Discovering a Common Purpose: Creating Physician Engagement (Webinar)
Discovering a Common Purpose: Creating Physician Engagement
Bryan T. Oshiro, MD Chief Medical Officer, Health Catalyst
March 11, 2015
Learning Objectives [00:01]
[Dr. Bryan Oshiro]
Thank you so much. Today, we’d like to go over the following learning objectives – One, to describe the importance of physician engagement in quality improvement (the “why”); Number two, to describe the challenges and barriers to truly having physicians lead quality improvement (the “what”); and finally, to identify strategies on how to enhance physician engagement (the “how”).
Best in the World! [00:46]
Well first of all, I think most Americans would agree that we provide the best care possible anywhere in the planet. And most American hospitals and physicians do provide safe and effective care for the vast majority of patients, for the vast majority of times. And in fact, if you look at world leaders, where did they go to get their care? Italian Prime Minister Silvio Berlusconi decided to come to the Cleveland Clinic when he had his heart operation. The late King Hussein of Jordan, when he needed to get treatment for lymphoma, where did he go? He came to the United States. Our ability to provide safe, effective care is nothing short of miraculous.
But are We? [01:35]
But sovereign news is that perhaps we’re not the best at providing equitable care across the continuum. A very enlightening and dire note was published in the 1999 Institute of Medicine report that estimated that 48,000 to 98,000 Americans die in hospitals from preventable errors. It was noted by Berg in 2005 that up to 40% of all maternal deaths in the United States may be preventable. More people die from hospital-based preventable medical injuries than from breast cancer or AIDS or motor vehicle accidents. Injuries from drive direct health care costs totaling approximately $9 to $15 billion per year.
American health care “gets it right” 54.9% of the time [02:31]
And in a survey by McGlynn, et al, published in the New England Journal of Medicine back in 2003, they did an extensive poll of patients and they found that in reviewing the patient’s care that we get it right 55% of the time.
Where do we rank in health and wellness world wide on the social progress index? [02:50]
So, our first poll question. Where do we rank in health and wellness world wide on the social progress index? A) Top 10; B) 11 to 25; C) 26 to 50; or D) Greater than 50.
Alright. Well, we have that poll open. Dr. Oshiro, we’ll leave that open for a few moments to allow everyone to answer this. And we would like to remind everyone that you can enter your questions and comments in the questions pane on your control panel.
Alright. We’re going to go ahead and close this poll now and take a look at the results we have.
Social Progress Index: 2014
Health and Wellness [03:30]
So everyone who voted on this poll, we’ve got 4% said at the top 10, 22% 11 to 25, 54% 26 to 50, and 21% at greater than 50.
[Dr. Bryan Oshiro]
I was very much surprised at the results of this social progress index scale. And as you can see on this screen that we came in ranked at 71. Needless to say, ranking above Burkina Faso or the Czech Republic wasn’t really encouraging to me.
Life Expectancy at birth: 1970 and 2011
OECD Health Statistics 2013 [04:12]
Life expectancy at birth back in 1970, which is represented by the black diamond there, we were near the top for life expectancy at that time. But since that time, we are now below the median value for OECD health statistics for 2013. So we’ve slipped a bit compared to other countries that are in the developed world.
You get what you pay for!?
Per capita health expenditure, 2011 [04:40]
And what do we get for all of this money that we’re spending? And if you can see here, that the United States ranks first in the world as far as per capita health expenditure. This is approximately two and a half times the average for the industrialized countries.
U.S. Healthcare Spending [05:03]
U.S. healthcare spending continues to increase. So, not only are we first but the pace at which we’re growing, as far as healthcare expenditures, is also rapidly outpacing the rest of the world.
What We Pay For… [05:18]
Healthcare Revolves Around Physicians [05:19]
So this is a major issue, how do we pay for healthcare in the United States? This affects each and every one of us. It has been noted that approximately half of the $2.9 trillion that’s spent annually in healthcare expenditures in the United States can be saved by taking out wastes from the system. And if we do, then we can probably salvage the treasures for our future generations to come.
And the reason why we’re talking about physician engagement today is because of the importance of physicians in everything that we do, as far as healthcare is concerned. So, if you look at whatever processes that happened within and without the hospital walls, in the clinics, at home, much of what we do, as far as health outcomes is concerned, is really under the perusal guidance of the physician. So under those worlds, every strategy to fix the problem revolves around one thing – physicians.
Engagement matters [06:29]
So engagement really matters. And if you look at this report, 75% to 85% of the decisions that drive quality and cost are determined by physicians. A Gallup report showed that at one health system alone, outpatient volume increased 17.5% for engaged physicians in the top quartile for improved engagement. Disengaged physicians in the bottom quartile, their outpatient volumes declined by -11.7%.
Physician Engagement and The Bottom Line [07:00]
And this is outlined in this report here in the Gallup Business Journal.
