engaging physicians in the health care revolution thomas h. lee, md chief medical officer, press...

Engaging Physicians in the Health Care Revolution

Thomas H. Lee, MD

Chief Medical Officer, Press GaneyProfessor (Part Time) of Medicine, Harvard Medical SchoolProfessor of Health Policy and Management, Harvard School of Public Health

December 8, 2015

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Values Spread With Same Patterns as Infectious Diseases

© 2015 Press Ganey Associates, Inc.

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How Do We Deliver What Our Patients Need?


• We are entering a marketplace driven by competition on value:• Meeting patients’ needs• Doing so as efficiently as

possible• To thrive in this marketplace, health

care providers must:• Understand the root causes of

the chaos of modern medicine• Recognize the imperatives to

improve• Measure – and use data wisely• Develop social capital and use

social network science to make high value health care the norm, not an exception

4© 2015 Press Ganey Associates, Inc.

What Do Patients Really Value? Outpatient Analysis

High: Confidence in Provider1.9% Fail to Recommend

High: Worked Together28% Fail to Recommend

Low: Worked Together90% Fail to Recommend

Low: Confidence in Provider74.6% Fail to Recommend

High: Concern for

Worries0.6% Fail

Low: Concern for

Worries5.6% Fail

High: Concern for

Worries6.3% Fail

Low: Concern for

Worries22.3% Fail

High: Listens

Carefully24.7% Fail

Low: Listens

Carefully45.7% Fail

High: Courtesy

78.2% Fail

Low: Courtesy

92.8% Fail

3% of patients 68.4% of patients2.4% of patients 5.9% of patients0.8% of patients 3.4% of patients11.4% of patients 2.5% of patients

High: Worked Together1% Fail to Recommend

Low: Worked Together11% Fail to Recommend

8% of patients 72% of patients14% of patients 5% of patients

81% of patients19% of patients

All Patients15.7%

Recommendation Failure Rate

High Risk Low Risk


Emergency Departments

High: Info re delays

97.0% LTR

Low: Info re delays

82.6% LTR

High: Info care at home

77.5% LTR

Low: Info care at home

56.0% LTR

High: RN attn to needs

58.1% LTR

Low: RN attn to needs

33.3% LTR

High: Info care at home

38.4% LTR

Low: Info care at home

10.3% LTR

8.5% of patients 37.3% of patients2.6% of patients 3.7% of patients6.5% of patients 6.2% of patients20.4% of patients 2.1% of patients

Low: Dr Courtesy12.9% Top Box LTR

High: Staff cared about you91.4% Top Box LTR

High: Dr Courtesy45.4% Top Box LTR

Low: Staff cared about you24.1% Top Box LTR

High: Dr kept you informed94.5% Top Box LTR

Low: Dr kept you informed68.6% Top Box LTR

6.6% of patients 51.2% of patients23.6% of patients 12.9% of patients

59.0% of patients37.4% of patients

All Patients65.0%

Top Box LTR (% Very Good)

Low = Non-Top Box ResponseHigh = Top Box Response


Association Disappears When Information is Accounted For

Mean Score Likelihood to Recommend

How Long Did You Wait in the ED?

Info

rmat

ion

re D

elay

s


Good, Better, and Best News From the Data

Good news: The factors that drive likelihood of recommending providers are within our control: Coordination Communication Empathy

Better news: The factors are the same across all settings of care.

Best news: The factors are completely consistent with our most noble professional values

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Four Key Influences


Michael Porter, Ph.D. – Harvard Business School. Strategy as the response to competition; organizing around improving value – i.e., meeting needs as efficiently as possible.

Leemore Dafney, Ph.D. – Kellogg School of Management. Competition at every level of the health care system as the best driver of improvement.

Ronald Burt, Ph.D. – University of Chicago. Social capital, the relationships among people that allow organizations to achieve goals it otherwise could not achieve .

Nicholas Christakis, MD, Ph.D. – Yale. Use of social network science to foster spread of values, making empathic, coordinated, high value care the norm rather than happy accidents.

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Four Key Influences






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Re-thinking Strategy


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Strategy vs Operational Effectiveness

Operational effectiveness – doing a better job at what we currently do

Learning best practices from others

Taking waste and unreliability out of the processes

Attracting and retaining good people

Working hard

Strategy – making choices about what we will do

Two key questions:

– What are we trying to do for whom?

– How are we going to be different?


