The Role of Hospitals in Physician Development and Lifelong Learning

Transcription

1 The Role of Hospitals in Physician Development and Lifelong Learning AHME Institute May 14, 2015 John R. Combes, MD Chief Medical Officer and Senior Vice President, American Hospital Association 2015 American Hospital Association

2 Overview The Changing Health Care Environment The Physician Leadership Imperative Integrated Leadership Gaps in Physician Competency Development The Strategic Use of CME and GME

3 The Changing Health Care Environment

4 Health Care: Time of Uncertainty What s driving uncertainty? Economic needs Demographic shifts Purchaser value expectations What has the ACA accomplished? Greater focus on coverage and costs, performance based payment Created new insurance market options Spurred some new delivery/payment model development and experimentation (e.g., ACOs)

5 Health Care Costs Will Resume their Rise Healthcare costs are rising and industry spending is projected to grow at an annual rate of ~5.35% beyond Projected % Change in Per Capita Year over Year Healthcare Spending Healthcare Spending is projected to grow at an average annual rate of ~5.35% beyond 2016 due to improving economic conditions, the Affordable Care Act (ACA) coverage expansions, and the aging of the U.S. population. National Health Expenditures Gross Domestic Product National Health Expenditures as % of GDP Sources: Centers for Medicare and Medicaid Services, Office of the Actuary

6 How Much We Spend in U.S. U.S. health care spending (in billions of dollars) 2013, 2015, 2020 projected Source: Centers for Medicare and Medicaid Services, July 2014

7 Forces of Change Evolution of the payment system: Reimbursement based on cost of care to Reimbursement based on diagnoses and groups of services to Payment system driven by value (quality & cost performance) with prospect of fixed payment based on groups of people (populations) Fixed payment systems requires a focus on outcomes, efficient care processes, lower cost treatment options and overall appropriateness of care. Fundamental changes in insurance market Markets (e.g., public and private exchanges) Products (e.g., HDHPs, tiered plans) Incentives (e.g., shared risk, capitation) Provider sponsored plans The rise of: Consumerism Retail New Entrants

8 Predictable Outcomes Lower relative and (absolute) costs Meaningful clinical integration and coordination Continued migration of care to outpatient/ ambulatory settings Greater risk associated with performance and populations Quality and cost performance and transparency More patient oriented and consumer driven Consolidation (read bigger Health Care Companies ) More competition and blurring of lines ROI based technology and capital decisions

9 Path to the Second Curve 9

10 In 5 years what will the field look like? Strategic Directions Movement away from fee-forservice toward integration Emphasis on value vs. volume Emphasis on quality vs. quantity First curve to the second From illness to health IN 5 YEARS, OVERALL FORECAST

11 ACA or Not: Needs and Trends Continue More INTEGRATION across the silos Increased coverage Delivery system reforms Payment reforms Increased transparency Adoption of health IT More AT RISK FUNDING More PUBLIC ACCOUNTABILITY and reporting

12 Leverage: Physicians, Hospitals, and Insurers Physicians Hospitals Insurance Plans Primary Mission Manage patient care Accommodate medical needs of the community Manage cost, hold providers accountable View of the Other Hospitals are our lab ; Plans are a nuisance, adding no value Physicians are central to care and our natural partners Plans are a nuisance and add limited value Physicians are important but need discipline, tools and sensitivity to costs Hospitals are inefficient, non-transparent and the root cause of high costs Major Concern Protection of clinical autonomy, patient trust & economic security Sustainability: protection of operating margin as bad debt and operating costs increase and plans negotiate more aggressively Capital: to transition from acute to population-health focus Protection of role as organizer of health services, driver of cost accountability Key Asset 1) Patient Trust 2) Clinical Knowledge Local reputation Technology Access to Capital (declining) 1) Data (clinical, financial) 2) Capital 3) Relationships with group purchasers Key Vulnerabilities 1) Data 2) Leadership 3) Capital 4) Scale 1) Cost structure 2) Transparency 3) Physician resistance to change 1) Trust 2) Differentiation Source: Paul H. Keckley, PhD; Navigant Healthcare Insights, August 2014

