Engaging Physicians in Leading Quality...

EngagingPhysiciansinLeadingQualityImprovement

Carol Peden, MB ChB, MD, MPH Felipe Osorno, MSCEP Kaveh Houshmand Azad, MSCIE

Keck Medicine of USC University of Southern California Los Angeles

Disclosures CarolPedenisashareholderinFidelityHealthandaFellowandFacultyofIHI.Wehavenootherrelevantfinancialrela;onshipswiththeproductsorservicesdescribed,reviewed,evaluatedorcomparedinthispresenta;on.

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CarolPeden,MBChB,MD,MPHFelipeOsorno,MSCEPKavehHoushmandAzad,MSCIE

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OBJECTIVESOFTHISSESSION

1-Tounderstandhowtodevelopastrategyandframeworktocreateaprogramforphysiciansinleadershipandqualityimprovement2-Tounderstandhowtoimplementaframeworktoenablephysicianstoleadqualityandperformanceimprovementprojects3–Tolearnfromsuccessstoriesfromourphysicianqualityandimprovementprogram,aswellaslessonslearned

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KeckMedicineofUSC

3Hospitals

619Beds

60+Clinics

4,000+Employees

1300FacultyandScien;sts

9000ClinicalTrials

900Residents

$1.6BNetRevenue

Bornin2009

5 Source:UHC,Q32016–Q22017

2.96KeckMedicalCenterofUSCCMI

2.78CityofHope

2.46MoffiQCancerCenter

2.50ClevelandClinic

2.53Univ.ofMarylandMedicalCenter

2.43StanfordHealth

2.27UCLAHealth(RonaldReagan)

2.34MayoClinic

2.11UCSFMedicalCenter

1.92JohnsHopkinsMedicine

Weseesomeofthe

sickestpa]entsinthena]on

2.72SylvesterCancerCenter

CMI=CaseMixIndex

Innovation at Keck

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CharlesHeidelberger,firstassociatedirectorforbasicresearchatUSCNorrisComprehensiveCancerCenterandof5-Fluorouracil,themostwidelyusedcancerchemotherapydrug

FirstFDA-ApprovedHigh-IntensityFocusedUltrasoundSurgicalAbla]onforKidney&

ProstateCancer

FirstImplantableAr]ficialRe]natoRestoreVisionfromRe]ni]sPigmetosa

FirsttoTreatUncontrolledEpilepsywithFDA-ApprovedResponsiveNeuros]mula]onSystem

FirsttoOfferBronchialThermoplastyOutpa]entTreatmentforSevereAsthma

FirsttoEstablishRela]onshipofCancerandEpigene]cDNAMethyla]on

Keck’s Revenue Growth – An Academic Start Up • Revenuehastripledin6years–reached1.6Bin2017•  30%growthinthelast2fiscalyears

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$460M$550M

$620M

$790M

$1.15B

$1.31B

$1.5B

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

2010 2011 2012 2013 2014 2015 2016

Los Angeles Health Care •  SignificantMedi-cal(37%ofLACountyand33%ofCA)andMedicarepa;entpopula;on

•  LosAngelesisoneoftheleastconsolidatedhealthsystemsintheUS• Markeddemographicdiversity

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Health Spending Per Capita Per State 2014 (most recent data)

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Source:KaiserFamilyFoundaOonhPps://www.kff.org/other/state-indicator/health-spending-percapita

From a For-Profit Hospital to an Academic Medical Center in a changing healthcare world

• Challenges!

• Culture

• Developingdatainfrastructure

•  LiQleimprovementinfrastructure

• Rapidgrowthanddevelopingsystems

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Who we are? • CarolPeden,Physician–anesthesiologistandintensivist30yearsfront-lineclinicalexperience,IHIFellowandFaculty,experienceofdesigningandleadingQIprojectsandcurriculaaroundtheworld.

•  FelipeOsorno,MITChemicalEngineer,6yearsinconsul;ngatMcKinsey,LeanandSixSigmaTrained,experienceandpassionincrea;ngsystemstoempowerfrontlinestafftoimprovevalue.

