engaging physicians in quality and performance improvement

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© All Rights Reserved. Engaging Physicians in Quality and Performance Improvement Wendy M. Novicoff, Ph.D. Associate Partner, Creative Healthcare USA Manager and Assistant Professor UVA School of Medicine

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Page 1: Engaging Physicians in Quality and Performance Improvement

© All Rights Reserved.

Engaging Physicians in Quality and Performance

Improvement

Wendy M. Novicoff, Ph.D. Associate Partner, Creative Healthcare USA

Manager and Assistant Professor UVA School of Medicine

Page 2: Engaging Physicians in Quality and Performance Improvement

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ACGME Competency Related to Quality

• According to the ACGME, to be qualified as competent physicians,residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

– analyze practice experience and perform practice-based improvement activities using a systematic methodology

– locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

– obtain and use information about their own population of patients and the larger population from which their patients are drawn

– apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

– use information technology to manage information, access on-line medical information; and support their own education

– facilitate the learning of students and other health care professionals

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Definition of Quality

“ the degree to which health care services for individuals and populations increases the probability of desired health outcomes and is consistent with current professional knowledge of best practice.”

Institute of Medicine, 1990

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How Can Performance Improvement Impact Quality?

Three distinct parts:• Using data and statistics to measure • Using a proven problem-solving

methodology• Employing a management philosophy

with quality as a fundamental goal

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Bringing in EBM and Guidelines

• If we know a specific clinical process is a “best practice” leading to “optimal” outcomes, then variation in that process may constitute a quality deficiency

• If we have no clear “best practice,” then seeking it, or eliminating ineffective practices are desirable goals

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The Purpose of EBM and Practice Guidelines

“The purpose of Evidence-Based Medicine and practice guidelines is to provide a stronger scientific foundation for clinical work, to achieve consistency, efficiency, effectiveness, quality, and safety in medical care.”

Timmermans and MauckHealth Affairs, 2005

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Definition of Clinical Guidelines

Clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

Institute of Medicine, 1990

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How is This Accomplished?Define best medical practice

�Determine why variation occurs

�Make changes in practices and procedures to support shift to best practice

�Monitor the effects of the changes

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Financial Rationale for EBM?

↑↑↑↑ Costs

Present Practice

Revenues ↓↓↓↓Costs ↓↓↓↓ Revenues ↑↑↑↑

Assure best practicesReduce needless variation

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Evidence-Based Medicine

↓↓↓↓ ↓↓↓↓involves managing processes of care

not

managing clinicians

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Supporters of EBM

• Standards will reduce costs, reduce variability, and increase access to care

• Means to measure efficacy, effectiveness, and efficiency of practice using data, not personal experience

• Create better-informed patients and providers• Can be used to make better health policy

decisions based on fact, not politics

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Critics of EBM

• Evidence is not always available or strong enough to make sound guidelines

• Loss of autonomy of individual practitioner

• Disincentive for innovation and progress (“cookbook” medicine)

• May lead to practitioners unprepared for natural variation in patient populations

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Adherence to Guidelines

• Asthma example: surveys showed low compliance with guidelines (between 35% and 68%)

• “Core Measures” example: JCAHO and CMS require adherence to guidelines for care for pneumonia, AMI, and HF patients

• Meta-analysis showed average compliance across conditions at about 50%

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Barriers to Adherence

• Lack of awareness of guideline

• Lack of familiarity with guideline• Lack of agreement with guideline

• Inertia• Autonomy and discretion inherent in

professional work

• Lack of incentive/disincentive to adherence

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Causes of Practice Variation

�Complexity of modern medicine

� Insufficient evidence base for most treatment choices

�Subjective judgment/uncertainty

�Expert medical opinion often anecdotal�Practice guidelines alone may not change

practice

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Quality Improvement in Reducing Variation

0

5

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Data Distributionbefore process improvement

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5

10

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Data Distributionafter process improvement

LCL UCLLCL UCL

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Examples of Variation in Health Care

• Time needed to get test results to MD’s

• Actual time that 2 P.M. medication is actually administered

• Number of transfers per month into ICU• Number on medical records coded per hour• Percent of surgery patients per month that

develop post-op fever/infection

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Must Break the “Cycle of Fear”

Fear“my patients are sicker than yours”

Kill the messengerplace blame

defensive response

Filter the datagame the system, change methods, question data

Micromanagewasted activity & resources

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Lessons from Brent James

1. The core problem is variation in clinical practice.2. Real benefits accrue when inappropriate practice

variations decline.3. For most physicians, financial rewards are

secondary to good patient care. Efforts that emphasize patient care quality are much more successful, even for managing costs, than those that focus on costs alone.

4. Guidelines are nothing new to healthcare.

http://intermountainhealthcare.org/quality/institute/Pages/home.aspx

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Lessons from Brent James

5. “Control” is a central issue.6. Implementing process management requires a

partnership between physicians, administrators, and other stakeholders

7. Local consensus is essential for implementing guidelines.

8. Effective guidelines require feedback on compliance and outcomes, using credible clinical data.

9. Physicians will lead guideline implementation if…values, structures, and realities are aligned

Page 21: Engaging Physicians in Quality and Performance Improvement

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How are Quality Problems Handled?