13 The Physician Leadership Imperative

14 Care System of the Future Administrative Clinical Institutional management Patient management

15 Environmental Pressures Environmental Pressures Administrative Clinical Institutional management Patient management Transformed Vision Clinical Management Population management

16 Vision of Transformation Providers taking responsibility for populations Better coordination across care settings and providers More effective management of chronic disease by both providers and patients Greater role for primary care Support from both provider and payer leadership

17 Implications for Physicians RIP Community Hospital & Medical Staff Separate, but equal Hey, it worked almost 100 years

18 Physician Leadership Opportunities The organized medical staff will focus on organizational tasks such as credentialing, privileging, corrective actions, and physician behavior Economic linkages, managerial roles, and risk sharing will characterize the key relationship with physicians Development of shared vision and strategy with aligned physicians will be critical Broader physician leadership roles in: Medical Group Governance Co managed Clinical Services Lines Boards of ACOs, PHOs, JVs, etc. Quality Improvement and Patient Safety Programs Care Redesign and Transformation Governance and leadership roles will be based on essential competencies

19 CONCEPTS OF LEADERSHIP The role of the leader is evolving from a top-down approach to a more collaborative approach Traditional Leader crafts vision Leader demands performance Paternalistic model Emphasis on leader's intellect Leader seeks to control others Modern Group crafts vision that leader articulates Leader inspires performance Partnership model Emphasis on leader's emotional intelligence Leader seeks to empower, motivate and empathize with others Team focuses on work arena Team seeks balance between work and home Source: Catherine D. Serio, PhD, Ted Epperly, MD, Physician Leadership: A New Model for a New Generation: Today's leaders need more than vision and a high IQ. Fam Pract Manag Feb;13(2):51 54.

20 Embracing Leadership

21 New Competencies for Clinical Leaders

22 Integrated Leadership

23 Integrated Leadership Collaborative discussions between AHA and AMA Opportunity to redefine care delivery to achieve the Triple Aim through new care and payment models Six principles for integration between physicians and hospitals

24 Principles for Integrated Leadership 1. Physician and hospital leaders with: shared vision and mission similar values and expectations aligned financial and non financial incentives goals aligned across the board with appropriate metrics shared responsibility for financial, cost, and quality targets service line teams with accountability shared strategic planning and management shared focus on engaging patients as partners in their care 2. An interdisciplinary structure that supports collaboration in decisionmaking, preserving clinical autonomy (defined as putting the needs of the patient first) needed for quality patient care while working with others to deliver effective, efficient and appropriate care. 3. Integrated leadership at all levels and participation in key management decisions. Teams of clinicians and administrators leading together at every level Teams accountable to and for each other and can commit for each other

25 Principles for Integrated Leadership 4. A collaborative, participatory partnership built on trust. Sense of interdependence and working toward mutual achievement of the Triple Aim Physicians and hospital leadership must trust in each other s good faith and abilities 5. Open and transparent sharing of clinical and business information by all parties across the continuum of care. 6. Clinical information system infrastructure that allows capture and reporting of key clinical quality and efficiency performance data and accountability across the system to those measures.

26 Leadership Skills Both physician and hospital leaders must possess the knowledge, skills and professional attitudes to be effective leaders and managers in empowermentoriented, and consensus based management models. Physician leader skills Mission and strategy development, alignment and deployment Understanding of patient and consumer expectations Quality measurement and improvement Team building, negotiation and management Effective adoption of health care clinical information technology Risk, finance and cost management in various types of practice organizations Understanding payment based on care, quality, outcomes and accountability Population health management Hospital leaders skills Understand medical professionalism, care delivery processes and clinical decision making Knowledge of physician practice finances and workflow Ability to achieve consensus with physicians Understand need for physicians to advocate for patients Accept need for physician clinical decision autonomy in specific settings while expecting physician accountability for overall institutional success Willingness to create true integrated leadership model by sharing management responsibilities and accountabilities

