologists” were on a speaker phone from our board room and they began by asking how my sons were doing in the swim meet. I do not remember my reply, but asked them how the ‘cardiac’ review was going. They responded that we had a fairly average to below average cardiovascular program and there were no new surprises - except for one. The consulting cardiac physicians proceeded to tell me that we had one cardiologist that was an imminent danger to patients. Their recommendation was for me to call a special meeting of the MEC, the Board, or whoever had the authority to terminate the privileges of this particular cardiologist before he inflicted any more harm on patients. Listed below are excerpts from the AMF cardiologists’ review of the cath films and charts of patients treated by this physician. Review of a Cardiologist’s Patient Records by AMF Physicians One: “There were no critical lesions seen by any of the reviewers. Nevertheless, a 2.0 mm balloon was ruptured in the distal LAD. Attempt to withdraw this balloon led to what we believe was likely dissection of the left main by the guiding catheter. This death was avoidable and clearly related to a series of errors in judgment on the part of the physician.” Two: “ The cardiologist’s decision to go on and diffusely treat the LAD and circumflex seems extremely aggressive……we believe her death directly derived from her invasive coronary events, which led to ……a cascade of medical catastrophes that led to her ultimate arrest.” Three: “Stenting of a perforation is generally not a good idea as it runs a distinct risk of perpetuating the rupture site.” Four: “The RCA ruptured when the balloon ruptured at 19-20 ATM during stent deployment. This balloon in only rated to 12 ATM. Without a compelling indication, this is too high of a pressure to use with this balloon.” Five: “This is a QA issue since it is a technical problem resulting in death.” Six: “It is either the guiding catheter or his management that may be leading to these complications. None-the less, in this particular case, it remains unknown exactly why she died. This is a QA issue.” Seven: “This case is quite troubling to the reviewers since we do not feel that there was any indication for the procedure, which was subsequently complicated and produced an anterior myocardial infarction in this patient.” 8 Although this sample of cases is very disturbing there were more cases with bad outcomes, all from the same cardiologist. The AMF physicians were adamant that this cardiologist’s privileges be terminated and a plan of correction be implemented immediately. They recommended at the very least that this particular cardiologist “should be directly supervised on all cases until he can demonstrate he has received appropriate training. He should attend a six month fellowship or should work directly under the direction of another cardiologist for at least 100 cases.” The final outcome was a recommendation by local physicians that the cardiologist’s privileges were restored after a temporary suspension by members of the Board and MEC (joint conference committee). The cardiologists, in a meeting of the cardiac services committee, indicated they would monitor the cardiologist’s performance. To my knowledge, formal monitoring with written progress reports, including chart reviews of specific cases never occurred. Even the casual, loose review, fell by the wayside in 2-3 months. A formal retraining program did not occur and the six months onsite monitoring/training program, as recommended by the AMF physicians, did not occur. Meanwhile the cardiac surgeons were becoming more and more openly hostile to each other. The oldest cardiac surgeon, who was now doing very few cases, filed complaints to the Cabinet of Health Services regarding the one board certified cardiac surgeon, Dr. Pathey. There were additional anonymous complaints regarding Dr. Pathey’s clinical outcomes and his billing practices. Dr. Whitecoat was reportedly reading the patient charts of Dr. Pathey’s patients, which is forbidden without the consent of Dr. Pathey. Due to Dr. Walter’s poor clinical outcomes the MEC and the Board continued to debate the establishment of clinical standards focused on mortality and volume of cases. The result was the MEC and the Board imposed a standard for mortality wherein a surgeon’s mortality could not exceed 2.0 times the predicted mortality using the STS methodology. On a practical basis the standard was not useful in the short term because the mortality rate was to be reviewed on a rolling 12 month basis. This provision was added because physicians argued that any physician could have a bad run. The second standard was that each surgeon needed to perform at least 50 cases (open heart procedures) per year. One of the outside consulting surgeons argued the number should be at least 100 cases. Clearly this was not an acceptable number to the cardiac surgeons and the result was to begin with 50. Complaints continued against Dr. Walters and he eventually took another position at a new program at the hospital in Pineville, KY. The official outcome of what happened in Pineville, as reported by the State Board of Medical Licensure is a matter of public record. Even with the departure of Dr. Walters, the cardiac program was the focus of the medical staff and the board, as the anonymous letters had not been resolved. It was amazing that throughout this entire ordeal not one lawsuit was filed. One family requested files, medical records, etc. but never followed up with a lawsuit. Cardiac Surgeon Behaving Badly Throughout all of these issues Dr. Pathey was behaving badly. Due to multiple affairs his marriage ended in divorce. Dr. Pathey, who ended up marrying his marriage counselor, did not learn from his previous wayward ways. Shortly after his second marriage Dr. Pathey was rumored to be having additional affairs with staff members of the hospital. While it is not the business of the hospital to pass judgment 9 on anyone’s personal affairs, as long as those affairs do not impact job performance, the fact that one of the nurses Dr. Pathey was having an affair with came to nursing administration and human resources to seek counseling through our employee assistance program was confirmation of at least one active affair since his second marriage. By this time the senior cardiac surgeon had retired, Dr. Walters was in Pineville and Dr. Savemed was not getting any referrals due to concerns expressed by cardiologists regarding what they termed “serious quality concerns.” Given the concerns expressed by the cardiologists, the chief of staff, the chair of the cardiac services committee, the Senior V.P. of Medical Staff Affairs, and two external consultants an external review of cardiac surgery was recommended. Dr. Williams, the consultant from Ohio State’s cardiac surgery program, met with Dr. Savemed and recommended he relinquish his cardiac surgery privileges in December of 2001. In an effort to temper any animosity from Dr. Savemed, the chair of cardiac services presented an opportunity to Dr. Savemed to be the Medical Director of Regional Development and to lead the development of a “heart institute.” Dr. Savemed, who was losing the confidence of the cardiologists, was a generally very likable physician. Dr. Savemed’s partner, Dr. Pathey, influenced his decision not to take the position. Many believe Dr. Pathey liked having a “weak” partner so he would get most of the business and his clinical outcomes would look good in comparison to his partner. By this time, both surgeons were being evaluated by STS, the Anthem Blue Cross Coronary Services Network, Health Grades, and a host of other rating agencies. A split among the cardiologists developed regarding their support or lack of support for Dr. Savemed. Members of the medical staff expressed their views that the support was based on a dislike by some physicians for Dr. Pathey and the fact they wanted a choice when making referrals for their open heart cases. In fact, three of the cardiologists wrote a report analyzing the cardiac program in general and the cardiac surgeons in particular. Some saw this as a preemptive attempt to challenge or to refute the latest external review by Dr. Pilot from Tulane who was contracted to review the clinical outcomes of Dr. Savemed. Specifically, Dr. Pilot was retained to methodically review 15 death charts of Dr. Savemed. Dr. Pilot’s conclusion was that the care rendered by Dr. Savemed did not meet acceptable standards. Dr. Savemed could see the handwriting on the wall and began to explore options outside of Kentucky. He eventually took a non-cardiac surgery position in the state of North Carolina. Dr. Pathey now has all of the open heart business and allegedly is working to recruit an associate, although a number of physicians think the effort is disingenuous. Just when Dr. Pathey has the program all to himself his latest “flame” informs him she is not going to see him anymore. Staff members and physicians unaware of the latest in his personal life report that Dr. Pathey to be despondent and depressed. Within a couple of days of being told by his latest “flame” that she does not want to see him anymore, Dr. Pathey attempts to take his life with an overdose of barbiturates. He is unconscious for 3-4 days and when he regains consciousness it is not known whether or not he has suffered brain damage as a result of the overdose. As CEO what is your recommendation for the Cardiac Surgery Program? For your information you should know that Dr. Pathey makes what appears to be a full recovery from his suicide attempt and he wants to resume his practice. Within a year he is divorced from his second wife. 10