The Challenge [07:07]
The challenge is that although almost every aspect of care as determined by physicians, that lives and impact to the physicians are also changing and not necessarily for the better. So, physicians are challenged because of the changes through their autonomy, possible changes through their income, and their social stature. Physicians are going through something that came to through the station of grief and most are beyond the denial stage and many are stuck at the anger stage. So, how do we get the physicians to play a positive and constructive role needed for this change?
Systems Issues [07:55]
And these are some of the systems issues that we face today as physicians. Physicians are too busy, physicians are not compensated for their help, they have poor knowledge management support, there are malpractice issues to consider, there’s lack of meaningful measurements, and there’s poor data analytic support.
Back in the late 1990’s and early 2000, when I was working at Intermountain Healthcare, we had a guidance from the administration who was now mainly physician led that said we have to do patient care better. By improving the processes, we can not only take care of patients better. We think that the bottom line for the hospital system as a whole will be impacted positively. At that time, it was just a grand experiment, and we needed physicians to get on board. But it was very difficult to do that. They didn’t see that it was in their best interest, why would they come to the plate. But with encouragement from above and the support, we were able to make extremely drastic changes to it and how to deliver care to the betterment of patients.
Barriers to Strong Physician Engagement [09:08]
So some of the barriers to strong physician engagement include physicians that’s overwhelmed and ill-equipped and have limited understanding of how their behavior contributes to healthcare waste and inefficiency. Providers and payors are focusing only on employment as a means to get physicians to be engaged. Organizations over-weigh the importance of compensation to influence physician behavior, and physicians have a poor understanding of risk-based payment models themselves.
Our doctors are ___ to participate in QI at my hospital or clinic? [09:38]
And this was done from a survey. It came from a survey from the Mckinsey Physician Survey back in 2011. And I found this to be true, that we are so overwhelmed. I remember when we first converted over to a new electronic medical record system at my hospital that not only were we spending hours beyond the 5 o’clock clinic deadline, but because of the new information system, we were actually spending two to three hours beyond the clinic just to document things. It’s gotten a little bit better, but nonetheless there’s a lot of patients to be seen and the documentation requirements seemed to be overwhelming.
In addition, most places do not have the luxury of being employed as a physician. And we are a community-based and so forth, so this model really doesn’t work for many places. And there’s not enough money in the system right now to compensate physicians to influence their behavior, and in fact, this is really not a great lever for most physicians. And most physicians are not business people, and so the last item there is very true.
So this is our next survey question. Our doctors are ____ (not willing, somewhat willing or very willing) to participate in Quality Improvement at my hospital or clinic.
Alright. We’ve actually got that poll open right now and we’ll leave that open for a few minutes to give everyone a chance to answer that. It looks like we’re getting in some great questions. I would like to remind everyone that you can input your questions into the control panel.
Alright. We’re going to go ahead and close this poll and let’s share the results.
It looks like we’ve got a vast majority, 79%, at somewhat willing.
MD Willingness to Change:
Removing Waste from Healthcare System [11:40]
[Dr. Bryan Oshiro]
Okay. From that same McKinsey Physician Survey in 2011, it seems that the majority of physicians are willing to change to remove waste from the healthcare system. Of course, it depends on where that is. If it’s an ineffective discharges versus medical device variability, there were some differences as far as how willing they were.
Physicians Likely to Change (%) [12:08]
And how likely they were to change based on evidence-based medicine or tracking or cost-savings was very similar. When we instituted changes, for example, as our first project with clinical integration programs at Intermountain Healthcare, we decided that there were too many elective deliveries that were occurring before 39 weeks. Many of the physicians looked at this and said, “It really isn’t a problem for us.” And they were only likely to change because we showed them the evidence that A) that there was a problem within the system that we did have too many of these patients that were being delivered early; and B) when we showed them the data that the units were being harmed by this practice, only then that they were likely to change.
So if it is due to something that has to do with patient care, that we can help them make patient care safer, physicians are more likely to respond positively. If it was only because of cost benefit to the hospital, they weren’t so much interested because that really didn’t drive their behaviors.
Stages of Engagement [13:22]
But going back to where we are in the stages of grief, and as far as engagement, these are sort of the things that’s more or less people go through – that physicians are no different. They either don’t like change, so there’s an aversion to it, then they say, “Well, okay, I really don’t mind the changes but then I’m really not enthusiastic.” And only after a lot of education and a lot of commitment do they get to the engaged stage but they have to see value in where this is going.
Audience Participation [13:57]
So the next poll question is, which stage best describes the engagement level of the vast majority of physicians in your organization? A) Aversion; B) Apathy; C) Engaged; or D) Unsure.
Alright. We’ve got that poll question open. We’ll leave this open for a few moments to give everyone a chance to respond to this. If anybody has any questions or comments, and we’re getting some good ones in. I’m very excited. We will be answering those, again, during the questions and answers period of the presentation.