27 Cultural Needs A focus on health of entire population served by integrated health system Common mission, vision and values Mutual understanding and respect despite different training and perspectives Sense of common ownership of integrated health system and its reputation Joint commitment to performance measurement and improvement Focus on individual patient s care over time and across the continuum Performance data that is understandable, timely and trusted Fair financial and non financial incentives aligned to improve care and manage costs across the organization Shared governance and involvement in decision making A sense of responsibility for the integrated health system Consensus decision making between all parties

28 Challenges to Success Commitment to business model transformation Differing mind sets Lack of clarity on values Lack of more accessible and generalizable models of physician organization Lack of integrated leadership and management skills Need for robust of primary care involvement Need for payer partnering and new payment models Legal and regulatory issues Contractual issues Ancillary services issues Coordination of the Organized Medical Staff

29 Gaps In Physician Competency Development

30 Physician Leaders Key Competencies 1. Technical knowledge and skills 2. Knowledge of health care 3. Problem solving prowess 4. Emotional intelligence 5. Communication 6. A commitment to lifelong learning Source: Stoller JK. Developing physician leaders: Key competencies and available programs. J Health Admin Ed, Fall 2008

31 ACGME/ABMS Competencies Medical knowledge demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Patient care provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Practice based learning and improvement must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Systems based practice demonstrate awareness of and responsibility to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Professionalism demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Interpersonal and communication skills demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates.

32 Evidence vs. Importance Gap Medical knowledge Patient care Practice based learning and improvement Improve patient care practices System based practice Provide cost conscious, effective medical care System based practice Work to promote patient safety System based practice Coordinate care with other healthcare providers Professionalism Interpersonal & communication skills demonstrate skills that result in effective information exchange Work effectively with health care team Use of Informatics

33 Key Observations Greatest Gaps and Least Evident System Based Practice: Provide cost conscious, effective medical care Communication Skills: Effective information exchange System Based Practice: Coordinate care with other providers Communication Skills: Work effectively with health care team Most Important Patient Care System Based Practice: Promote patient safety Medical Knowledge Communication Skills: Work effectively with health care team Missing Competencies Conflict management/performance feedback End of life/palliative care Systems theory and analysis Customer service/patient experience Use of informatics

34 Lifelong Learning: Physician Competency Development Lifelong Learning: Physician Competency Development released July 2012 Excerpt published in the Journal of Graduate Medical Education, September 2012 Joint effort with ACGME to host a stakeholder workgroup that brings together accrediting groups and those involved in education and training of physicians. Goal: create a more system level approach to physician development over a lifetime by addressing the findings and recommendations in the report.

35 Addressing the GAP Through CME and GME

36 Hospitals and CME CME provides support for continuous learning and improvement and addresses gaps in professional practice In 2013, hospitals provided: 35% of overall activities Nearly 90% of local activities 1122 hospitals and health systems 47,843 activities 4.5 million contacts Over 61% of CME income comes from providers parent organization or registration fees 26% comes from commercial support Over 50% of CME in didactic sessions Less than 2% formal performance improvement

37 Field Assessment: Value of CME Obtained AHA member input on value of CME to hospitals, how it is currently being used particularly to engage physicians in practice based learning, and identify challenges. Members were asked to develop recommendations enabling greater use of CME as a strategic resource. Resulting report shared with accreditation and continuing medical education community for input and feedback.

38 Published September 2014 Available at:

39 Survey Results June 2012 report: Lifelong Learning Physician Competency Development

40 CME Topics Ethics 4% EMR/ IT 4% ICD 10 2% Leadership development 18% Specialityspecific 54% Quality and safety 18%

41 CME Formats Case/Peer Reviews 4% Participation in committee 2% Journal Club 2% Collaboratives 2% Simulation/ Skill lab 1% Projects 4% Tumor boards 7% Conferences/ Lecture 41% On line 17% Grand Rounds 20%

42 CME as a Strategic Resource Hospitals find value of CME to address: Care coordination Clinical integration Change implementation Teamwork and future leader development Behavior change System based performance improvement Reaching community physicians Reducing medical liability premiums Successful CME programs link offerings with: ongoing practice evaluation, credentialing requirements, existing certifications, while tying content to hospital strategic needs.

