The Michigan Primary Care Transformation (MiPCT) Project Physician Champion Program April 8 th, 2015 1

The Michigan Primary Care Transformation (MiPCT) Project

Physician Champion ProgramApril 8th, 2015

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The Leadership Challenge: Deloitte’s Global Human CapitalTrends 2014

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Companies cite four issues as the most urgent

1. Leadership,2. Retention and engagement,3. The re-skilling of HR, and4. Talent acquisition and access.

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Building leadership capabilities

•By far the most urgent issue: ▫38 percent of all respondents rated it

“urgent.” In a world where knowledge doubles every

year and skills have a half-life of 2.5 to 5 years, leaders need constant development.

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Where leadership development programs fall short

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The Leadership Challenge

•Researchers/authors Kouzes and Posner

•Million leaders•Worked backwards from great

team achievements•Identified characteristics and

practices

Leadership Characteristics

•“What qualities do you most look for and admire in a leader, someone whose direction you would willingly follow?”

The survey says . . .

•HONEST 88%•FORWARD-LOOKING 71%•COMPETENT 66% •INSPIRING 65%

• Source: Kouzes & Posner, The Leadership Challenge, 3rd edition, 2002

Research on Structure and Culture in Modern Primary Care

•Practices are highly individual and personality driven enterprises▫Split deeply between physicians and staff

•Embracing Radical Changes (PCMH or EMR)▫No fundamental redefining of roles or creating different

hierarchy within practice

Health Affairs 29,No. 5 (2010) 874-879

Field Study of Three Primary Care Practices-2010•Observations and Structured Interviews by

Professional Anthropologist▫A solo Practice▫A certified PCMH▫A multi-physician academic practice

How Teams Work-Or don’t-In Primary Care

Benjamin J. Chesluk and Eric S. Holmboe


Study Results

•Practice team operates in separate social silos▫Different experience of time, space, and work within

the practice▫Isolates Physicians from staff▫Disorients patients


Physicians—The Frantic Bubble•Series of non-stop, one-on-one interactions with a

stream of patients, •“Fictive Schedule”

▫ The”real” schedule in physicians’ heads was informed by their knowledge of the actual patients.

•Not nearly enough time during office schedule to do routine documentation ▫ Several hours in evening to catch up

•Extraordinary diversity of patients and complaints▫ Physicians presented calm, friendly faces to all patients

•Handled each visit essentially alone▫ Minimal Verbal exchange between physician and staff


Practice Staff—The Flexible Team

•Practice Staff work in more flexible and collaborative manner▫Collective work ebbed and flowed

•Staff would “team up” in groups▫Handle a host of jobs

Greeting patients Answering phones Scheduling visits Preparing charts Rooming patients


Patients—In Limbo

•Even more isolated than the physicians•Long wait times

▫Unpredictable, open-ended periods of waiting In designated public areas, In cold, sparse exam rooms, Sometimes partially clad in thin gowns

•Left confused and disoriented at the end of visit▫Left to sort things out for themselves▫“Where do I go now?”


Meetings

•Physician meetings▫Discuss practice from clinical and business standpoint▫How to tweak flow of patients and information▫Non-physicians absent from meeting

•No regular meetings with staff and physicians


The Evolving Culture of Medicine • 20th Century Characteristics

▫ Autonomy▫ Solo Practice▫ Continuous learning▫ Infallibility▫ Individual Knowledge

• 21st Century Characteristics▫ Teamwork/systems▫ Group practice▫ Continuous improvement▫ Multidisciplinary problem

solving▫ Change

Shine, KI. Acad.Med. 2002;77:91-99

TransforMED Recommendations •Medical home requires more than just the four pillars and

technological support ▫(four pillars: access, comprehensive care, coordination of care,

relationships over time) • In addition, it requires a strong organizational core (material

and human resources, organizational structure, clinical process) and adaptive reserve (healthy relationship infrastructure, an aligned management model, facilitative leadership). Crabtree et al, Summary of the National Demonstration Project and Recommendations for Patient-Centered Medical Home.Ann Fam Med 2010: 8 (Suppl

1) S80 – S90

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What have we learned?

•The experience of practice transformation has noted that the harder changes such as team involvement in care or redesigned clinical visits are those most likely to change performance indicators.

•This requires that providers will need to move towards facilitated leadership skills and away from authoritative ones

Facilitating Change: Lessons from the TransforMED National Demonstration Project, AHRQ 2009 Annual Conference, Sept. 14, 2009, Elizabeth E. Stewart, PhD, Independent Evaluation Team from Center for Research in Primary Care & Family Medicine

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What have we learned?

•Practices that never get started have leadership that is either ineffective or opposed to change.

•Practices that transformed have Adaptive Reserve – the ability to learn and change.

•Key feature of adaptive reserve is unified leadership that can:▫envision a future,▫have a strategy for getting there,▫facilitate staff involvement, and▫devote time to make and evaluate changes

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Crabtree et al, Summary of the National Demonstration Project and Recommendations for Patient-Centered Medical Home.Ann Fam Med 2010: 8 (Suppl 1) S80 – S90

Qualities of Physician Leadership •High performers in the organization, •Respected by colleagues for their

integrity and conduct within the group, •Possess the ability to influence others

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Practicing Excellence. A Physician’s Manual to Exceptional Health Care. Stephen C. Beeson, MD. 2006 Studer Group LLC.