Alright. We’re going to go ahead and close the poll now. And let’s share the results. We’re showing 12% aversion, 40% apathy, 22% engaged, and 26% unsure or not applicable. Any comments on that?
[Dr. Bryan Oshiro]
Boy, that really is pretty much what we see across the board when we go to different hospitals for our work, is that we really don’t see a lot of engagement. We see a lot of apathy. So this is quit reflective of the type of hospitals that we’ve been visiting.
Levels of Physician Engagement [15:09]
So, when hospitals do these following things, then the engagement increases.
Confidence – physicians believe that the hospital can always be trusted to consistently deliver on its promises. This is really important because this is a matter of trust. And so, if the hospital has not been trustworthy as far as delivering on commitments in the past, such as we promise to open up OR slots so that we can have more time for your patients to have surgeries performed in a timely fashion, or we promise to have simple things such as a place for our physicians to gather, a physician lounge for example, and it’s delivered on time and so forth. Those are very important aspects of creating confidence and trust.
Integrity – physicians believe that the hospital always treats them fairly and will satisfactorily resolve any problems that might occur. Again, this is another indication of trustworthiness and pride. Physicians feel good about using the hospital and the hospital use reflects upon them. So this is a matter of building up the services that support great patient care.
Passion- physicians view the hospital as irreplaceable and as an integral part of their lives and their practice of medicine. Sometimes hospitals are more involved with trying to make the bottom line work so that they are cutting services and so forth and so physicians don’t feel that this is an irreplaceable place, an integral part of their practice and so forth.
The best level to engage physicians in QI is to? [16:49]
Another question. The best lever to engage physicians in Quality Improvement is to? A) Place doctors in leadership positions; B) Employ them; C) Create financial incentives; or E) None of the above.
Alright. We’ve got this poll question up right now, Dr. Oshiro. Best lever to engage physicians in QI is to – place doctors in leadership positions, employ them, create financial incentives, or none of the above? We’ll leave this open for just a few moments to give everyone the opportunity to respond to this poll question.
Alright. We’ll go ahead and close that poll question. Let’s share the results.
Everyone responded. We’ve got 33% responded as placing them in leadership positions, 10% employ them, 27% create financial incentives, and 30% none of the above.
[Dr. Bryan Oshiro]
Well this really wasn’t a fair question and I just put it up there just to get input from the participants and so forth.
Weber’s Motives of Social Action [17:53]
If you look at what motivates and drives people to do social change, we can look back to Weber’s Motives of Social Action. And what he said was there are four things, four levers that we need to work on, and in actuality, any of them in isolation really doesn’t work. So we want to have shared purpose. So if we’re going to do something for the country, for example, or if we’re at war, we have a shared purpose, we have a common enemy. So we’ll do something for the country.
Similarly, if we’re going to get physicians involved at the hospital level, there has to be some sort of shared purpose and that shared purpose really is not about financial issues, although that does appeal to the self-interest, the second thing there. It’s not that you should ignore that because that’s also important, but the shared purpose really has to revolve around patient care.
And earning respect, both parties have to have a respect. The hospital has a reputation and the physician themselves have to feel that they are doing something that is worthwhile and that people can look up to them. And finally, there is a tradition involved in many facilities, for example, if there’s a longstanding tradition, how we act or portray ourselves within the medical community or a particular facility. That goes a long way. So these four levers themselves work together.
Engaging Physicians in a Shared Quality Agenda
Now, another way to look at that is actually published in engaging physicians in a shared agenda by IHI and they looked at six things here. So, in order for a great engagement of physicians, they reformatted those four levers into these six. So 1) Discover common purpose; 2) Reframe values and beliefs; 3) Segment the engagement plan; 4) Using “engaging” improvement methods; 5) Show courage; and 6) Adopt an engaging style.
So we’ll go over these one by one.
Discover Common Purpose [20:08]
Discover common purpose. I said it before but it can’t be overemphasized. It has to be number one and foremost that we’re going to do what’s best for the patient. This is what drives physician base. If you ask a physician to perform emergency care on somebody that fell on the street or in the time of disaster, physicians aren’t going to say, “Well what’s in it for me?” We are trained to care for patients. That’s the entire purpose of why we became doctors. It’s not to make money. It is to care for patients and to make lives better for patients around us. So this has to be the primary focus of whatever we do at hospitals or facilities or anywhere that engages physicians. Work on that aspect of it.
Another thing is that we can’t do it and ask physicians to increase their time, increase their busyness or activities. We have to be very cognizant that we do it in a very efficient way. And we have to understand the organization’s culture. We just can’t go over there and just ask people to do things without understanding the culture of the local organization.
So, you have to understand, our physicians, nurses, caregivers, and the hospital administration, are we ready? And maybe we have to do a readiness assessment. And if possible, we have to learn from efforts in other areas, not only just in other hospitals but in other areas of other industries that have done this as well.