43 Challenges Accreditation Staff intensive Lack of clarity in regulations Cost Difficulty in accrediting new formats/topics Organization specific programs Time and labor intensive to create Gap analysis takes time Inter departmental politics/silos can hamper organization wide efforts Physician interest and buy in Champions to lead CME development/rollout Time crunch Need for different education delivery methods Generational differences Fear of losing clinical skills education time

44 Report Recommendations Recommendations to four groups: Hospital Associations Hospital and Health System Field Accreditation and CME Credit Systems Community Hospitals, Health Systems and the Accreditation Community in partnership Each set of recommendations includes examples of successful practices

45 Hospital and Health Systems Recommendations to the hospital and health system field: Use CME to advance strategic goals and engage physicians as partners in strengthening organizational competencies. Consider the use of existing non traditional CME applications to encourage improvement efforts and physician engagement in strategically oriented CME. Develop physician champions. Encourage stronger links between CME and quality improvement. Use community health assessment and other available data to inform CME. Encourage inter professional and team based learning opportunities.

46 Accreditation Community Recommendations to the accreditation and credit system communities: Employ standards that foster closer collaboration between CME and hospital quality improvement and patient safety. Employ standards that encourage team based, interprofessional training. Develop clearer guidelines for non traditional CME activities. Consider increasing the use of performance improvement CME or other means to allow for activities where learning does not occur in measured credit hours. Consider moving away from time based activities to outcomes based activities for granting CME. Increase diversity in accreditation. Streamline process for application.

47 System based Practice Milestones Demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Work effectively in various health care delivery settings and systems. Coordinate patient care within the health care system. Incorporate considerations of cost awareness and risk benefit analysis in care. Advocate for quality patient and population care and optimal care systems. Participate in identifying system errors and implementing solutions. Perform administrative and practice management responsibilities commensurate with one s role, abilities, and qualifications. Participate in different team roles to establish, develop, and continuously enhance interprofessional teamwork. Use the knowledge of one s own role and the roles of other health professionals to appropriately assess and address the health care needs of the patients and populations served. The capacity to accept that ambiguity is part of clinical medicine and to recognize the need for and to utilize appropriate resources in dealing with uncertainty.

48 Systems based Practice Milestones for Hospitals Demonstrate a systems approach to care delivery seamlessly delivering high quality, safe, effective, and efficient patient driven care to communities and populations for which it is accountable. Demonstrate a culture of high reliability in all parts of the organization by safely delivering patient care, minimizing risk, and eliminating preventable harm. Provide coordinated care across the continuum, avoiding errors at handoffs and seamlessly transferring patients across settings and back into the community. Provide efficient care, eliminating non value added treatments and procedures and simplifying processes to eliminate waste. Integrate continuous improvement of quality and outcomes into the workflow of the organization. Systematize an approach to error identification and reporting, as well as an understanding of the causes of error, and proactively identify the potential risks and mitigation strategies. Provide opportunities for training and practice of communication skills and team functioning for individuals and inter professional groups. Organize the system s resources to appropriately assess and address the health care needs of the patients and populations served.

49 The Continuum of Development of the Physician Novice Advanced Competent Proficient Expert Master Beginner SAT Transition to College Transition to Medical School Collegiate Accreditation MCAT LCME NBME FSMB Transition to Residency Transition to Practice Performance in Practice ABMS Certification, MOC FSMB Licensure, MOL TJC OPPE/FPPE Hospital Credentialing Mastery In Practice Minimum Level of Performance In Practice

50 Transitions Across the Continuum Novice Advanced Competent Proficient Expert Master Beginner Transition to Medical School Transition to College Collegiate requirements MCAT Transition to Residency Medical School Admissions Milestones at start of residency Transition to Practice Milestones at end of residency ABMS Board results MOC CME programs Hospital Credentialing

51 Summary Health care is transforming Needs to meet the challenges of disruptive innovation by consumerism, retail, technology Physician leadership is imperative Large gaps in system based practice and other competencies GME and CME can develop and address those competencies, including professionalism, if used more strategically

52 Questions/Comments John R. Combes, MD Chief Medical Officer and Senior Vice President American Hospital Association President, Center for Healthcare Governance Chicago, IL