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Session #11 – Creating Physician Engagement

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Bryan Oshiro, MD Chief Medical Officer, Health Catalyst

Session #11 Creating Physician Engagement

Dr. Oshiro is currently the Chief Medical Officer for Health Catalyst. He is also currently an Associate Professor at Loma Linda University School of Medicine in Loma Linda, CA and was the clinical leader of the first quality improvement initiative at Utah’s Intermountain Healthcare, in the 1990s. Dr. Oshiro obtained his M.D. degree from Loma Linda University, where he also completed his residency in obstetrics and gynecology. He has participated in numerous multi-center trials and has published numerous articles and book chapters in the areas of quality improvement, perinatal infectious diseases and high-risk pregnancy conditions.

Dr. Spahr is a specialist in Pediatric Emergency Medicine and currently serves as the Director of Quality for the pediatric emergency department. Dr. Spahr was one of the clinical leaders in the design and implementation of a new electronic health record system and continues to lead the optimization of the EHR to improve patient care. Dr. Spahr is serving as a primary physician leader in the design and development of an enterprise performance management program. Dr. Spahr has been pivotal in engaging providers in change and adoption of a data driven culture with prioritized improvement areas.

Christopher D Spahr, MD Enterprise Quality Program Development Executive, Children’s Hospital of Wisconsin

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Learning Objectives

• To describe the importance of physician engagement in quality improvement (the “why”)

• To describe the challenges and barriers to truly have physicians lead quality improvement (“the what”)

• To identify strategies to enhance physician engagement (the “how”)

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Exercise Objective:  To build the tallest self-supporting structure with the contents of one box of Tinker toys.

1. Each group has exactly 3 minutes to plan their work.

2. During the planning phase, there can be no assembly  of parts, even for practice.  Pieces can be looked at and handled, but cannot be connected to each other.

3. At the end of the planning phase, all pieces go back in the box with the lid closed.

4. At the signal, you will have exactly 40 seconds to assemble your structure.

5. At the end of the construction phase, all team members will step away from their structure.  The structure must stand alone, without resting on any other object and without personal assistance, for 30 seconds.

6. Each team should attempt to draw upon the principles of team work and good management in planning and executing this assigned task.

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Healthcare RevolvesAround Physicians

Opening line…

“The words “alignment” and “coordination” have been tossed about as the government and the healthcare industry wrestle to provide more value for every healthcare dollar spent. Under those words, every strategy to fix the problem revolves around one thing: physicians.”

HealthLeader's Media Breakthroughs. Aligning Hospitals and Physicians toward Value. Dec. 2009. In collaboration with PricewaterhouseCoopers.

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Engagement matters

• 75-85% of the decisions that drive quality and cost are determined by physicians

• Gallup reported at one health system, outpatient volume increased +17.5 for engaged physicians in the top quartile for improved engagement.

• Disengaged physicians in the bottom quartile, their outpatient volume declined -11.7%.

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Gallup Business Journal “ what the doctor ordered” Sept 8, 2005

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The Challenge

• Almost every aspect of physicians’ lives is changing or seems uncertain

Autonomy

Income

Social stature

• Physicians are going through something akin to the stages of grief

Most are beyond denial

Many are stuck at anger

• How do we get these physicians to play a positive constructive role in the needed change?

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The Realities of Engagement

• The physician is at the center of health care delivery

Ordering drives most health care actions

Physician engagement is a key component to successful quality improvement (QI) projects.

• The physician's focus is primarily on their own practice or quality of care

The physician’s goal and hospital’s goals and incentives may not be aligned

Lack of commitment (time, support) to system improvements

• Personal responsibility for quality is powerfully engrained in physicians.

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Systems Issues

• Physicians are too busy

• Physicians are not compensated for their help

• Poor knowledge management support

• Malpractice issues

• Lack of meaningful measurements

• Poor data analytic support

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What Won’t Work

• Isolated simple measures combined with good intentions

Inspirational speeches

Appointing physicians to key leadership positions

Financial incentives for improvement

Sharing of best practices

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Maslow’s Hierarchy of Needs

Self-Actualiz-

ation

Esteem

Belongingness and Love

Safety

Physiological

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Focus on What We are Trying to Create• We spent too much time talking about what’s wrong

with healthcare

• We need to spend more time talking about what we are trying to create

• That future vision has to be something important and noble

It could be better for patients- and just might be great

It is more important than the concerns of any of us as individuals

To imply otherwise would be to mislead our colleagues

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First question: Engagement with What?• Traditional definition – extent to which clinicians see their own

futures as intertwined with those of larger organization

Want MDs to be “loyal” with referrals

Want them to be cooperative

• Needed- a modern concept to unlock transformation of healthcare

More than agreement not to sabotage – but to actually integrate care, be creative, and relentlessly push for better outcomes/ experience and efficiency

Engagement with other care givers in real teams

Engagement with community of colleagues so that peer pressure actually works

Engagement with greater goals of organization

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Roger’s Adopter Categories

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Stages of Engagement

Aversion Apathy Engaged

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Levels of Physician Engagement

• Confidence: Physicians believe that the hospital can always be trusted to consistently deliver on it’s promises.

• Integrity: Physicians believe that the hospital always treats them fairly and will satisfactorily resolve any problems that might occur.