And we have to understand the legal opportunities and barriers that have taken place. Physicians right now are very worried about getting sued, and although it may not be in the forefront, there’s always this tendency to over-order tests, over-order procedures and so forth and this has to be addressed.
Reframe Values and Beliefs [22:02]
We have to reframe our values and beliefs. Make physicians partners, not customers. Many times what I see is that the hospital administration looks at appeasing physicians because they look at physicians as customers. But I think we have to redirect where we have our emphasis. We have to partner with physicians, partner with the hospital to make care better for the patients. Again, it’s where is our focus. And we have to promote both system and individual responsibility for quality. Personal responsibility for quality is powerfully engrained in all physicians. We do what’s best for our patients. When we see a patient and we want to spend 20 minutes because we feel we need to, we’ll spend 20 minutes, even though we are going to get locally behind the rest of the day. Personal responsibility for quality is very much engrained in what we do each and every day.
How well do you feel the physician and health system goals are aligned in your organization? [23:00]
So, audience participation question again. How well do you feel the physicians and health system’s goals are aligned in your organization? A) Not aligned; B) Somewhat aligned; C) Moderately aligned; or D) Very aligned.
Alright. We’ve got that poll up. We will leave it open to allow everyone to answer the questions. I would like to remind everyone, if you have questions or comments, you can enter those into the questions pane on your control panel. We’ll leave this open for just a few more seconds.
Alright. We’re going to go ahead and close this poll now. And let’s take a look at the results.
Alright. We’ve got 8% as not aligned, 53% answered somewhat aligned, 35% as moderately, and 4% as very aligned.
[Dr. Bryan Oshiro]
This is actually very good because there is some synergy here at your facilities, from what you’re pointing out, that at least there is a common goal and a common purpose. It may not be great in some, it may be better in others, but at least this is a starting point.
Segment the Engagement Plan [24:06]
And another anecdote is that there was resistance to having universal bilirubin screening at our hospitals and the pediatricians, and in fact, one of the main pediatricians that practices at one of our larger hospitals, very well respected, been practicing a long time, did not see the need for universal bilirubin screening. He thought that his clinical acumen was such that he can identify this quite readily.
So after we instituted universal bilirubin screening and so forth and with his resistance, it was quite a problem. But one day, after universal screening was implemented, one of his patients who he had just examined that morning and whose results came in later that day indicated that this baby had very high bilirubin levels. And he went back and thought that was an error, repeated the test, and looked at the baby, he could not see a difference and could not identify that this baby had high bilirubin levels. Of course, if this baby had gotten home, there’s a potential that there could have been a problem. And after that, it was a wakeup moment for him that really engaged him in this process. And he became one of our champions.
So, it’s really because of the way that we crafted this program specifically about patient care that he was actively engaged and became a champion for us. And because of this physician within the community, he wasn’t the department chairman of pediatrics nor was he in any kind of management role, but he was influential. So when you have an engagement plan, it’s really important to identify and activate champions. Those champions may not have a title but they do have a position of influence within the community.
It’s important also to educate and inform structural leaders. Show them the evidence and be transparent about the data – because structural leaders, such as a department chairman or a medical director, has the authority given to them by nature of that position to influence change as well. And we need to develop project management skills in these leaders and we need to provide support and education not only for them but for the rest of the staff as well – because without that, physicians do not work well in an environment when there is not a lot of understanding about what to do.
Engage the physicians’ intellect. Allow for review of improvement ideas or tests of change. This goes along with Deming’s teaching of how to inform the line workers and so forth. It’s really interesting where in U.S. automobile plants of the past where line workers under Taylorism principles were just thought to be cogs in the wheel. The technicians and the engineers would design a car and the line workers were just supposed to be the extensions, the manual extensions of the thought process of management and so forth. But that turned out to be not a great thing. And when Deming’s ideals permeated through and with Toyota management, for example, in a GM plant in Torrance, California where they were struggling to improve their output for vehicles and to make quality vehicles, it had the reputation of being the worst car production plant in the GM family and all of the United States, they had high absenteeism rates. But when they asked Toyota management to take over running the plant, they brought in these ideals and management skills of teaching the line workers and why they were so important, understanding where they fit into the process, that plant turned around, and within two years, it’s producing the highest quality cars in the GM family, without firing a single person.
So it’s important again to engage the physicians’ intellect, to give them the understanding as to why they’re doing these changes.
Rogers’ Diffusion of Innovations [28:14]
Some people feel that you have to work on the laggard and so forth. But really if you look at Rogers’ Diffusion of Innovations, and many people have seen this already, is we really need the early adopters, and these early adopters, such as that pediatrician I talked about who was able to lead that early majority and pushed quality and innovation forward.
