to keep doing things the same way results annual meeting presentations/general sessions...eligible...
TRANSCRIPT
1 ©Jay Kaplan, M.D. & Studer Group 2013
Physician Engagement & Collaboration
Jay Kaplan, MD, FACEP
Practicing Clinician and Director, Service/Operational Excellence, CEP America
Medical Director, Studer Group
Board of Directors, American College of Emergency Physicians
Caveat #1: What Brought Us to this Dance . . .
Ain’t Going to Get Us to the Next One . . . .
To keep doing things
the same way
and expect different
results . . .
Caveat #2 –The Best Definition of Madness is
2 ©Jay Kaplan, M.D. & Studer Group 2013
Caveat #3 How Most of Us Approach Change
Caveat #4: Double Vision is Required
Systems People
PatientsStaffProcess Outcomes
Physicians
While we give care seemingly individually,
The Patient and Family Experience is dependent upon the coordinated actions of all members of the team . . .
From the moment they walk in, to the moment they walk out or on . . .
Success is never achieved alone.
If it’s not always . . . It’s not great . . .
Caveat #5: It’s About The Team
3 ©Jay Kaplan, M.D. & Studer Group 2013
The Big Question
How can you, as an organization, create a consistent high quality compassionate experience for your patients, despite:
Staff Diversity
Different approaches/training
Different years of experience
Different and rotating personnel
The pressures for doing more with less
Time – Time – Time
????
If it is about “Always,” What is Required …
Consistency of Practice
Dependability of Performance
Uniformity of Behavior
And yet . . .
The American Journal of Medicine(2012) 125, 356-364.
Variation in Clinical Practice is Rampant
4 ©Jay Kaplan, M.D. & Studer Group 2013
Head CT examinations were ordered in 8.9% of emergency department visits
Unadjusted rate of head CT ordering 4.4–16.9% overall, per physicianFor patients diagnosed with atraumatic headaches 15.2–61.7%
Two-fold variation in overall head CT ordering (6.5–13.5%), Three-fold variation in head CT ordering for atraumatic headache (21.2–60.1%). Variation persisted after adjustment for confounding variables.
Variation in Clinical Practice
Where We AreHow We Need to Feel . . . What We Need to Do
Burnout and Satisfaction with Work-Life Balance – Arch Int Med August 2012
Physicians who reported at least 1 symptom of burnout
Compared to gen population, likelihood of burnout
Compared to gen population, dissatisfaction with work-life balance
45.8%
increased 10.1%
increased 17%
5 ©Jay Kaplan, M.D. & Studer Group 2013
Emergency Medicine
Gen Internal Medicine
Int Medicine Subsp
General Pediatrics
General Surgery
Mean
Orthopedic Surgery
Family Medicine
Ob/GYN
Gen Surgery Subsp
Preventive Med/Occ Health
A Plain Fact
Physicians are not trained for many of the roles they are being asked to play in today’s healthcare environment.
And even the role for which they were trained . . . has changed.
The Roles We Must Play . . . Every Day
Define the Vision and Get Everyone on Board (Leader)
Help Create a Great Practice Environment -Fix the Systems (Manager)
Engage Your Staff and Providers - Create The Team (Team Player)
Ensure Consistent Clinical Quality and Compassion (Healer)
6 ©Jay Kaplan, M.D. & Studer Group 2013
“ER”
Key Definitions
Engage (The Why)
to attract and hold by influence or power; to pledge oneself; to begin and carry on an enterprise or activity
Align (The What)
to get or fall into line; to be in or come into precise adjustment or correct relative position
Creating Physician Trust
If physicians don’t trust those that lead them,
they will, at best, become indifferent and
uninvolved in organizational efforts. More
likely, they will protest and resist efforts to
defend their differing agenda.
7 ©Jay Kaplan, M.D. & Studer Group 2013
Path for Hospital/Practice Leaders
Create the Burning Platform
Connect Service and Quality
Define the Experience/Service Economy
Answer “What’s in it for me?” (closer to now and to home)
What you can ask physicians to do for you
To improve the patient experience
To improve the team
To help themselves
The Burning Platform
Declining Reimbursement
Workforce Shortage
Malpractice Risk
Transparency of Data
Pay for Performance – VBP
Quality and Service are Inseparable
Relationship between patient satisfaction, complaints and lawsuits
Physicians with lower patient satisfaction results are more likely to have patient complaints (RR 1.79;95% CI 1.38-2.33; p<.001)
Each one point decrement in patient satisfaction scores is associated with a –
6% increase in complaints (RR 1.06, 95% CI 1.03 – 1.08;p<.0001)
5% increase in risk management episodes (RR 1.05, 95% CcI 1.01 – 1.09;p< .008)
Lower performing physicians were at greater risks for lawsuits (RR = 2.10;p 95% CI 1.13 – 3.90; p<.019)
75% of complaints were related to communication issues
Stelfox HT, et al, The American Journal of Medicine 2005; 118: 1126 – 1133
8 ©Jay Kaplan, M.D. & Studer Group 2013
The Transparent Environment –Quality On-Line
Pay for Performance for Hospitals is Here . . .
Core Measures(45% Weight)
HCAHPS Composites(30% Weight)
1.25% Base operating DRG payments
50th percentile or improved over the previous reporting period to “win” the $ back!