• Pride: Physicians feel good about using the hospital and hospital use reflects upon them.

• Passion: Physicians view the hospital as irreplaceable and as an integral part of their lives and their practice of medicine.

Gallup Business Journal “ what the doctor ordered” Sept 8, 2005

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Audience participationPoll Question 1

Which stage best describes the engagement level of the majority of physicians in your organization?

a. Aversion

b. Apathy

c. Engaged

d. Unsure or not applicable

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Scenario 1

• Situation: Hospital management wants to implement a quality initiative to decrease the rates of Elective Deliveries before 39 weeks.

• Background: Other initiatives were imposed on physicians which changed their work load and work flow through increased documentation and time burdens on the MDs. The programs were generally not successful and caused tension and mistrust of administration.

• Setting: A hospital administrator is trying to get convince physicians on board with this program.

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Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)

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Discover Common Purpose

• Improve patient outcomes

Primary focus of your aims

“Wisconsin kids will be the healthiest in the nation”

• Reduce hassles and wasted time

• Understand the organization’s culture

Improvement Readiness Assessment

If possible, learn from efforts in other areas

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Reframe Values and Beliefs

• Make physicians partners, not customers

Make them part of the decision making

Enterprise Performance Management Plan

• Promote both system and individual responsibility for quality

System-wide improvement structure, process, and plan

All key stakeholders involved

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Audience ParticipationPoll Question 2

How well do you feel the physician and health system goals are aligned in your organization?

a. Not aligned

b. Somewhat aligned

c. Moderately aligned

d. Very aligned

e. Extremely aligned

f. Unsure or not applicable

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Scenario 2

• A follow-up meeting occurs with physicians where data is presented showing a lack of compliance with the 39 week elective induction program.

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Engage the Physicians’ Intellect

• Show them the evidence and be transparent about the data

Utilize tools like the KPA to provide direction and then perform deeper investigation

• Show them what others have achieved

Look outside your system

• Show them you can do the same!

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Segment the Engagement Plan

• Identify and activate champions

• Educate and inform structural leaders

• Develop project management skills

Provide support and education

• Identify and work with “laggards”

Allow for review of improvement ideas or tests of change

One on one meetings with trusted colleagues

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Use “Engaging” Improvement Methods

• Standardize what is standardizable no more

• Use data sensibly

Focus on system performance first

• Make the right thing easy to try

Address the perfectionist culture

Agile project management

• Make the right thing easy to do

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Show Courage

Provide backup all the way to the board

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Adopt an Engaging Style

• Involve physicians from the beginning

• Identify real leaders, early adopters

Director, CMO, Chair, senior physician

Opportunities for career growth

• Choose messages and messengers carefully

We will function as a system

• Make physician involvement visible

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Adopt an Engaging Style

• Reward the efforts of the Physician Champions Reimburse for their time Clinician-Administrator promotion track Maintenance of Certification

• Build Trust within each quality initiative

• Communicate candidly, often Call a time out

• Value physicians’ time as equally as any

hospital executives’ time

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Physician Contracts• Hospital will provide support for percent of physicians’

time

• In return, physician will do the following:

Monitor and improve quality

- Implement CHF bundle and CLABSI toolkit

- Hold regular meetings with team

- Involve other members of Medical staff in quality

- Report CHF bundle compliance and CLABSI rates and learning from defects results to senior leaders and board

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Physician Contracts - continued

• Furthermore, physician will do the following:

Work with hospital to clarify what will be measured, who will measure it, and who will produce reports

• Meet quarterly to discuss progress

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Action Plan

• Cultivate a healthy and safe culture for physicians

• Create a shared vision

• Create a support structure and align resources• Administrative support• Data analytics and reporting• Training

• Develop communication and education plan

• Listen to physicians concerns and answers concerns in a timely fashion

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Audience participationPoll Question #3

Which of the action plan steps do you feel would be the most important in your organization to increase physician engagement?

a. Cultivate a healthy and safe culture for physicians

b. Create a shared vision

c. Create a support structure and align resources

d. Develop communication and education plan

e. Listen to physicians concerns and answers concerns in a timely fashion

f. Unsure or not applicable

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On the Journey Together

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Analytic Insights

AQuestions &

Answers

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Session Feedback Survey

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1. On a scale of 1-5, how satisfied were you overall with this session?1) Not at all satisfied2) Somewhat satisfied3) Moderately satisfied4) Very satisfied5) Extremely satisfied

3. On a scale of 1-5, what level of interest would you have for additional, continued learning on this topic (articles, webinars, collaboration, training)?

1) No interest2) Some interest3) Moderate interest4) Very interested5) Extremely interested

2. What feedback or suggestions do you have?

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Upcoming Keynote Sessions3:45 PM – 4:40 PM

13. Healthcare Reform 2.0: Anticipating What’s NextGovernor Mike Leavitt Founder and Chairman of Leavitt PartnersFormer Secretary of the Department of HHS

4:45PM – 5:15PM - Speakers Corner

5:15PM – 6:00 PM - Reception

6:00PM – 7:00 PM - Dinner

7:00PM – 8:00 PM

14. The Acceleration of Technology In The 21st Century: Impacts on Healthcare and Ray KurzweilChairman, Kurzweil TechnologiesDirector of Engineering, Google

8:15 – 9:00 PM - Entertainment

Location

Main Ballroom