• KavehHoushmandAzad,MScIndustrialEngineering,10yearsofexperienceinhealthcareperformanceimprovement

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Getting Physicians Engaged in Improvement

• Whythisprogramforusnow?• GrowthandInfrastructure• Valueinhealthcare• Transforma;onalchange• Theissuesallhealthcareorganiza;onsarefacing

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We are all facing similar challenges

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End-to-End

BundlesV VALUE

Changesinreimbursement

models

Risingsupplyandlaborcosts

Wasteininternalprocesses

Varia]onamongproviders

Needforchange

Burnout

WestetalLancet2016;388:2272-81SalyersetalJournalofGeneralInternalMedicine201614

Strategies to reduce physician burnout

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hPps://newsnetwork.mayoclinic.org/discussion/mayo-clinic-reversing-physician-burnout-using-nine-strategies-to-promote-well-being/

•  Acknowledgingandassessingtheproblem•  Recognizingthebehaviorsofleadersthatcanincreaseordecreaseburnout

•  Usingasystemsapproachtodeveloptargetedinterven;onstoimproveefficiencyandreduceclericalwork

•  Cul;va;ngcommunityatwork•  Usingrewardsandincen;vesstrategically•  Assessingwhethertheorganiza;onsac;onsarealignedwiththestatedvaluesandmission

•  Implemen;ngorganiza;onalprac;cesandpoliciesthatpromoteflexibilityandwork-lifebalance

•  Providingresourcestohelpindividualspromoteself-care

•  Suppor;ngorganiza;onalscience(Studythefactorsinyourownins;tu;onthatcontributetotheproblem,andinvestinsolu;ons.)

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Achieving The Quadruple Aim

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ImprovedPa]entOutcomes

LowerCostofCare

ImprovedPa]entExperience

ImprovedCareGiverExperience

Why not a multidisciplinary team approach? • Culture• Nomedicalschooltraining(todate)inQIatUSC

•  Time•  LiQleestablishedinfrastructure• Needtorapidlydevelopacohortofleaderswhocouldthenworkwiththeirteams

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CultureofImprovement

DataAvailabilityandTransparency

BuildingCapabili]es

System-WideImprovement

Specialty-LevelImprovement

EngagedPhysicians

Our System-Wide Strategy

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hPp://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

ModelforimprovementdevelopedbyAssociatesinProcessImprovement

•  Approachfromboth“Lean”and“ModelforImprovement”•  Usingbackgroundresearchandtheteam’sexperience

Designing the program

LeanThinking

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hPps://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_0.pdf

hPps://paOentsikkerhed.dk/content/uploads/2016/02/psskatalog_uk_www.pdf

hPps://www.rcplondon.ac.uk/projects/learning-make-difference-ltmd

Experience and Learning

The “Secret Sauce”

AmericanJournalofMedicalQuality2017.

•  “Earlyengagementofaphysicianleader–whocanlisten,engage,andleadothercolleagues–tobeanearlyadopter”

•  “Theymustbeequippedwiththetrainingandtoolstoleadothers,requirededicatedprotected;me,andtheautonomytocoordinateandimplementchanges”

•  “Theengagedphysicianleaderrequirestrainingingovernance,leadershipandmedicaleconomics…andmentorship”

EPOCH Aim and Theory

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EPOCHTrial:EnhancedPeri-Opera;veCareforHigh-riskPa;ents£1.5M/90Hospitals

Front-line clinical staff will be enabled

to achieve improvements in care for patients

undergoing Emergency Surgery

which will lead to improved outcomes

Evidencebased

interven;ons

Measurement&datafeedback

Mo;va;onandfocus

Communityofprac;ce

QIskillstraining

MDTapproach

Ethnography and physician engagement “Becausehistoricallyweassurgeonswouldfinishanemergencyandouenleavetheopera;ngtheatretowritetheopera;onnotes,andthenouentheconsultantwouldleave,andtheregistrarmightcomebacktoseewhatisgoingon,butouenyouwould…findoutthenextmorningwherethepa;enthadgone.Whereasthisnow,gevngusintomoreofacultureof:‘Isthispa;enthighrisk?Shouldtheygotointensivecare?Whatisourplanofmanagement?Doweextubate?’Thosekindofthingsareconversa;onsIthinkweshouldhave’.”(SurgicalFellowHospital2)

