Leadership in the Era of Risk Bruce McCarthy, M.D., M.P.H. President, Ascension Medical Group Wisconsin Nov. 16, 2016
Outline Who We Are Our Results Establish The Why Develop Structures to Promote Leadership Teaching Leaders to Lead Using Incentives
Ascension WI 27 Hospitals 114 Primary Care Clinics Multispecialty Group with 950 MDs and 1300 Total Providers Columbia St. Mary s 4 Hospitals 26 Primary Care Clinics Multispecialty Group with 300 MDs and 400 Total Providers 3
Our Journey to Population Health 4
Increasing Responsibility for Value Publicly Reported Data Wisconsin Collaborative for Health Care Quality (WCHQ) P4P Medicare Advantage and Commercial Gainsharing Narrow Networks Owned Health Plan Network Health - 137,000 members Medicare Advantage Full Risk 2017
Steady Improvement in Quality Measures 90% 85% 80% 75% 70% 65% 60% Breast Cancer Screening Colon Cancer Screening DM A1C Control <8 DM BP Control <140/90 55% FY10 FY11 FY12 FY13 FY14 FY15 FY16 6
A Leader in Quality in the State 7
Medicare Advantage Quality Performance 2015 ACO Metric Breast Cancer Screening Colorectal Cancer Screening Diabetes Care: A1c <9.0% Diabetes Care: Cholesterol Screening Diabetes Care: Controlling BP Diabetes Care: Eye Exam Diabetes Care: Renal Monitoring Adult BMI Assessment All Cause Readmission ACO Metric Osteoporosis Mgmt in Women w/ Fx Rheumatoid Arthritis Rx Mgmt SNP Medication Review SNP Functional Assessment SNP Pain Screening Monitoring Physical Activity Monitoring Bladder Control Reducing the Risk of Falling Nephropathy Screening - Diabetic Medicare Advantage Financial Performance 2014/2015 2014 2015 Medical Loss Ratio 79.8% 78.3% 8
What has worked? Policies, Workflows Team-based Care Leadership Creating a Culture
Establish The Why and Create a Tangible Vision 10
First establish What are we fighting for? Establish the bigger vision, e.g. FFV, strategic intent, and our mission Also the specific rationale for a given change Colon cancer is the second leading cause of cancer death in the U.S. There is convincing evidence that screening can prevent 20 colon cancer deaths for every 1,000 patients screened. Screening for Colorectal Cancer. US Preventive Services Task Force Recommendation Statement, 2016 Approximately 1 in 5 Medicare patients discharged from the hospital are readmitted within 30 days. Readmissions can be reduced by 20% with effective care management. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. Leppin AL, et. Al. JAMA Intern Med. 2014;174(7):1095. Resource: Simon Sinek: How great leaders inspire action. TEDxPuget Sound 18:04 Filmed Sep 2009 You Tube
Establish the moral high ground Focus on the why Don t talk about the numbers, talk about patients Don t focus on patients we can t help, focus on the ones we can Use patient stories (e.g. patients who have been readmitted) Explain the importance of financial success too
Create Transparency with Other Systems Show the gap between what is and what s possible
Align Leadership 14
Establish Dyad Leadership Examining the "dyad" as a management model in integrated health systems. Zismer DK, Brueggeman J. Physician Exec. 2010 Jan-Feb;36(1):14-9 15
Leadership Structure To Support Physician Voice and Accountability Medical Group Board CSM President CSM COO Medical Group Operations Council Quality Committee Regional Medical Director Regional Director Regional Medical Director Regional Director Compensation Committee Lead MD Mgr Physicians Lead MD Mgr Physicians Lead MD Mgr Physicians Regional Leadership Council Clinic Meeting
Spread Change 17
Execute a specific communication plan that includes the staff Craft simple, consistent, evidence-based messages that are meaningful and transmissible Create a drumbeat Have local leaders, and opinion leaders, carry the message Ask MDs to present to staff the why and what specifically we are asking them to do Check that the message got through Every physician and staff member should be able to articulate the why.
Prove that systems can support practice and improve care Evidence-based Practice : Pilot new workflows/policies or visit sites that already use them or check the literature Consistency breeds reliability
Implement Process Changes Get specific about the what and the who Measure a lot Coach a lot Tenaciously check that workflows and policies are reliably followed every time Establish culture through action A policy not observed is much worse than no policy at all.
Teach Leaders to Lead 21
Teach Leaders to Lead Quarterly Leadership Meetings Create a learning collaborative (and support group) Develop specific skills How to be a good dyad partner Communicating the evidence and importance Leader rounding on staff Leader rounding on physicians Coaching
Coaching Influencing skills Positive feedback Teach Leaders to Lead Coaching skills for 1:1 meetings with physicians Dealing with Resistance Crucial Conversations All change eventually requires one clinician to talk to another about changing behavior.
