Excerpted from Healthcare Executive (March/April 2014) (American College of Healthcare Executives, 2014). Physician EngagEmEnt Strengthening the Culture of Quality and Safety By Jane Calayag
Physicians want to deliver the highest quality and the safest care, says Tejal K. Gandhi, MD, CPPS, president of the National Patient Safety Foundation, Boston. That is their primary motivator they don t want to harm patients. Many healthcare leaders share the same objective, as evidenced by the burgeoning improvement programs in hospitals and systems. They understand the fiscal, moral, regulatory and health urgency to do no harm. Plus, they view it as a primary, collective duty of everyone in the institution. Patients expect high quality from us and reasonably so, explains Richard A. Hachten II, FACHE, president and CEO, Alegent Creighton Health, Omaha, Neb. We have a responsibility as a team to deliver that quality of care. Despite their common purpose, many leaders struggle to involve physicians in organizationwide quality and safety efforts. In fact, 71 percent of respondents to ACHE s 2013 Top Issues Confronting Hospitals survey identified engaging physicians in improving the culture of quality as a specific challenge. Complicating this concern is that many physicians are autonomous or belong to an independent practice association (IPA). For Beth D. Zachary, FACHE, president and CEO, White Memorial Medical Center, Los Angeles, engaging nonemployed physicians is a challenge for several reasons. First, those physicians may only spend a limited time at any one hospital in order to meet their IPA-imposed productivity goals throughout the day. Second, they may know little of the hospital s mission and culture and consequently may not be as invested in its quality agenda. With health reform mandates and the shift from volume-based to value-based reimbursements and incentives in progress, Gandhi believes that aligning the interests of both leaders and physicians in quality and safety is more critical than ever. We have done a lot since 1999 [when landmark Institute of Medicine report To Err Is Human was published] in terms of how to report errors, how to talk about errors and how to fix errors, but we re not all the way there, she says. Bertine Colombo McKenna, PhD, FACHE, executive vice president and COO, Bassett Medical Center, Cooperstown, N.Y., agrees. She argues that more can be done. There s an opportunity for both the clinical and business sides of healthcare to partner to make sure the country s healthcare system improves to the point where we have zero defects, she says. This allows us to become a high-reliability organization. One way to accomplish this is to strengthen the organizational culture of quality and safety with the help of clinicians. Strategies for engaging physicians vary from one organization to another, Gandhi notes, but several common strategies may be employed. Commit to quality and safety first. Before senior leaders can gain buy-in from physicians, they first must demonstrate their own commitment and understanding of the work needed. Given the current focus on population management and cutting costs, I worry that instead of continuing to invest in please contact Copyright Clearance Center at info@copyright.com or visit www.copyright.com. Reprinted from Healthcare Executive 29
quality and safety, leaders might shift their resources to other things, Gandhi says. In fact, having a strong foundation in quality and safety will help organizations achieve population management and reduce costs. Embed physicians in the leadership structure. Leaders should appoint physicians to head a specific office such as director of quality and safety or invite them to serve on committees, advises Gandhi. Occupying these roles enables physicians to work in partnership with other staff and clinicians, not as someone who tells others what to do, she explains. Gandhi adds that a co-leadership model is ideal to minimize hierarchy and maximize collaboration. Alegent, for example, established a chief quality officer position as part of its senior leadership team. We also established campus chief quality officer positions with each of our hospitals, our rural network and our physician enterprise, says Rick Miller, DO, FAAFP, senior vice president and chief quality officer, Alegent. Furthermore, physicians serve on the clinical practice committee and the patient safety and quality committee, both of which are overseen by the board of directors and present reports and recommendations at each board meeting. Use valid and reliable data. Outcomes, performance, benchmarks and other data all point to achievements, progress and areas that are trending below standards. Numbers substantiate the call for changing clinical processes and clinician behavior. As McKenna explains, Data is particularly critical to physicians. Evidence speaks volumes in terms of engaging physicians in the fix. If you don t have evidence and have no robust system in place to make change happen and support that change, then the frustration that results gives way to nonengagement. Alegent uses data to demonstrate transparency and to continually support physicians. We ve developed an evidence-based process that provides physicians with the data and evidence behind identified best practices, which has helped physicians buy in to the There s an opportunity for both the clinical and business sides of healthcare to partner to make sure the country s healthcare system improves to the point where we have zero defects. This allows us to become a high-reliability organization. Bertine Colombo McKenna, PhD, FACHE Bassett Medical Center effort over time, Miller says. It also allows us to analyze and determine the validity of the measurements we use to monitor quality performance. White Memorial regards data as a tool for monitoring and averting the unintended consequences of clinical decisions. We are very vigilant about changes in processes and fluctuations of target goals and keep our eyes open in all avenues of care, says Mara Bryant, senior vice president of organizational excellence. Provide training. Organizational quality principles are typically not taught in medical schools. Yet, as Gandhi notes, many physicians get involved in running improvement projects. She argues that educating physicians on the core hospital s quality and safety improvement processes would enable them to participate more actively and constructively. As a learning organization, Bassett offers its clinicians various opportunities for education and training. We have an orientation process for new doctors that discusses our quality and safety programs, to give them a sense of how they may want to be involved, McKenna says. We have the Bassett Institute for Learning, an internal, self-directed university that includes leadership studies and quality and safety modules. We will launch a Lean module soon but as a way of working, not as a new program. 30 Reprinted from Healthcare Executive please contact Copyright Clearance Center at info@copyright.com or visit www.copyright.com.