23 EPOCHTrialSociologyofHealthandIllness2017;39:1314-1329

How to make change happen

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What does engagement really mean to physicians? 1.  Respectformycompetencyandskills2.  Feelingthatmyopinionsarevalued3.  Goodrela;onshipswithmymedicalcolleagues4.  Goodwork/lifebalance5.  Avoiceinhowmy;meisstructuredandused6.  Faircompensa;on7.  Goodrela;onshipswithnon-clinicalstaff8.  Abroadersenseofmeaninginmywork9.  Avoiceinclinicalopera;onsandprocesses10. Opportuni;estoexpandmyskillsandlearnnewskills

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From:IncreasingPhysicianEngagement:startwithwhat’simportanttophysicians.RobertStarkThejournalofmedicalpracOcemanagement2014;30:171-5

How was our program developed?

SPO

NSO

RS

HIP

DES

IGN

HealthSystemLeadership

ValueImprovementOffice(“LeanTeam”)+CenterforHealthSystemInnova;on

DepartmentChairs

ValueImprovementOffice(“LeanTeam”)+CenterforHealthSystemInnova;on

SELE

CTI

ON

DEL

IVER

Y

Why it was designed this way? •  Tohelpcliniciansunderstandthecomponentsofvalue•  Toequipthemwithimprovementsciencetools•  Toprovideleadershipdevelopment•  Toeducateonchangemanagementconcepts•  Toprovidebasicsonorganiza;onalstrategyandgoals•  Todemonstratehowtouseandinves;gateins;tu;onaldatae.g.Vizient•  Tohelpfosterresearchandpublica;oninqualityimprovement•  Tosupportselec;onanddevelopmentofaprojectonwhichtoapplytheseskills

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Program Structure

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Day

1Day

2

Day

3Day

4

§  QualityandLeanIntroduc]on

§  SystemThinking§  A3andPDSA§  ProjectSelec]on

§  ValueStreamMap§  RunCharts§  RootCauseAnalysis

§  ChangeManagement§  Innova]on§  StakeholderAnalysis§  Leadership

§  Publica]on§  Benchmarking§  Sustainability

AdultLearningprinciplesIncludinggameandsimula;ons

1:1coachingsessions

DataSupport

Introduction to the program

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Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

•  Selec;ngandscopingpoten;alprojects

•  Selec;ngandcalcula;ngprojectmetric(s)

QIPIday2QIPIday3

•  Formingprojectteams•  Mappingprocesses•  RootCauseAnalysis

•  Developingcountermeasures•  Implemen;ngcountermeasuresCommunica;ngtheprojectwithotherstakeholders

•  Re-measuringprojectmetrics•  Makingnecessaryadjustments•  Finalizingthepresenta;on

QIPIday1

Jul17

Aug17

Sep17

Oct17

Nov17

QIPIday4

Ongoingcoachinganddatasupport

CohortSelec]on

Sharingtheresultandlearnings

Educating and Inspiring our Staff - QIPI

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Crea;ngacollabora;veandposi;veoff-siteexperienceFastpacedlearningandapplica;onoftoolsInvitedguestspeakerstoenrichthelearningexperienceOpportuni;esforpublica;ons

Crea;ngacollabora;veandposi;veoff-siteexperience

Fastpacedlearningandapplica;onoftools

Opportuni;esforpublica;ons

Invitedguestspeakerstoenrichthelearningexperience

Summary of successful projects

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Dr.BrigneyDeClerckImprovingEMRU;liza;on/efficiency

indermatologyclinics

Dr.ArmandDorianAppropriate“Pa;entStatus”

Determina;onat;meofAdmission

Dr.JayHudginsImprove%oftransfusedcasesvs.