Explanation / Answer

Pay-for-performance will be most effective in situations in which health insurers and providers of medical care have the right combination of information and ignorance. Specifically, the following three conditions must be in place: (1) health insurers must not fully understand which medical processes improve health, which we refer to as the health production function; (2) individual providers must know more about the health production function than insurers do; and (3) health insurers must be able to measure a patient's initial risk-adjusted health, his or her ultimate health, and each provider's contribution to the change in health.

Consider a situation in which medicine could be codified into a “cookbook,” so that if physicians ordered certain tests and performed certain procedures, a patient's health would improve as much as possible. Armed with this cookbook, health insurers could implement an “optimal” fee-for-service system by increasing fees sufficiently to encourage physicians to use the effective processes and reducing fees (possibly to zero) for ineffective processes. We describe such a system later. Although health insurers could achieve the same results using a process-based P4P system that gives providers extra payments if they use effective processes, the point is that when health insurers have complete knowledge of the health production function, such a P4P system will not provide any benefit beyond a well-designed fee-for-service system.

Now consider the more probable situation in which health insurers know that all providers should use certain medical processes (e.g., blood sugar tests for diabetic patients); there is no evidence to justify evaluating other processes; and insurers do not know the best way to combine many possible processes to produce the best health outcomes. Some providers, however, have more complete knowledge regarding how to produce good health outcomes based on their unique clinical experience, knowledge of individual patients, willingness to experiment, and/or superior management systems, such as information technology or care pathways.

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