Less Effective Approach to improvement: “Punish the Outliers” [28:39]
And it’s less effective if you try to just cut out the poor outcomes performers because if you just do that, you really don’t raise the bar for everybody.
Effective Approach to Improvement: Focus on “Better Care” [28:49]
But if you get the early adopters to pull everybody forward, you actually tighten the curve and produce better change.
Use “Engaging” Improvement Methods [28:56]
Use “engaging” improvement methods. So what this refers to is it’s important as to how you do the change and how you get people on board. So today, we look at checklist and people have instituted certain pathways of care and people think, well this is just a cookbook medicine. But what we need to understand is that we should standardize what is standardizable and no more. And physicians need to understand that this is not cookbook medicine. This is something that we’re trying to do to engage them, to make them not waste their brain power, and if it falls outside of those 80/20 rule, that that’s where they really need to engage their brains.
And we need to use this data sensibly and focus on system’s performance first. For example, when we instituted an induction of labor protocol, we looked at something called the Bishop score which is sort of a readiness of the cervix to be induced, and physicians over time have wanted to induce patients for various reasons. But when we instituted this cervical check and we, number one, showed the data as to what the bright points were on the cervix scores from 0 to 13, 13 being the most inducible. And when we showed this across the board, the first thing that we showed them was that there was actually a difference between patients that had delivered a baby before and patients that were first-time moms. And we looked at it and it was quite evident that it really didn’t make a difference for the patients that had delivered babies before. So, being transparent, we took that away and said, “It really doesn’t matter. We don’t want to restrict you in this manner.” But because of that, because of the trust that was displayed, they looked at it and just said, “Gees, you guys really showed us the data and you said we shouldn’t worry about this, so you took that restriction away.” And they looked at the remaining data and they said, “Well, why are we looking at a Bishop score of 8, where that’s where the standard practice was from the American College of OB-GYN recommendations.” And said, “Our data clearly shows a bright point of 10.” And they themselves, because of the ability to look at what we had standardized process on, but they looked at it and they tweaked it on their own because they saw a better process. This is what happens when you engage physicians, they can engage their brains and we say, “All protocols are made to be changed and we do this in an open and transparent manner.” So we make the right thing easy to try and we change it as we go along. It’s not written in stone. So not only do we make it easy to try but we made it such that it was easy to do.
Build Trust [31:58]
Building trust – oh this is just so important. Again, I put the top bullet as the focus must be on the patient because it always should be. We talk about an actual preventable patient safety case but again, it has to be focused on the patient. We build trust within each quality initiative. We communicate often and candidly. We create a communication pathway. This could be through morbidity and mortality, conferences through Grandrounds or department meetings or quality meetings, etc. And we address concerns and issues in a timely and obvious manner. If there’s a problem with a pathway or if there’s problems with a standardized note or if there’s a problem with order sets or so forth and physicians bring it up, it shouldn’t be that we send it to a committee, it languishes in committees for months on and by the time changes come down, the situation has changed or people have forgotten about it. Identify and overcome barriers to engagement. Again, this has to be something that’s open, something that people can address things to, and that the administration and leadership within the organization are very responsive to. All these things go up to build trust.
Provide backup all the way to the board [33:17]
Finally, show courage. Sometimes it really isn’t safe for physicians to change because they feel like there’s no backup or support for what they do, or perhaps they don’t have the right resources. So this is something that is so important to really bring forth and say, “You know what, I support our physicians, I support the best practice of medicine, and I’m going to get resources.” So perhaps we need a better OR pack for a certain procedure or perhaps we need a different type of staffing for a night shift because that’s the best practice. And if you can show that this is something in the best interest of the patients and the physicians are there requesting this, it shouldn’t be an issue, even though it’s an increase cost upfront. It should be looked at as an investment and this is something that you should have a courage to do, no matter what your administrative role is, to go up all the way to the top of the food chain to ask for it.
Adopt an Engaging Style [34:24]
And again, adopt an engaging style. Physicians want to be involved from the very beginning and this as well is interesting when I worked at Intermountain Healthcare – is that physicians were asked not to cut costs, not to come in late, but ask this one particular question – how can you make care for the patients better? Because the underlying supposition was improving patient care is going to help us because by improving the care of the patient, we’re not going to make mistakes, we’re not going to have to do tests again and again, the patients are going to get the right care at the right time, in the right place, so that they are going to go home and not come back because we did something wrong.
We have to work with the real leaders and the early adopters. Sometimes we cater more towards the squeaky wheel or the nail that sticks up and we try to work on those, but really it’s getting the real leaders and the early adopters on board and then the early majority will come and follow. It’s not really good to work on the ones that are laggard and so forth because they may never come on board and spend a lot of energy. We can spend a lot less energy getting the real leaders and the early adopters to move the entire curve.
Choose your messages and messengers carefully. Again, even the same message can be given in a good way and a way that’s appealing, a way that’s not insulting, and a way that is very engaging. So this is another way that we really need to be careful.