Operational effectiveness is and will always be critically important – but the new health care marketplace demands choices and the development of a real strategy


An Overall Strategic Framework

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A Six Component Framework


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Four Key Influences






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Merging With Others Is Not a Strategy


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Why This Time Is Different

Middle class budgets are stretched Powerful trend that you can expect to accelerate:

Patients/consumers are picking health insurance products that they can afford:

– On exchanges– With more choices at employer open enrollment

Bundled payment initiatives are starting to get traction

Implication: The market is moving toward competition on value – alternative options are … unattractive!


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• Providers and payers have been nervous about competition for several reasons.

• Risk aversion

• Not organized in teams to create value

• Conflict aversion

• Paralyzed by exceptions

• Competition for market share puts the focus on improvement of actual outcomes of patients (and efficiency)

• Improvement requires learning new ways to do things and collaboration (rather than just working harder)

Competition Drives Improvement


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• Providers who anticipate and embrace competition are more likely to be successful

• To overcome causes of paralysis takes:

• External pressures that reinforce intrinsic motivations

• Leadership

• Teamwork

• Creation of social capital

Take Home Messages re: Competition


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Four Key Influences






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• Focused and effective teamwork

• Multidisciplinary

• Clear roles and responsibilities

• Ready to fill in for each other

• Value orientation

• Meeting patients’ needs

• Efficiency

• Reliable

• Striving to improve

• Proud

The Real Competitive Differentiators for 21st Century Systems


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• Relationships that enable organizations to accomplish goals they otherwise could not.

• Brokerage

• Increases variation within organizations

• Nurturing new ideas

• Bringing in ideas from other places

• Closure

• Reduces variation

• Convergence on best practices

• Requires trust – confidence that you will be treated fairly in situations that you have not even thought of yet

Social Capital


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1. Making people in two different organizations aware of each other’s interests and challenges.

2. Transferring best practices

3. Drawing analogies between two groups that were thought to be irrelevant to each other

4. Synthesis -- Creating something that does not exist on either side of “the bridge”

Brokerage – Four Levels


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Closure: Max Weber’s Four Models for Social Action

1. Tradition – e.g., Mayo Dress Code

2. Self-interest – e.g., Performance bonuses

3. Affection – e.g., Peer pressure

4. Shared purpose – e.g., Reducing suffering

• We need to press all four levers. • But the first lever that must be pressed is creation of Shared

Purpose.• In isolation, any of the other three levers is ineffective or

potentially perverse.• But in pursuit of a shared purpose, all three other levers can

be embraced.


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Four Key Influences






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1. Connections matter Who had ties to who

The strength and durability of those ties

Patterns are important, e.g.:

– Tom has 3 friends

– Kelly has 3 friends, and they know each other

2. Contagion

One positive person can make group more positive

One negative person can make group more negative

Happiness matters -- Isolated/lonely people impede team performance

Social Network Science – Two Key Points


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1. We shape our networks Most people have 4 close social contacts (range 2-6)

12% cannot name any

Only 5% have 8 or more

Transitivity matters

2. Our networks shape us

JG courtship example

3. Our friends affect us

Social networks are agnostic – they amplify

4. Our friends’ friends’ friends affect us

3 degrees rule

Stimulus crowds

Rules of Networks


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Transparency: Screen Shot From University of Utah Find-a-Doctor Site


NURTUREa culture ofcontinuousinnovation

HOW DO WE

Transform the system?

DEVELOPyour

teams

ESTABLISHmetrics

ENGAGEphysicians

staff and trainees

EMPOWERfront-lines

COMMUNICATEthe need for change

© Vivian S. Lee, 2014

Patient SatisfactionPROVIDERS AT 99TH %ILE OR ABOVE

% o

f t

ota

l pro

vid

ers

2009 2010 2011 2012 2013 20140%

5%

10%

15%

20%

25%

30%

1%3%

13%

17%

25%26%

*All Facilities Database includes the following

Number of Physicians: 142,411Number of Patients: 2,783,597

And the number of dollars that U of Utah physicians have in incentives for improving

patient experience is …

$0

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1. Embrace value as the overarching goal of health care

2. Embrace market forces as drivers of a new health care marketplace

3. Recognize competition as the secret sauce for a better health care system.

4. Embrace empathic, coordinated care as core components of high value health care.

5. Measure the outcomes that matter to patients.

6. Organize to improve those outcomes -- and do so efficiently.

7. Make social capital as important as financial capital.

8. Identify the teams that are the real units of value creation – and use social network science to enhance their effectiveness

9. Use financial incentives for financial issues

10. Use non-financial incentives for non-financial issues, including driving the organization’s epidemic of empathy.

Ten Key Steps Forward


engaging physicians in the health care revolution thomas h. lee, md chief medical officer, press...

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