physician - hospital partnerships: the rules of engagement
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Worldwide Conventions and Business Forum’s Lean Six Sigma and Process Improvement in
Healthcare
Robert Lancey, MDChief of Cardiac Surgery
Co-Director, Heart Care InstituteBassett Healthcare Network
Clinical Associate Professor of SurgeryColumbia University
Physician – Hospital Partnerships:
The Rules of Engagement
Disclosures
No financial interests to declare
What does ‘Quality in Healthcare’ mean to you?
Introduction: The Facts
quality has historically been ill-defined in healthcare
definitions not standardized (Center of Excellence?)
patients not standardized (risk-adjusted)
care not standardized (evidence-based medicine)
meaning not standardized
What does ‘Quality in Healthcare’ mean to patients?
What does ‘Quality in Healthcare’ mean to patients?
depends on whom you ask . . .
AHRQ: Understanding Health Care QualityDoing the right thing (getting health care services you need)At the right time (when you need them)In the right way (using the appropriate test or procedure)To achieve the best possible resultsAvoiding underuse (not screening for high blood pressure)Avoiding overuse (performing unnecessary tests)Eliminating misuse (medications with dangerous
interactions)
AHCAQuality is defined as the combination of care and services
that meet or exceed customer needs and expectations.
What does ‘Quality in Healthcare’ mean to patients?
clinical skillfeeling secure the doctor is prescribing the right
remedy the doctor understands the problem, offers solutions
and treatments, if neededOUTCOME; will it improve my quality of lifebest possible outcomes dedication to quality of lifeboth acute and preventative care trust that the provider knows, or can determine the
problem, and then do his/her best
What does ‘Quality in Healthcare’ mean to patients?
servicedoctors that don't see patients at record breaking
speed house callssame for any service organization: turnaround time,
communication being able to ask any questions having a good supporting cast (nurse, techs, etc) who
worked together to focus on the patient needs the opportunity to meet with an experienced
practitioner that is willing to spend time with you to analyze, discuss, and follow up on your diagnosis and treatment
What does ‘Quality in Healthcare’ mean to patients?
servicewhen a doctor takes additional time to more fully
analyze alternative explanations and discusses any concerns you have with warmth and empathy
skilled, accurate, confident, and compassionate doctors and nurses
respectful administration and customer facing organization
patient & patient family focused operations understanding patient needs and compassion communicate and interact to improve patient health reduce wait time and spend more time with patients
rather than filing paperwork
What does ‘Quality in Healthcare’ mean to patients?
servicepatient-centric healthcare - everything must be
around the patients’ needs and convenienceCOMPASSION!high availability, high accuracy, low aggravation it would be a pleasant surprise if the doctor spent
more than 10 minutes with me before he/she has to run to the next appt
What does ‘Quality in Healthcare’ mean to patients?
financialable to select the insurance plan that is best for meavailable insurance that provides peace of mind free-market for insurance - with subsidies provided to
certain demographics based on income
otherno more pharma ads
What does ‘Quality in Healthcare’ mean to patients?
1.Patients see it as a patient-provider relationship that helps them reach their goal of health, quality of life
2.Patients have little understanding of what actually constitutes the ‘right care’ or the correct treatment
3.From their perspective it is based on having a close relationship with their medical provider that is based on trust
Do quality processes of care = quality outcomes?
orDoes adherence to performance measures
actually lead to better outcomes?
few studies have supported this
others studies in fact question it (the law of unintended consequences)
1. hyperglycemic control after open-heart surgery2. beta-blockade before open-heart surgery3. timing of antibiotics for community acquired
pneumonia
1. Hyperglycemic control after open-heart surgery
2001: NEJM (2001;345:1359-67)randomized prospective study of 1,548 ICU patientsintensive insulin therapy led to lower mortality, infections,
RF
adopted by CMS and SCIP as quality metric6 a.m. blood sugar of < 200 mg/dL on post-op mornings 1
& 2
no evidence of benefit of either timing or level
tighter control leads to hypoglycemia up to a two-fold increase in mortality
2. Beta-blockade before open-heart surgery (NQF,
STS)
2002: JAMA (2002;287:2221-7) study of 630,000 CABG patientsmortality benefit with β-blocker (3.4% vs. 2.8%) if unmatchedNO benefit when matched
2006: MaVS study, Am Heart J (2006;152:983-90)prospective study of patients with known heart diseaseno difference in cardiac eventsmore hypotension, bradycardia in β-blocked patients
POISE study in Lancet (2008;371:1839-47)largest randomized trial (> 8000 patients) with / at risk for
CADlower MI rate, but higher death and stroke rates (15 vs. 8 +
5)
STS National Meeting, 201012,855 patients undergoing CABG (known heart disease)no difference in mortality, stroke, or MIs
3. Timing of antibiotics for CAP
2003: Infectious Diseases Society of America guidelinesantibiotics within 4 hours of arrival if admitted with
pneumoniabased on unpublished analysis of old Medicare data (not
RCT)senior author sat on consensus panel
adopted by CMS and JCAHO as quality metric and tracked
resultover-diagnosis of pneumoniaantibiotics given without knowing in order to be in
compliance
eventually changed to 6 hours
Can the pursuit of quality hinder the arrival?
the law of unintended consequencesstinting
limiting access to care that improves quality but costs more
quicker-sicker dischargedischarging patients earlier than clinically indicated
cherry-pickingtreating only healthier patients
steeringavoiding sicker patients
Quality in Healthcare
it is here to stay (are ACOs?)
transparency, and the desire for it, will not go away
better to embrace it and become part of the process, because what matters is . . .
What ‘Quality in Healthcare’ mean to payers!