Make physician involvement very visible. For some reason, we as physicians, we feel this camaraderie with other physicians, we feel it’s a closed club perhaps, but we should have it such that physicians are placed in leadership positions and that other physicians can see this and say, “Yes, administration is on our side and we can see this because we have Dr. Schmidt or Dr. Jones and we really respect them and they talk the same language as we do.”
We have to build trust with each quality initiative, in other words, sometimes there’s not a lot of input that physicians need to make but at least they need to touch it. And when they touch it, they feel ownership. They said, “Yes, we were involved.” So even if you don’t think that the physician needs to be because this is a supply chain issue, perhaps physicians can contribute to that.
We need to really communicate candidly and often. I just don’t remember a time in which I over-communicated but I tell you, there were so many times which I under-communicated and I really regret those times because it really came back to bite me.
And really value physicians’ time as your own time. The culture and the workflow of physicians is very much different from anybody else in the hospital because usually, whenever you have a meeting within the hospital, you have a staff meeting, nurses are paid to attend or administrators are paid to attend. But when you ask a physician to come to a meeting, remember, they have to take that time on either before clinic or during clinic hours and that’s where they’re making their money and it’s impacting their pocketbook and it’s impacting their ability to see patients and care for patients. So be very careful about the time commitment that you’re asking from your physicians.
Which do you feel would be the most important to increase your physician engagement? [37:48]
A poll question. Which do you feel would be the most important to increase your 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) Listen to physicians concerns and answer concerns in a timely fashion; or E) Unsure or not applicable.
Alright. We’ve got that poll question up right now. We’ll leave this up for a bit to give people a chance to read through every choice and select their answer. We have had a few questions come in about the recording of this webinar and the slides. We would like to remind everyone that shortly after this webinar, we will be sending out an email to all attendees and registrants with a link to the recording of this webinar, as well as a link to the slides and all of the results of these many poll questions.
Alright. Let’s go ahead and close this poll and let’s take a look at the results.
We’ve got 6% answered cultivate a healthy and safe culture, 41% create a shared vision, 33% create a support structure and align resources, 17% listen to physicians’ concerns and answer concerns in a timely fashion, and 3% answered unsure or not applicable.
[Dr. Bryan Oshiro]
Well, there really again isn’t a right or wrong answer for this. So, this is just to see what people’s responses were. But I think that the message is clear as we need to create a shared vision and we need to create a support structure and align resources. But the other ones were also valid as well.
So in summary, I would like to highlight these points.
People, including physicians, resist loss or possible or perceived loss, not the change itself. So it’s really important on how we message this and really to make sure that we address those questions that physicians have.
Again, most importantly, we have to create a shared vision – and that is to keep the patient as a “North Star”. Everything that we do within healthcare is, of course, to make it better for patients.
Thirdly, we have to identify real leaders and early adopters. These are the people that again make change happen within the hospitals, within the clinics, within the organization and so forth. So find these real leaders. Equipping them with the right tools, the right education, the right resources is highly important. You can’t do the job, even if you have somebody that’s very willing, if you don’t have the right tools.
Fourthly, you have to create a support structure and align resources within the institution to provide this infrastructure for change. So without this, it is really difficult even if you have the right tools and the right education as a leader to implement and go forth with change.
Fifthly, to try to surface and mitigate real and perceived loss. Again, this is something that is very important and it’s something that’s going to take a lot of discussion and a lot of contemplative thoughts. And this is not something that is a cookie-cutter issue that can be mandated for all hospitals or all situations and so forth. This is something that is very very much local.
And finally, you have to create trust. And so, whatever you promise, you should deliver on, and this will go a long way. Once you have one success and you deliver on what you said you were going to do, this will be a building block that will very much help you in the future.
On the Journey Together [41:40]
Thank you again for listening to this presentation. This is a long journey that we’re going to have to travel on together and now we’ll open it up for questions.
|What do you feel is the role that financial rewards should play in physician engagement?||It’s very interesting. Financial rewards are a very tricky subject. Physicians aren’t really driven by financial rewards, per se, to engage our higher thinking and so forth, because we want to do good. Financial reports are not really a positive but they can’t be a negative. So for example, when we organized leadership physicians or asked physicians to come to committees on a regular basis, we did reimburse them for their time. It wasn’t the same amount of reimbursement that they would have gotten if they had stayed in their clinics or get surgery but at least it wasn’t something that was a complete drain on the resources, and it was more of an acknowledgment that this is much appreciated, we knew that they were taking time out of their busyness, out of their patient care time, and so forth.The other interesting thing that somebody once told me was they were a group in a partnership and they had very great attendance at these monthly partnership meetings. But the business manager decided that he would pay $25 to each physician that came to the meeting. And all of a sudden, participations rot because now there’s a dollar figure attached to it and they said, “Well, if this meeting is only $25, I’d rather just not come back.”