• Problem: Last month Dr. Smith’s patients had the highest complication rate following Cardiac cath.

• Response: Have the head of the QA Committee send Dr. A a strongly worded letter.

• Results: Next month Dr. Jones’ patients have the highest complication rate.

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How are Quality Problems Handled?

• Problem: The Billing Office is overwhelmed by complaints about errors on patient bills and delays in billing.

• Response: Replace the Nifty Version 3.0 automated system with the SuperCool Deluxe version 4.1.

• Results: During the conversion period 2 weeks of bills are lost. Errors and delays continue.

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How are Quality Problems Handled?

• Problem: a patient is upset because she had to wait 4 hours in the ER before being seen.

• Response: A soothing phone call from a customer relations employee, followed by a written apology from an administrator.

• Results: Customer relations requests 4 more FTEs to handle the increasing workload.

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10 Ways to Sell Change

• Perceived advantage (WIIFM)• Compatible with current practice• Simplicity of usage• Can be tried one at a time• Can be explained using existing lingo• Reversible: can back out if it does not work• Economy: time, money, effort• Credibility of innovator• Dependability• Consequence of failure

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Stakeholder AnalysisStrongly

SupportiveModerately SupportiveNeutral

Moderately Against

StronglyAgainst

Key Stakeholder

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Three D’s Matrix

Negative consequences if actions aren’t followed

Demand

Show how project will positively impact people and processes

Demonstrate

Charts, graphs, statisticsData

ExamplesApproach

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Preparing the Organization

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Elements for Successful Projects

• High frequency events (hourly, daily, weekly)

• Established measures and data collection

• Narrow scope• Jurisdiction – authority to make changes• Significant business impact ($$,

satisfaction, growth etc…)

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But What Is Really Needed?

• Support from Management

• Sponsor• Owner• The “right” team

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Problems In Project Identification

• Having a predetermined solution

• Trying to make “everything” a project instead of making reasonable or necessary changes (Just Do It)

• Projects that focus on improving inputs exterior to the department or company– Increases complexity and time for project– Great likelihood that solution may not be

implemented unless project partnering exists

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Adding Structure

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Integration with Existing Methods

• Most institutions have existing programs – do not dismiss previous work or prior training

• Build on success and use “failures” as launch pad for new projects

• Promote the “toolbox” approach

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Guiding Principles

• GPs give a framework for all project work

• Example primary guiding principle: a quality process is safe, evidence-based, patient-centered and efficient

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Pick the Right Project Leaders

• These are often not the people you assume they will be:– Prior training can be a barrier– Need to get people at the right level

• Don’t underestimate personality inventories

• Build a “team” of people with different strengths

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Required Training at All Levels

• All leadership (managers and above) required to attend two-hour session

• All leaders required to participate in one project per year as either Project Champion or “support” person

• All employees required to attend at least 20-minute introductory session

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Support Systems and Communication Plans

• All trainees given two support people in addition to team members and Project Champion– Manager-level – Prior trainee

• Regular tollgate reviews with standardized forms• “Graduation” certificates• Broad-based, multi-modal communication plan• Semi-annual project fairs in public areas

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Project Examples

Page 38: Engaging Physicians in Quality and Performance Improvement

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Comprehensive Improvement in Orthopaedics

Outpatient Clinics

Page 39: Engaging Physicians in Quality and Performance Improvement

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Major Areas for Improvement

• Patient safety• Access/scheduling• Clinic throughput• Nurse triage• Employee satisfaction • Patient satisfaction

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Prioritization – The Pay-Off Matrix

High Hards

Jewels

DROPLow Hanging Fruit

high

PAYOFF

low

easy EFFORT hard

Page 41: Engaging Physicians in Quality and Performance Improvement

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Measureable Impacts So Far…

• Average wait time on the phone (Call Center) has been reduced from 78 seconds down to 17 seconds.

• Percent of calls answered after 30 seconds went from a high of 58.2% to 14.3%.

• Phone abandonment rate went from a high of 18% down to 2%.

• Time to third next available appointment has seen a significant trend downward for all physicians.

• Average days to 3rd available appointment was 19 days in 2008-2009; it is now an average of 13 days.

• Patients reporting that they would “Definitely Recommend” the practice went from 70% in Spring 2009 to 76% in Fall 2009.

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Improving Compliance with Core Measures

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Tell ‘Em Like It Is

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A Little Competition Never Hurts…

Physician names go here – for ALL to see

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Updating Inpatient Status

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Current State

• Rule: Observation patients must be discharged or reclassified as inpatients within 24 hours

• Problem: Average time from patient entering system to decision about discharge was 25 hours, 24 minutes (range = 8 hours to 3 days)

• Current Medical Center policy: – 24-hour response time allowed for consults,

radiology, and cardio-pulmonary testing – 6-hour turn-around time for lab testing

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Future State

• Improvements focused on revising standard operating procedures and institutional policy– Limiting turn-around-time for decisions and testing– Introduction of ordering templates to streamline

communication– Transfer of patients to hospitalists if attending MDs

were not responsive• Total mean time savings: 15 hours, 27

minutes• Still room for improvement, but much better

turn-around-time with relatively little effort