Use Incentives 24
What We Know About Incentives Three basic types of incentives: Financial Social Moral (intrinsic) Financial incentives change behavior. 36
What We Know About Incentives Mastery, Purpose, Autonomy Resources: Dan Pink: The puzzle of motivation TEDGlobal 2009 18:36 Filmed Jul 2009 RSA ANIMATE: Drive: The surprising truth about what motivates us. YouTube 10:48 36
Drive: The surprising truth about what motivates us 27
Problems with Financial Incentives Financial Incentives Can Create a Culture of Do This Get That. When the financial incentive stops so does the behavior. Financial incentives change how you feel about what you get paid for. Financial incentives can displace social and intrinsic motivation. Social and Intrinsic Incentives are More Powerful and More Flexible then Financial Incentives. Financial incentive systems are too much work. 34
An Alternative: Use Intrinsic and Social Incentives to Change Behavior 29
Appeal to Intrinsic Motivation Use comparative data (Mastery) Involve them in designing solutions (Autonomy) Focus on the why (Purpose) 34
Use Social Incentives Transparent data (internal and external) Involve the staff Leadership reinforcement and coaching Opinion leader discussions 39
Create Transparency within Medical Group Percent Receiving Colorectal CA Screening by Clinic (Visits through September 2016, n = 45,955) 100% 95% 90% 85% 80% 75% 70% 65% 60% FY 16 Goal (82.0%) 32
Create Transparency within Medical Group Percent of HTN Patients with BP Controlled 33
Use Social Incentives Coaching Peer Reviews Leadership Crucial Conversations (Performance Improvement Process for physicians) 39
When to Use Financial Incentives For activities not intrinsically motivating To compensate for non-rvu work Time spent in care management activities Form completion To allow gain-sharing For group goals When there are resources/help to reach goals 39
Conclusions Leadership is everything Establish The Why Develop Structures to Promote Leadership Teaching Leaders to Lead Use the right Incentives
Appendix PERFORMANCE IMPROVEMENT PROCESS The process is designed to give senior leadership staff an orderly way of addressing various types of performance and behavior issues and to protect the organization from claims or discrimination and/or wrongful discharge. The process will also facilitate coaching and decision-making on the part of physicians regarding their performance and in some cases the advisability of continuing his/her employment with Columbia St. Mary s (CSM). These are guidelines and there will be circumstances in which deviation from these guidelines may be appropriate. PROCESS: This process pertains to matters of conduct as well as the staff member s practice patterns. Any staff member who does not display satisfactory performance in his or her position may, in certain cases, without resorting to the steps set forth in this process be subject to Corrective Action pursuant to the Columbia St. Mary s Bylaws. CSM requires that staff conform to certain standards of patient care, productivity, customer service, conduct, work performance and follow defined administrative practices and procedures. When a problem arises in these areas, the Senior Leadership will coach the staff member with the objective of finding an effective solution. If, however, the member fails to respond or an incident occurs requiring formal intervention, the following three-step process should be used. There is no minimum timeframe for each step. Under normal circumstances, Senior Leadership are expected to follow the three-step process below. There may be particular situations, however, in which the seriousness of the offense justifies the omission of one or more of the steps in the procedure. Likewise, there may be times when CSM may decide it is appropriate to repeat a step. Human Resources will be consulted when these situations may be indicated. Definitions: Senior Medical Leadership: Chief Medical Officer, District Medical Directors, Lead Physicians 37
Step One: Advisory 1. The Senior Leadership will meet with the member making sure that the member understands the nature of the problem and expected remedy. The purpose of the conversation is to remind the member of exactly what the rule of performance expectation is and remind him/her of his/her responsibility to meet that expectation. 2. The staff member will be informed that the Advisory is the first step of the process. 3. The Senior Leader will fully document the Advisory. If the problem is corrected, the Advisory will be deactivated after 12 months. 4. Documentation remains in the department and is not placed in the staff member s permanent record unless another incident requiring intervention occurs. Step Two: Warning If the staff member s performance doesn t improve or if, while the Advisory is active, there is another violation of CSM practices, rules or standards of conduct, the Senior Leader will discuss the issues with him/her after reviewing the situation. Note that the second violation need not be the same as the first violation. During this discussion, the Senior Leader will emphasize the seriousness of the problem and need for the member to immediately remedy the problem. Following the conversation, the Senior Leader will: 1. Write a memo summarizing the discussion to the staff member. 2. The original memo will go to the staff member, with a copy sent to Human Resources along with the Advisory. 3. Human Resources will place the copy in the member s permanent file to which the staff member may submit his/her written response to the issues discussed. 38
Step Three: Decision-Making Leave If the staff member s performance doesn t improve, or the Warning is still active and he/she again violates CSM practices, rules or standards of conduct, the member will be placed on a Decision-Making Leave. This is the final step in the CSM Performance Improvement Process. The Decision-Making Leave is a paid administrative leave of one to five days. The member spends time away from work deciding whether to correct the immediate problem and conform to all CSM practices, rules and standards of conduct or resign and terminate his/her employment with CSM. If the decision is to return to work and abide by the CSM practices, rules and standards of conduct, the Senior Leader will write a letter to the member outlining areas of concern, expectations for improvement and consequences for failing to meet this commitment. The member will be required to sign the letter to acknowledge receipt and concurrence. A copy is sent to the Vice President, Human Resources and another copy will be forwarded to Human Resources to be placed in the member s personnel file. The member returns to work with the understanding that if a positive change in behavior does not occur immediately, or another problem surfaces over the next 24 months, the physician will be terminated. If the member is unwilling to make this commitment, action may be taken against the staff member, which may result in termination. This policy does not negate or avoid the obligation of CSM of State or Federal reporting, if the conduct requires reporting. If no further problems occur during the active period, the process will be formally deactivated at the end of the appropriate time period (Advisory = 12 months, Warning = 24 months, Decision-Making Leave = 24 months). The Senior Leader will initiate a memo advising the member of the inactive status and, where appropriate, commend him/her on performance improvement. Nevertheless, the written reminders and documentation relative to Decision-Making Leaves will remain in the staff member s personnel file for a period of at least 5 years, after which they may be expunged. NOTE: Steps taken and documentation prepared in accordance with this process does not constitute Corrective Action under the CSM Bylaws. Accordingly, staff members affected by the Performance Improvement Process are not accorded the procedural rights available under the Bylaws. 39