Furthermore, Bassett presents learning in more creative ways such as through case reviews, rounds, observations and hands-on experiences. Offer financial incentives. Time spent on quality work is time spent away from patient care or revenuegenerating duties. That is the reality for many physicians. For physicians who have their own practice, this type of work ends up being a financial hit, Gandhi says. There has to be a way to reimburse physicians based on the improved quality achieved that could help offset some of the time they carve out. At Alegent, employed physicians are compensated for meeting annual quality metrics, but nonemployed clinicians are unpaid for their quality participation. Physicians at Bassett do not yet receive financial incentives for quality efforts, but the organization will be considering such an arrangement in the future. Make the workplace psychologically safe. No one is going to speak up about unsafe practices, medical errors, near misses or potential sources of adverse events if that person expects to be yelled at, belittled or berated in the process, cautions Gandhi. Bassett s just culture is the embodiment of a psychologically safe environment, in which people feel safe to report issues, says McKenna. We hold people accountable when there has been a pattern or trend worthy of action. The following cases detail how three healthcare organizations established their quality and safety culture and how they engage their physicians. Alegent Creighton Health In 2005, Alegent made a bold decision: publish the less-than-perfect, widely varied quality scores of all its metropolitan-area hospitals in the local newspaper Omaha World- Herald. The move was not only a resolute step toward organizational transparency but also a public declaration of Alegent s cultural commitment to high quality and safety. Overall, it was not only the best practices that drove our success; it also involved continuous measurement, transparency, and uniformity of practice across all categories and sites of care. Richard A. Hachten II, FACHE Alegent Creighton Health This caught the attention of our community, physicians, staff and leadership, says Hachten. Equally important was that it united Alegent s internal stakeholders and facilities in pursuing a common goal: provide only the best and safest care to patients. Initially guided by an external consultant, Alegent developed and deployed a best practice-based quality program. For example, we deployed care bundles to reduce infection rates, Hachten explains. Overall, it was not only the best practices that drove our success; it also involved continuous measurement, transparency, and uniformity of practice across all categories and sites of care. Since then, members of the medical staff have been active participants in sustaining and advancing Alegent s quality-focused culture. Not only do they implement, guide and monitor quality initiatives as chief quality officers, but they also influence clinical performance and safe practice as representatives on quality committees. This involvement in committee work has, according to Miller, evolved to a point where our physicians see it as their job to promote and ensure that patient care is of a high quality in all sites of care and all specialty areas. He adds that although physicians are not currently paid for the time and effort it takes to adequately coordinate care for patients, educate them about 32 Reprinted from Healthcare Executive please contact Copyright Clearance Center at info@copyright.com or visit www.copyright.com.