Value-Based Purchasing: Milestones
health insurance through employment (WWII)
establishment of Medicare (LBJ, 1965)
DRGs (Yale, 1982)
the ‘Quality Cure’ (McClellan and Cutler, 1995)
pay-for-participation
value-based purchasing
What does VBP mean to Medicare?
“The overarching goal of these initiatives is to transform Medicare from a passive payer of claims to an active purchaser of quality health care for its beneficiaries.”
“We have worked with stakeholders to define measures of quality in almost every setting. These measures assess structural aspects of care, clinical processes, patient experiences with care, and, increasingly, outcomes.”
“CMS views value-based purchasing as an important step to revamping how care and services are paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of merely volume.”
from Medicare Program; Hospital Inpatient Value-based Purchasing Program [CMS 3239-P], released January 2011
What does VBP mean to Medicare?
6 quality goals
effective
safe
timely
efficient
patient-centered
equitable
What does VBP mean to Medicare? hospitals will be scored in three quality domains
processes of careReporting Hospital Quality Data for Annual Payment Update (RHQDAPU) AMI, Heart Failure, Pneumonia, Surgical Care
Improvement Project Healthcare Associated Infections
patients’ perspectives of care Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey
outcomes 30-day mortality measures for AMI, HF, PN
What does VBP mean to Medicare?
future
readmissions
hospital-acquired conditions
Value-Based Purchasing: % dollars at risk
Is ‘quality’ the ultimate goal, or is it ‘value’?
competition on the wrong level
advantages of a ‘value’ approach
more consistent with integrated approach
keys to taking a ‘value’ approach
Are we getting value?
The Triple Aim in Healthcare (IHI)
Improve the health of the population
Enhance the patient experience (access, satisfaction)
Reduce / control the cost of care
Why Health Care Reform?
three basic goals
increase access
decrease the rate of cost escalation
improve quality
It all comes down to: VALUE = QUALITY / COST
. . . and physicians control QUALITY and (87% of) COST
Getting your organization engaged in quality
physicians / providerseducation
residentsVO TO , HCAHPS, HSQ Committee
nursing stafffeedback; HCAHPS surveys
ancillary staff
operational staff
What is the role of the physician in ‘quality’?
Engaging physician in quality initiatives
understand how they see the world
outline expectations of the organization
seek common ground
invest in the physician leaders
Cultures in Conflict!
Expert Culture (docs)
an individual’s success is a result of the individual’s knowledge, skills, and ambitions
success of the group depends on how each individual participates
the whole is equal to the sum of the parts
motivation for success is individual accomplishments and power
Collective Culture (hosp)
teamwork is paramount
success of the group depends on how well they work together
the whole is greater than the sum of the parts
motivation for success is the need for acceptance and recognition
from Atchison & Bujak, Leading Transformational Change, ACHE Health Administration Press, Chicago
Strongest characteristic of physicians
desire for autonomy
competitive core
Understanding physicians: autonomy
focus in medical school: personal responsibility for patient outcomes
accountability goes with autonomy
focus on, “What is in it for me and my patient?”
personal contract with each patient vs. social contract to practice socially responsibly
contrary to systems approach (basis of quality improvement)
Understanding physicians: competitive spirit
in simulations, do not seek win-win solutions
are hesitant to seek cooperation
would prefer to have everyone lose rather than give any others a chance to get more than their fair share
Understanding physicians: competitive spirit
when working with mixed groups (attending, residents, students), perform even worse
why:
training is all about competitionpre-medical college programs pyramidal residency programs
How do you get quality to work for you?
measure it: gather data
convert it into information (what does it mean)
transfer it to knowledge (evidence-based practices)
convert it to action
How do you get quality to work for you?
track it and gather more data on performance
incentivize complianceextrinsic: reimbursementintrinsic:
why it is good for patientswhy it is good for the organization (Balanced
Circle)
data that is MEANINGFUL important to physicians and patients
data that is RELEVANT being recorded and reported by outside
agencies
data that is RELIABLE quantifiable, risk-adjusted
data that is ACTIONABLE can be modified by improvements
data that is TIMELY recent
Outlining expectations
the importance of communication
the need for consistency (builds trust)
link rewards with behaviors
extrinsic rewards (bonuses for productivity)
intrinsic rewards (feedback on patient satisfaction)
clarity in goals: the value of report cards
How to build trust
create shared visions and goals
recognize common principles
recognize differences, but emphasize commonalities
identify the benefits of collaboration
consider barriers and how to overcome them together
How to build trust
openly discuss the disadvantages of not collaborating
celebrate wins along the way
share: information, credit, work, expectations
act on data, not opinions
focus on the future and not the past
Report cards
a.k.a. performance updates
to align behaviors (financial incentives with quality)
individual performance vs. department-level data vs. national benchmarks
physicians are data driven, but . . .
use data to shed light, not fire
Reinforcing expectations: compensation
Common ground = interdependency
How? develop collaborative partnerships safetyqualityworkflowschedulingpatient satisfaction
form creative shared business models
search for and leverage shared values
The Balanced Circle
Effective clinical leadership raises the performance of health care organizations
hospitals with the highest clinician participation in management scored 50% higher on important drivers of performance than hospitals with low levels of clinical leadership1
organizations with strong clinical leadership are more successful in performance improvement than those without2
1 Castro et al. A healthier health care system for the United Kingdom, mckinseyquarterly.com, February 2008
2 Managing Change and Role Enactment in the Professionalised Organisation, National Coordinating Centre for NHS Service Delivery and Organisation, 2006
To promote clinical leadership
establish appropriate incentives
identify, train, and mentor
create the environment (highlight the successes)
importance of training and mentoring (ex: PLA)
“Doing more of what you are already doing and expecting a different result is a sign of insanity.”
Albert Einstein
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