Health care

•Need more effective models of care delivery▫Stubbornly high costs ▫Expected care needs of aging baby

boomers

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Leading Clinicians and Clinicians LeadingRichard M.J. Bohmer, M.B., Ch.B., M.P.H.NEJM 368;16 nejm.1468 org april 18, 2013

Successful implementation of Care Delivery Models •Depends on two local factors:

▫Effective care teams▫Good management of local operations

(“clinical microsystems”).•Clinicians influence both of these

factors▫Prospects for care redesign and

performance improvement depend on clinician leadership

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Informal Leadership•The need for leadership by clinicians deeper

in the organization — usually without any formal title, authority, or leadership job description— is increasingly recognized.

•Clinical microsystems are composed of and controlled by frontline clinicians whose primary work is patient care. Although many have little interest in leading, the success of health care reform depends on them.

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Front-line clinicians leading localsystems have four key tasks.•Task 1:

▫Local leaders must help identify care goals that unify diverse multidisciplinary teams and align these with the patient’s health goals, the local environment’s financial demands, and the wider organization’s mission.

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Front-line clinicians leading localsystems have four key tasks•Task 2:

▫Local clinical leaders speak and act to help define local team culture The team’s culture guides decision making

where protocols fail to provide appropriate variation and encourages compassion in technical settings.

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It’s All About Culture

Culture eats strategy every day.

Until we address it and change it, culture may remain the

downfall of our system design and improvement efforts.

Charles M. Kilo, MD, MPHFellow, Institute for Healthcare ImprovementCEO, GreenField Health

Efforts Toward System Improvement are Thwarted by Our Culture

Physician practices created to maintain

individual rights (Autonomy)

Change capacity essential to

execute strategy

Courtesy of Jack Silversin

Culture: Mismatched “Promise” And Imperatives

Autonomy

Protection

Entitlement

Teamwork (interdependency)

Improve quality

Deliver service

Reduce costs

Attract & retain staff

Traditional “Promise” Imperatives

Jack Silversin

Creating a Facilitative Leadership Culture

• Communicate to all staff-- make a compelling case

• Describe how it will be better • Describe the plan for making the

change happen • Contributions and expectations

from all • Welcome open and constructive

“resistance” • Create a solid and realistic plan

“The culture of an organization is a reflection of the values of its leaders. Thus, cultural transformation begins with the personal transformation of the leaders”

From “Building a values-driven organization” Richard Barrett

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▫The clinical leader’s third task is monitoring system performance. Reviewing aggregate process and outcome

data and influencing others’ behavior Detailed population-specific data and un-

blinded peer comparisons discussed in small groups can help reduce inappropriate variation and improve quality and efficiency.

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▫Improving performance. Clinical leaders must model the combination

of humility, self-doubt, restless curiosity, and courage to explore beyond accepted boundaries that drives organizations to relentless improvement despite colleagues’ preferences for stability and familiarity.

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Clinical leadership of expertpeers involves:•Inviting the team to define its purpose

and design the most effective way of achieving it.▫Leaders create an appropriate

environment, guide the conversation, and occasionally choose among competing options.

▫Clinical leaders are simultaneously part of the team and apart from it.

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Informal Authority

•Without formal authority, the only tool that clinical leaders have is their behavior:

•What they say, how they say it, and how they model good practice. ▫The choice of language

Expressing the team’s purpose in terms of creating value, curing disease, preventing harm, and caring for patients

▫The tone of voice is also an essential leadership tool.

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Leading peers in the four key tasks requires asking questions:•“What are we trying to achieve?”•“What is the best way to achieve it?” •“Are we getting the desired results?” •“What can we do to get even better

results?”•“Are our systems keeping patients safe?”

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Clinicians want a greater leadership role

•Surveys suggest that clinicians want a greater leadership role but feel unprepared or disempowered.

Gilbert A, Hockey P, Vaithianathan R, Curzen N, Lees P. Perceptions of junior doctors in the NHS about their training: results of a regional questionnaire. BMJ Qual Saf 2012;21:234-8.

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Resources needed for Clinical Leaders •Data

▫Data remains the single most important motivator and tool for a clinical leader. High-quality, comparative, unit-level and

individual- level clinical and financial data can both create the need for clinician leadership and be the starting point for the four tasks.

•Protected time, •Training and mentorship•Clear organizational expectations of clinician

performance.

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How can MiPCT enable and encourage front-line leadership among today’s clinicians?

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PO Physician Champion Role (one per PO)

•2015 Contract Expectations:▫The intent of the PO Physician Champion as

per the contract, is to communicate with the physicians in the PO and practice about team care and the PO/practices’ deployment of the MiPCT clinical model. This includes the PO and practices’ work on

clinical focus areas, practice learning activities, care management oversight and support, etc.

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Physician Champion Leadership Training (Open to All Interested MiPCT Physicians)•2015 MIP CT learning activity requirements:

▫Physician champion leadership training (4 hours). This option consists of physicians to physician training and best practice sharing that supports team based care and embedded care management.

▫Plan to provide Webinars What are you currently doing with physician

leadership training? What would be helpful for physician leadership

training?

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Documents

The Michigan Primary Care Transformation (MiPCT) Project Physician Champion Program April 8 th, 2015 1