typeandscreenorders

Dr.BenjaminEmanuelImprovedoor;metoCT/MRI;mefor

strokepa;ents

Dr.JehniS.RobinsonImprovepa;entcycle;meinFamily

Medicineclinic

Dr.NaomiSchechterImprovingpa;enttransferstoNorris

Radia;onOncology

Dr.MichaelJohnsImprovePa;entthroughputin

OHNSclink

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Recognitions and presentations

Other QI physician engagement projects at KMUSC • CareDeliveryRedesignAmul;disciplinaryapproachleadbyhealthcareadministratorswithengagedphysicians,andsupportedbytheValueImprovementOffice•  SurgicalQualityImprovementOfficersAphysicianledprogram,fundedbytheDepartmentofSurgerywithnominatedsurgicalandanesthesiologyleads,supportedtoworkontheirownimprovementprogramswithfinancialcompensa;on.QIMentoringanddataanaly;cssupportprovided.

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Recipe for Care Delivery Redesign Steps:1.  AlignonBurningPlaxorm

2.  Iden;fyKeyOpportuni;es3.  GaugeReadiness&BuildCoreTeams

4.  EngageinCri;calReview

5.  CreateEnvironmentforChange

6.  FacilitateCross-Collabora;on7.  Sustain,Share,&Expand

KeyIngredients:q PhysicianChampionsq Mid-LevelProvidersq AlliedHealth

Professionalsq AncillaryServicesq Administra;veSupportq Execu;veEngagementq DataTransparencyq SharedVisionfor

Success

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1.AlignonBurningPlaiorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkAssessCurrentStateandBenchmarkEngageClinicalLeadersinthe“Why?”CreateASharedVision

Q+S+A $

OurSharedChallenge:

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1.AlignonBurningPlaxorm

2.Iden]fyKeyOpportuni]es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkUseDatatoDiscoverGapsIden;fyExis;ngImprovementsinProgressSelectFocusCohort

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1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkAssessReadinessforChangeIden;fyChampionsinKeyAreasAskWhoElseShouldBeInvolved

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1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri]calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkCombineClinicalandFinancialDataCri;callyReviewEveryDay,EveryCareDecisionIden;fyProcessFailuresAcrossDisciplines

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1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkAssembleImpactedStakeholdersCreateSafeSpacetoShareEncourageDifficultDiscussions

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1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora]on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkShareFindingsfromCri;calReviewsIden;fyCross-Func;onalTeamsLaunchShort-andLong-termImprovements

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1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkMonitorandSharePerformanceLearnfromSuccessesandFailuresCreateOrganiza;onalAwareness

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1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkShareFindingsfromCri;calReviewsIden;fyCross-Func;onalTeamsLaunchShort-andLong-termImprovements

Department of Surgery Quality Officers Program •  SupportedandfundedbyChairofSurgery•  Financialincen;ve•  SignificantdataandQIsupport• Onemee;ngamonthofgroup•  SomeQItraining•  Focusondevelopmentofleaders•  Financialcalcula;onstojus;fyROI• Celebra;onofsuccess

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DOS Quality Officers Desired Outcome

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Forumtosharequalitydata&ini]a]ves

Engage,mentor,&trainofficersonquality&

performanceimprovement

Leadandimplementquality&performanceimprovement

projectwithinthedivisionandscaletootherdivisions

1 2 3

Performance Improvement Process

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IDENTIFICATIONOFPROJECT

Regulations

QualityOutcomes

CostOperationalInefficiencies

Research

INVESTIGATION STRATEGY IMPLEMENTATION AUDIT/MODIFY/ITERATE REPORT

QualityOutcomes

CostOperationalInefficiencies

Research

Value=QualityCost

ProcessforPerform

anceIm

provement

(1yearTim

efram

e)

1 month 2-4 months 2 months 3-6 months 1 month

Using measurement and local data…to inform and drive improvement

• ProcessandOutcomedata• Crea;ngabuzz,acampaign,energy–thewishtobepartofsomething

•  Ini;alQItraining,followup,regularreviewandsharingwithstakeholders

• BasictraininginQItechniques,dataandsupport

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Sample Project: Increasing Efficiency & Decreasing Length of Stay

in Vascular Surgery • Hypothesis• Projectiden;fiedbysurgeons,engagedAQendingandDivisionChief•  Increasingiden;fica;onandearlymanagementofavoidabledelayswilldecreaselengthofstay–focusonpa;entswithO/Era;o>1day

