When I started as Interim Chief of Staff, I discovered that the clinical chiefs had not been encouraged to assume a leadership role, or take clinical issues to higher levels of administration, leaving them somewhat impotent and complacent.The Medical Staff By-laws adopted in 2010 essentially centralised the medical staff power in the office of the Chief of Staff. The BHB has agreed that these by-laws be abandoned for new ones, and that the active medical staff should become more of a force which takes on leadership responsibility for quality, improvement, and medical staff issues as a whole.An issue that has been raised quite a few times has been compensation at BHB. The highest paid group of staff employed by BHB are the physicians. Unfortunately, when I arrived, there was great variation in compensation methodology throughout the employed medical staff, with some groups far above the accepted benchmarks, some far below, and little in the way of productivity, or quality, benchmarks to justify salaries.One strategy of the previous administration was to fully employ anaesthetists, cardiologists and obstetricians. The obstetricians were employed because of the mistaken premise that this was the only method of securing affordable malpractice insurance for them.In addition, Bermudian obstetricians practicing abroad were encouraged to return. As a result, the number of obstetricians on the Island has proven too many for the number of deliveries performed, and BHB has sustained a substantial financial loss on the service.The obstetricians are being returned to the community. The contracts written for the anaesthetists were much higher than the usual benchmarks. At the same time, the very important emergency physicians were salaried well below benchmark. A consulting firm has recommended a new compensation system that is fair, and linked to quality of outcomes, and not utilisation.One success of the last few years is the evidence of rising patient satisfaction, especially with physicians after the hospitalist service was introduced.Although the majority of patients speak of their positive experiences with BHB or KEMH, they are drowned out by the few who feel differently. As in many communities, there do not seem to be realistic expectations of medical outcomes, and there is confusion between poor outcomes, and negligence.Programmes should be developed for informing the community as to realistic expectations, the rising costs of healthcare, and the reasons for it, as well as the community’s role in maintaining good personal health.But, patient satisfaction does not always equate to quality, and BHB has been providing greater focus in this area to prevent undesirable outcomes.BHB has introduced a system that allows all staff to report patient safety issues. This system is called Quantros, and everything reported goes directly to the Quality & Risk Department, and triggers an investigation.However, there is another piece to improving quality beyond reporting. Programmes directed at organisational improvement that begin at the top, and rely on momentum to drive appropriate goals down the chain of operations, are at risk of dissipating their energy before they reach the lowest levels.My recommendation would be to implement a programme that impacts all layers simultaneously, or works from the bottom up. The physicians, nursing, and pharmacy staff, must be constantly reminded to maintain concentration, attention, and vigilance until it becomes second nature.* This is the second of three articles looking at the cost of care by Dr Scott, who joined BHB in August 2012 and worked as Interim Chief of Staff until March 2013. Tomorrow he looks at BHB and the Hospitalist System.