RECOGNIZING AND REWARDING MEDICAL EXCELLENCE Kenneth W. Kizer, M.D., M.P.H. Distinguished Professor and Director Institute for Population Health Improvement University of California Davis Health System March 7, 2013
Presentation Preview Offer a historical perspective on the quest for high quality health care and clinical excellence Attempt to describe what is known to constitute clinical excellence Briefly highlight why it is especially important to recognize and reward clinical excellence today
WHAT IS THE INSTITUTE FOR POPULATION HEALTH IMPROVEMENT, UC DAVIS HEALTH SYSTEM?
Institute for Population Health Improvement Established as an independent operating unit in the University of California Davis Health System in mid-2011; has since developed a diverse portfolio of funded activities >$70M Population health the intersection of public health and the clinical sciences New value-based health care payment models require that population health management be a core competency for health care systems Serves as a resource for health care reform, health policy and clinical quality improvement Assists government health-related agencies in designing, implementing and administering programs Seeks to Improve the effectiveness and efficiency of clinical care Build health leadership and health care management capacity Leverage data sources to develop clinical intelligence Promotes understanding of the multiple determinants of health and appreciation of health being a function of the totality of one s circumstances
REPRESENTATIVE IPHI ACTIVITIES Provide technical assistance in quality improvement and other support to the state Department of Health Care Services for Medi-Cal (California s $60+B/yr Medicaid program) Medi-Cal Quality Improvement Program Delivery System Reform Incentive Payments (DSRIP) Program Designing the CA-specific Evaluation of the California Coordinated Care Initiative California s Non-Designated Public Hospitals DSRIP-like Initiative Manage operations of the California Cancer Registry Manage the California Health Information Exchange Development Program Provide technical assistance and support for multiple statewide chronic disease prevention and surveillance programs (e,g, heart disease, stroke, arthritis, tobacco control, cervical and breast cancer screening, healthy eating, active living) Conducting a statewide assessment of surgical adverse events Investigating the feasibility of developing Community Paramedicine Conducting various population health research programs Use of the OncotypeDx Genetic Assay in Medi-Cal Beneficiaries with Breast Cancer
THE QUEST FOR CLINICAL EXCELLENCE IS NOT NEW
The Quest for Clinical Excellence If a physician make a large incision with the operating knife and cure it,, he shall receive ten shekels in money. If a physician make a large incision with the operating knife, and kill him,, his hands shall be cut off. Code of Hammurabi, ca 1772 BC
The Quest for Clinical Excellence I would give great praise to the physician whose mistakes are small for perfect accuracy is seldom to be seen Hippocrates, ca 430 BC
Arete - The ancient Greek concept of excellence (also translated as virtue) or being the best you can be or reaching your highest human potential. This notion of excellence was linked with the notion of the fulfillment of purpose or reason for being: the act of living up to one's full potential. Also taken to mean using all of one s faculties to achieve the highest effectiveness.
The Quest for Clinical Excellence Grant me the courage to realize my daily mistakes so that tomorrow I shall be able to see and understand in a better light what I could not comprehend in the dim light of yesterday Maimonides (1135-1204)
The Quest for Clinical Excellence Students notoriously vote with their feet, seeking out the best and most innovative teachers of their subject. The most ambitious students have been travelling long distances for their education since universities were first founded in the thirteenth century, making their own educational pilgrimage or peregrination.
The Quest for Clinical Excellence... even admitting to the full extent the great value of the hospital improvements in recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable. Florence Nightingale, 1863
The Quest for Clinical Excellence To understand God s thoughts, we must study statistics, for these are the measure of His purpose.. Florence Nightingale
The Quest for Clinical Excellence In 1914, Earnest A. Codman, MD, advanced the concept of quality assurance (aka quality control) based on identifying and weeding out deficient practitioners
The Quest for Clinical Excellence Avedis Donabedian, MD, father of modern healthcare quality and medical outcomes research In the 1960s, advanced a framework for viewing healthcare quality: Structure Process Outcomes
Evolving Concepts of Healthcare Quality: Learning from Manufacturing Industrial quality improvement in mid- and late 1900s based on the teachings of - Walter A. Shewhart PDCA cycle, reduce variation, statistical process control Philip B. Crosby zero defects William E. Deming 14 principles; popularized PDCA, In God we trust. All others bring data. Kaoru Ishikawa fishbone cause and effect diagrams, quality circles Joseph M. Juran 80/20 rule, role of culture Peter Drucker decentralization, simplyfication, You can only manage what you measure Total Quality Management (TQM) Continuous Quality Improvement (CQI)
U.S. Healthcare Quality Tipping Point IOM National Roundtable on Health Care Quality. The Urgent Need to Improve Health Care Quality. JAMA 1998: 280: 1000-1005 Quality First: Better Health Care for All Americans, President s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998 The Milbank Quarterly, 1998; Vol 76 : #4 esp paper by Schuster, McGlynn and Brook, How Good is the Quality of Health Care in the United States pp 517-63 Ensuring Quality Cancer Care. IOM. 1999 To Err is Human: Building a Safer Health System. IOM. 2000 Crossing the Quality Chasm: A New Health System for the 21 st Century. IOM. 2001
The Quest for Clinical Excellence Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous Sir Cyril Chantler, Lancet 1999
THE SEARCH FOR CLINICAL EXCELLENCE HAS BEEN GOING ON FOR AT LEAST 4,000 YEARS.BUT THE SCIENCE AND TECHNOLOGY OF CLINICAL QUALITY IMPROVEMENT HAS ONLY BEGUN TO MATURE VERY RECENTLY.