So it’s one of those things that is really kind of interesting. It can be a negative but it’s not really a big positive for most physicians.
|There are no incentives to full-time clinicians to participate in QI initiatives other than they need to make a difference in patient care, which is great as a starting point. Assuming that clinical demands tend to drown these drives, how can a system be devised to promote these?||That’s a really great question and I’ll try to answer in this way. Most of the time, when we ask physicians to do an initiative, they’ll say, “Great. We’ll do it.” The first one is usually easy. And then the second initiative comes and then the third initiative comes and then it adds on to what the physicians have to document, how they have to order their order sets and so forth. So this is the issue – is that it should be looked at a holistic approach and said, “You know what, we can’t burden the doctors by adding more things.” And this is not just for the doctors. This is for the nurses too. Whenever we do quality projects, and I’ve been involved with many quality projects, the nurses just roll their eyes and say, “Not another quality project.”So, it’s important for leadership to understand that this could be a big burden. So when you ask physicians to do this and say, “How can I make it more efficient and more in line with the normal workflow of how they take care of patients and make it more streamlined?” For example, if you’re asking somebody to do an OR process and have a standardized way of having them go through the pre-anesthesia testing unit or through the PACU or whatever it is, if you can make a standardized order set, unless they have to do just one click, that makes it easy for them to do the right thing. And then there has to be a lot of physician involvement to get to that point, but at least it makes it easy to do that. And then when there’s another order set that needs to be done, if it’s something that the physicians do easily, or if it’s something that’s on a discharge program or something, that makes it very simple for them to comply. We can’t make it such that they are doing things over and over again.
|You mentioned in the webinar about communication and this question, I think, tends towards the communication to the physicians. So define that executives are more of an analyst level role as the best to be sharing data with the physicians. Sometimes we feel like the message gets passed along and shared with physicians by the ones that may not fully understand the data.||Well again going back to how we present data. So when we did our first project at 39 weeks, the physicians at our flagship hospital really sort of revamped me when I get data’s presentation because we didn’t actually have our own data. We were presenting things that the American College of OB-GYN said we shouldn’t be doing and a lot of the data was from other hospitals, which happens to be intercity hospitals or hospitals outside of the United States.So, I asked for data and fortunately, Intermountain Healthcare has a robust database and analytics and so forth. So I brought back the data which showed the physicians exactly what they’re asking for – was there harm being done? And it turned out that, yes, there was harm being done because if you deliver babies that were healthy otherwise, that the mothers did not have any risk, that below 38 to 39 weeks, it doubled the risk for having the babies end up in the Neonatal Intensive Care Unit, it doubled the risk for them to have RDS, Respiratory Distress Syndrome, and it doubled the risk for being on a ventilator. So that interpretation of that data, I had to discuss with the data folks. But taking that data and explaining it to the physicians, I knew that data intimately well. Because I was a physician and I work in this area, I could convey that information in a way that the physicians could understand.
So, if your data people are working side by side and know that area and can answer those questions, that’s great. If not, you’re going to have to come and bring somebody to help interpret that and bring it back and forth and so forth. But the most important thing I found was that you can go back and answer the questions in a timely fashion as far as data is concerned because there’s always questions about the validity of the data.
|Of the discussions involving physicians, how do we get nurses involved and also nurses can be considered key to change, not just cogs in the wheel? Do many of the strategies you’re recommending here, do they apply to nurses and other members of the care team?||Absolutely. We sort of segregate out nurses or other people in the hospital that provide care. And in fact, one of the people that are really overlooked are the housekeepers and so forth. Everybody that’s taking care of either maintaining the facility, taking care of patients, answering phones, they’re important part of the team.So, I found that it’s quite interesting that my office staff, the most important person in the office there, was the person that was answering the phones and receiving the patients. If they didn’t answer the phones in a timely fashion, if they didn’t address the patients very well, to begin with, that culled the entire operation, so forth.
So if you can educate nurses, if you can educate front office staff that this is the reason why it’s so important for you to take care of the patients. And remember, we’ve gone away from “I’m the captain of the ship” as a physician. We’re all in the same plane working to fly this plane together, we’re all teammates now. And so, we have to get away from that captain of the ship mentality and saying we’re all team members. And I think if we can make the argument and give patients and physicians and nurses, everybody, and make them understand that we’re all in it together, I think it’s going to go a long way.
|A couple comments on perception of engagement. As far as the line men, I think the perception of line men differs on whether the participants and executive or a practicing physician.Was the 2001 survey taken by physicians? All that, if it was asked through administration and nursing, the results would have been different.