• OverlappingprojectbetweenSurgicalQualityOfficersandCareRedesign• Results

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Current Process

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Proposed New Process for Workflow

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Surgical Quality Officers; Reflection -what we will do differently in the next

iteration •  InvolveAnesthesiology• Compensa;onlinkedtoaQendance• Projectsmoreclearlylinkedtoorganiza;onalgoals• Moreformal;meinQItraining•  Lessofa‘research”approachtodata,lessretrospec;veanalysis–moreuseofsamplingandruncharts

• GreaterinvolvementofhospitalQIdepartment• Morecelebra;onandpromo;onofsuccess50

We’ve shared our experience …. What does some of the research say….

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• Askdoctorstolead–mantrais“physician-led,data-driven,evidencebased”• Askdoctorswhattheywanttoworkon• Makeiteasyfordoctorstoleadandtopar;cipate• Recogni;onfordoctorswholead•  Supportformedicalstaffleaderswithcourage• Opportuni;estolearnandgrowGosfeldAG,ReinertsenJL(2010).AchievingClinicalIntegra;onwithHighlyEngagedPhysicians.Unpublishedmanuscriptin“MedicalEngagementtooimportanttobelektochance”ClarkJ.TheKing’sFund2012

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hPp://www.kingsfund.org.uk/sites/files/kf/medical-engagement-nhs-john-clark-leadership-review2012-paper.pdfhhPps://www.kingsfund.org.uk/sites/default/files/field/field_publicaOon_file/medical-engagement-a-journey-not-

an-event-jul14_0.pdf

Lessons from McLeod Hospital’s Transformation

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Consider Behavioral Economics

AnnInternMed2016;164:114-119

•  Improvingqualityispartofdoctorsprofessionaliden;ty-tappingintothiscanbeapowerfulmo;vatorforchange

•  Clinicianledqualityimprovementcanleadtogreaterstandardiza;on,moreequitablecare,greaterqualitycontrol,improvedpa;entsa;sfac;onandbeQerpa;entoutcomes

•  QImustbealignedwithresourcealloca;on,supportedbyprofessionaltraining,commissioningandregula;onandintegratedintoservicemanagement

•  QItobesustainablemustbeintegratedwithorganiza;onaldirec;onandresources

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www.health.org.uk

How do you get clinicians involved in quality improvement?

1.  Consideryourorganiza;onstrackrecord–emphasizewhythisprogramwillsucceed–howisitdifferent?

2.  Givedoctors;meandresourcestoac;velyengage3.  Explana;onsofthepurposeoftheprogramshouldbe

phrasedtoreflectpriori;esandconcernsofclinicians4.  Evidenceofefficacy–localevidencewillhelp5.  Externalexper;sewherepossibletoaddcredibility6.  Localprogramchampions(credibilitywithother

clinicians)7.  Managementinvolvement–inaposi;ontosupport

clinicians

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MedicalEngagementinorganisaOonwidesafetyandqualityimprovementprogrammes.

ParandetalQualSafHealthCare2010;19:e44

Seven Themes for Medical Engagement

Harness Passion • Whatistheirpassion,whatistheirclinicaldesire?•  Isittobethebestgastroenterologistever–howcanyouhelpthemgetthere?•  Tohavethelowestmortalityforsepsis–howcanyourQIworkgetthemthere?•  AskhowcanIhelpyou..bethebestdoctor…havethebestteam..savethemostpa;ents?

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In Summary • Wehavedesignedandledanumberofprogramswhichengageanddevelopphysiciansinimprovementleadership

• Wewillmodifythenextroundoftheseprogramsbasedonourexperienceandfeedback

• Wehaveseentangibleimprovements,ROIandjoyinworkincreaseforphysiciansandtheirteams

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THEKECKEFFECT

ENGAGEDPHYSICIANSIMPROVINGTHEQUALITYOFOURCARE

THANKYOU!