What Do We Know About Achieving Individual Clinical Excellence? Not as much as we should While we tend to recognize it when we see it, the science of clinical excellence is poorly developed and primarily qualitative There is no single defining characteristic of clinical excellence; it is multi-factorial
ACHIEVING CLINICAL EXCELLENCE REQUIRES CERTAIN CORE ATTRIBUTES AND DOING MANY THINGS EXCEPTIONALLY WELL
What is Clinical Excellence? THE 10 DEFINING CHARACTERISTICS OF INDIVIDUAL CLINICAL EXCELLENCE
Defining Characteristics of Medical Excellence #1 BROAD AND DEEP KNOWLEDGE Outstanding knowledge of the subject and matters in general are foundational Demonstrates a high degree of curiosity and a large appetite for learning
Defining Characteristics of Medical Excellence #2 DIAGNOSTIC AND TECHNICAL ACUMEN Thorough, careful, deliberative Analytic Keen ability to distinguish what is important from the background noise and to piece disparate parts into a coherent whole Outstanding judgment and intuition in the face of uncertainty Demonstrates wisdom
Defining Characteristics of Medical Excellence #3 INTERPERSONAL SKILLS Outstanding communicator, good listener Adept at tailoring the presentation of complex concepts and data to create understanding Ability to quickly connect and forge a meaningful relationship with patients and colleagues Inspires confidence and trust Responsive to and considerate of others Good teammate Flexible, adaptable Has a calming effect, relieves stress and anxiety in patients Able to help patients regain control
Defining Characteristics of Medical Excellence #4 PROFESSIONALISM Patient s interests take precedence over selfinterest Commitment to vulnerable or less fortunate populations Civic engagement and service for the common good Ability to balance one s multiple commitments (including patients, peers, organizational, society)
Defining Characteristics of Medical Excellence #5 Compassionate, genuinely caring, altruistic Thoughtful, reflective HUMANISM Nonjudgmental, understanding, forgiving Honest, trustworthy, high integrity Available and accessible to patients and colleagues, giving of his/her time Dedicated, committed Treats every patient equally Advocates for his/her patient
Defining Characteristics of Medical Excellence #6 WISE USE OF RESOURCES Practices evidence-based medicine Orders diagnostic tests judiciously and for clear and appropriate reasons Knows how to get things done
Defining Characteristics of Medical Excellence #7 SCHOLARLY APPROACH TO PRACTICE Thoughtful application of scientific knowledge and evidence to real world human circumstances and situations Logical, reasoned clinical decision making Reflective, deliberative Seeks to disseminate clinical knowledge and new findings
Defining Characteristics of Medical Excellence #8 PASSION FOR CLINICAL MEDICINE Enjoys doing it Dedication and commitment Infectious enthusiasm that is charismatic
Defining Characteristics of Medical Excellence #9 DESIRE FOR IMPROVEMENT Not satisfied with the status quo Forward looking Continually trying to improve both personal skills and systems of care delivery Willingness to lead change
Defining Characteristics of Medical Excellence #10 REPUTATION Respected and renowned by colleagues for past and continued accomplishments Sought out for especially complex problems or to treat VIPs Sought out by peers
AMERICAN HEALTH CARE IS IN A TIME OF PROFOUND CHANGE. AND WITH GREAT CHANGE COMES GREAT UNCERTAINTY ABOUT WHAT IS IMPORTANT
HEALTH CARE IN TRANSITION Affordable Care Act and Other Health Care Reform New Science and Technology New Payment Models Increased Demand for Services Deteriorating Population Health Culture Change; Changing Clinician-Patient Relationships
Stein s Law Things that can t go on forever, don t. Herbert Stein Chairman, Council of Economic Advisors for Presidents Nixon and Ford
WE MUST ESPECIALLY RECOGNIZE AND REWARD CLINICAL EXCELLENCE IN THESE TIMES OF CHANGE AND ITS MANY POTENTIALLY CONFUSING SIGNALS
Recognizing and Rewarding Clinical Excellence is Essential to the Future of Academic Medicine Retention and recruitment of faculty Teaching and providing role models for trainees Ensuring a future health care culture that values clinical excellence
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