|No, absolutely. Yeah. This was a physician survey that they did. And when I talk with executives and so forth, it’s more along the lines of this – “How can I get my doctors to do X, Y or Z?” That’s a wrong question. It’s “How can we provide care better?” Right?So let’s ask the physicians. Let’s bring them in. So at Intermountain Healthcare, this is the first time that I have ever experienced this scenario or situation – is that the leadership who was then turning over to the physicians, we asked ourselves a question, how can we provide care better to the patients? It wasn’t about how can we cut costs or how can we improve efficiencies or we’re struggling here. It’s a very different question. So again, who is the customer? If the administrators in the hospital believe that the customer is the physician and I think it’s all, you know, I need Dr. Jones, she is the only neurosurgeon that we have and/or that he is the most prolific orthopedic surgeon but he’s not the best one at saving costs and so forth. That’s the wrong question. It’s taking that question and making it such that how can we together take care of the patients better? Because if you cater to that one physician, how are the other physicians going to feel? Right?
So it’s a community of physicians that you’re addressing really but it’s having them as partners in the care or the patient care rather than looking at them as the ultimate endpoints.
|With different stakeholders, insurers, hospitals, patients, etc., how easy or hard do you think alignment and buy-in can be achieved?||A lot of this is actually a cultural question. Too often we see that the hospital, the payer, and the physicians are in different corners of a boxing ring and that we all have to go and box in and fight for our turf and territory. But in reality, we’re all in the same airplane. So we’re all flying together.So I saw a cartoon once in which there’s two elderly ladies around the airplane and one was speaking to other one and says, “Margaret, look at that engine out there. It’s on fire. Good thing we’re on the left side of the airplane.” So this is a ridiculous question really when you come to think of it, as that everybody either wins or loses together and people have to realize that.
|How do you make patients and the community part of the team? We are not a uniform Scandinavian that’s on the airplane.||If I had the answer to that, I think I could bank a million dollars right away. This is the most interesting question and you’re absolutely right. Too many times, I had this button that says I’m the doctor, trust me I’m the doctor, and so forth. But today, it’s really not about me as a healthcare professional taking care of patients. If you look at how much of what we do in hospitals and clinics impacts longevity in any individual, it’s only 10 percent. 40 percent is due to lifestyle issues and so forth, 30 percent is genetics, and the remainder is just some other environmental things. So, the majority of what impacts a person’s well-being is not based upon what I do as a healthcare provider. So we have to come to that realization.Just the other day I was working at a Medscape webinar and so forth and they highlighted this mother who had a baby that was ill and had otitis media, an ear infection, and so forth. Did she go to the doctor? No. What she did was she slapped on an otoscope device onto her cellphone, smartphone, she did a beta recording which she then submitted to her physician through telemedicine and the prescription was given. And there’s many things that could fit and other wearable devices are impacting care today. So there’s a lot that goes on.
So as we progress in the future, we’re going to have to have patients as part of our community of care. I believe that patients should be involved with how we design medicine. They should be part of our committees on patient care. We should not be afraid of letting them in the door.
|What is your appraisal of public physician report cards in meeting goals and targets? I hear a lot of distress and feelings of humiliation.||Yeah. I think all public reporting is meant to make it such that we can actually look at people to bring them in lines with peer pressure to improve care and this has been really a fault of the medical community in which we really were not transparent and so forth. But I think these are mere distractions. These public reporting things really do not improve care.So what we need to do is reassess the things that we do. For example, when we look at hospital-acquired infections or congestive heart failure or readmissions and so forth, the real ongoing thing is not to work on those specifically but it’s to look at the underlying costs and say, how can we provide care so that we can heal the patients, so that we can keep them out of the hospital, to begin with? Instead of readmission, why did they come to the hospital in the first place? That’s what’s going to drive improvement of care.
|As a member lower in the food chain, how does one go about proposing the system of incentives where physicians who want to go about quality improvement initiatives and participating in them?||Lower in the food chain. Again, I think that this is a situation in which it has to change in your facility. Perhaps, the individual that is asking this question, their facility really hasn’t had this flattening of the hierarchy and so forth. So, really many progressive pleasures have actually included nurses, pharmacists, dietitians, physical therapists, you name it, as part of the healthcare team and have restructured and reorganized themselves within their hospitals to provide care in the coordinated and chain-based fashion.So, how do you get started and how do you approach the subject? Well, really this again goes to human behavior and so forth. So you have to make the suggestions, you have to have a mechanism in which leadership can really address this, and perhaps the messaging has to be at the right time as well. So perhaps this isn’t the right time for your facility but it has to be raised. And I’m not sure, because of the culture of your facility, how to do that specifically but there has to be an ear in which your supervisor will have to get involved, your manager may have to get involved, or other leaders have to get involved and so forth. So this is a very interesting and most difficult question.
Alright. Well, I want to thank you very much for such an informative and wonderful presentation, Dr. Oshiro.
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On behalf of Dr. Bryan Oshiro, as well as the rest of us here at Health Catalyst, I want to thank you for joining us today. This webinar is now concluded.
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