Physician - Hospital Partnerships: The Rules of Engagement

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?


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.


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


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


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


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


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


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


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


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

Education

Physician - Hospital Partnerships: The Rules of Engagement