their care and follow up, physicians acknowledge that the data, resources and other support they receive in return enhances the value of their practice and the quality of care for their patients. In that way, Miller says, many times physicians who initially pushed back become champions for our initiatives. Automating manual processes, adopting a prospective rather than a retrospective approach to care and developing tools to support that approach are some other ways that Alegent continues to engage its physicians in its quality-focused culture. It is this same culture that has propelled Alegent to achieve much success. In 2013, it was named one of the top five mid-size health systems and one of the top 15 health systems in the U.S. by Truven Health Analytics. White Memorial Medical Center More than 20 years ago, White Memorial adopted the Baldrige Criteria for Performance Excellence as a framework for establishing and maintaining a quality-focused culture. The criteria turned our normal level of clinical quality and patient safety into a bigger model that is integrated into our strategic planning process, explains Bryant. We evolved across all metrics, and we continue to use that model. Zachary adds, While we have been systematic about building a patient safety program and getting better over the years, however, what really helped us achieve the progress we have made recently was a sentinel event. In 2006, an outbreak of Pseudomonas infection occurred in the neonatal intensive care unit. It was a horrible event, and we all took it personally. We lost a baby. We closed the NICU while we conducted an investigation with the California Department of Health Services and with Children s Hospital Los Angeles, recalls Zachary. It turned out we had not properly cleaned a laryngoscope. Although the event compromised White Memorial s credibility in the I love it when our organizational accomplishments or quality scores are recognized. We share those with our staff and doctors so that they can be proud of the work we do together. Beth D. Zachary, FACHE White Memorial Medical Center community and cost a significant amount of money to correct, it also served as a catalyst for change. Our board said, We re going to recommit our organization to patient safety, Zachary recalls. We turned ourselves inside out and accelerated the work we had been doing. To engage the medical staff in this renewal effort, leaders retained or installed four major mechanisms. First, physicians serve on hospital quality councils and lead medical staff committees, which help us monitor the progress of our clinical and safety targets and set the direction of our clinical quality objectives, says Bryant. Members of the medical staff attend a bi-monthly meeting with senior leaders to address concerns and share in the decision making. Second, physicians steer any initiative that has major implications on patient care, or they co-lead it with a hospital champion, Zachary explains. These initiatives stem from the departmentby-department culture of safety surveys. Departments that are in the danger zone are assigned a hospital executive and a physician who work directly with the department staff, she says. Together, they identify and fix the issue whether it s team communication, technology or medical practice. Third, physicians attend and guide the interdisciplinary care rounds on 34 Reprinted from Healthcare Executive please contact Copyright Clearance Center at info@copyright.com or visit www.copyright.com.
all patient floors. We asked the medical staff how we could make these rounds work. A number of them said they would like to lead them, Zachary says. Physicians were on teams that designed and implemented these rounds. They re on the units every day with hospital staff to make sure we are doing things right; they intervene as needed. Fourth, physicians are in the midst of developing clinical knowledge base alerts in our EMR system, Bryant says. We re getting to the point that they are comfortable with the EMR and are now analyzing what processes are so important that they need to have alerts. But we re also cautious of alert fatigue, so we want alerts triggered only for the most critical processes. California prohibits nonphysicians from employing physicians, which is a barrier to physician engagement. White Memorial, however, strives to overcome that by orienting or reorienting the medical staff to its quality and safety culture, programs, goals and achievements. It also appeals to physicians natural instinct to provide the best care. I love it when our organizational accomplishments or quality scores are recognized by U.S. News & World Report, Healthgrades and Leapfrog, Zachary says. We share those with our staff and doctors so that they can be proud of the work we do together. Bassett Medical Center Ten years ago, Bassett instituted a reach for excellence program with comprehensive components. Over the years, those components have been expanded and refined to award-winning, best-practice levels. We have received numerous national awards from various entities, McKenna says. But it s not the award itself that is important to us; it s the process of getting the care right. That process, she notes, is an ongoing, multidisciplinary effort of planning, doing, checking, and acting to enhance performance and outcomes across the spectrum of care. We believe we can improve constantly; that the journey is never over, she says. We believe ensuring a highquality and safe culture is our obligation to patients, so we are always testing and learning from our process. Bassett, for example, administers the Agency for Healthcare Research & Quality s safety culture survey, which allows people to anonymously report their perception of safety. Survey findings help leaders identify areas for improvement and develop action plans. In this culture, physicians encounter multiple opportunities to contribute and to team up with leaders, managers and front-line staff. For example, We have a robust safety action council of physicians, nurses and staff, says McKenna. They don t just review reports; they take action on how we can be a safer organization for patients and employees. Bassett also deploys a physician administrator dyad to resolve quality or safety issues. For example, if a quality or safety indicator for an area is below target, the work is handed to the physician leader and the administrator or nurse leader of that area, says McKenna. That team does a deep dive to understand and remove the barriers to meeting the target. We then learn from the experience and spread the best practices. Physicians are involved in safety rounding, designing parameters for the EHR system, monitoring and analyzing data and conducting root-cause analyses. Those who don t feel involved are immediately introduced to the many opportunities available. Clinicians are, by nature, high performers; therefore, engaging them in excellence is not hard as long as you do it in the right way, says McKenna. The only pushback we find is when we don t explain well the why and how of what we re doing. Jane Calayag is a freelance writer based in Chicago. Editor s note: Richard Hachten retired from his post as CEO of Alegent Creighton Health in March 2014. 36 Reprinted from Healthcare Executive please contact Copyright Clearance Center at info@copyright.com or visit www.copyright.com.