Outcomes(25% Weight)Note: Implementation FY 2014
Source: OPPS VBP Final rule 11.1.11
Pay for Performance for Physicians Coming Soon . . .
Quality
PQRS = Physician Quality Reporting System
PV = Physician Value-Based Payment Modifier
Electronic RX and EHR incentives
Payment is tied to quality and cost metrics
Cost and quality metrics are transparent via Physician Compare
Patient Experience CG CAHPS is the patient experience component for outpatient/office practice
HCAHPS is the patient experience component for inpatient practice
ED CAHPS will become the patient experience component for the ED
9 ©Jay Kaplan, M.D. & Studer Group 2013
Physician Value-Based Payment Modifier (VBPM)
Statutory Timeline for VBM Implementation
Reporting Period
Value‐Modified Payment Adjustment
Eligible Professionals Included
2013 2015 payments Groups ≥ 100
2014 2016 payments Groups 10‐99
2015 2017 paymentsALL ELIGIBLE PROFESSIONALS
P4P: Value-Based Payment
10 ©Jay Kaplan, M.D. & Studer Group 2013
= IncomeCare
The Old Paradigm
Exceptional Clinical Quality
&
Extraordinary Patient Experience
The New Paradigm
= IncomeOutcome
$$$=
Connect the Dots: Service = Quality
Some Would Say . . .
Clinical Quality is the real deal, the “hard stuff.”
Service Excellence is the “fluff stuff.”
11 ©Jay Kaplan, M.D. & Studer Group 2013
British Medical Journal 2013http://dx.doi.org/10.1136/bmjopen-2012-00157
Patient experience is positively associated with clinical effectiveness and patient safety.
Associations appear consistent across a range of disease areas, study designs, settings, population groups and outcome measures
Positive associations 429 studies
No association 127 studies
Negative association 1 study
Communication = Compliance = Quality
Physician communication correlates STRONGLY with adherence rates by patients in acute and chronic disease. There are now over 100 observational and 20+ experimental studies published demonstrating the correlation of communication (patient satisfaction) with compliance. Compliance with treatment regimens has significant influence on quality measures in chronic disease and outcomes.
Medical Care: August 2009 - Volume 47 - Issue 8 - pp 826
Simple Truth #1: We Live in a Service Economy
Our entire staff is committed to your
complete satisfaction and empowered to
deliver personalized
service to take care of your needs.
12 ©Jay Kaplan, M.D. & Studer Group 2013
Key Words for Us
Satisfyto please, to be adequate to an end in view, to meet an obligation
Astonishto strike with sudden and usually great wonder or surprise
Memorableworth remembering
Simple Truth #2: We All Believe We Give Great Service
= =Patient Satisfaction
Employee Satisfaction
We assume
Simple Truth #3: We think we’re doing better than we actually are . . .
13 ©Jay Kaplan, M.D. & Studer Group 2013
Wall Street Journal April 8, 2013
Doctors need to work on their people skills . . . It’s something patients have grumbled about for a long time . . . Doctors don’t listen. Doctors have no time . . .
What is Excellent Physician Communication?
The physician listened (RR 1.8; 95% CI 1.0 – 2.5; p< .001)
The patient got as much medical information as they wanted (RR 1.6;95% CI 1.1 – 1.9; p< .001)
The patient was told what to do if symptoms continued, worsened or returned (RR 1.4; 95% CI 1.2 – 1.5; p<.001)
The patient spent as much time as they wanted with their physician (RR 1.8; 95% CI 1.3-2.2;p<.001)
Keating NL, et al, Annals of Internal Medicine 2004; 164: 1016 – 1020
Provider Communication . . . Really?
Physician Communication When Prescribing Medications:
26% failed to mention the name of a new medication
13% failed to mention the purpose of the medication
65% failed to review adverse effects
66% failed to tell the patient duration of treatment
The Golden 2 Minutes
74% of patients are interrupted by providers when giving their initial history in an average of 16.5 seconds
(J Gen Int Med, 2005)
(Arch of Internal Med, 2006)
14 ©Jay Kaplan, M.D. & Studer Group 2013
Simple Truth #4: No Rest For The . . .
“If the other guy’s getting better,
then you’d better be getting
better faster than that other
guy’s getting better . . . or
you’re getting worse.”-- Tom Peters
The Circle of Innovation
What Do Physicians Want?
•Care Quality for Our Patients gives us peace of mind
•Appreciation for What We Do leads to loyalty and retention
•Responsiveness to Our Issues inspires confidence in administration and we not us/them
•Efficiency of Our Practice decreases the frustration quotient, assists productivity
Top Priorities for Meeting Physician Needs
15 ©Jay Kaplan, M.D. & Studer Group 2013
Once Physicians are “Engaged” . . . Tactics to Build Physician Trust
1. Include physicians in strategic planning
2. Create ongoing communication vehicles
3. Diagnose physician sentiment
4. Develop a physician satisfaction team
5. Round on physicians
6. Facilitate physician/nurse communication
7. Increase physician appreciation/recognition
8. Give physicians training to help them be successful
Tactic #1: Include Physicians in Strategic Planning and Goal Setting
Strategic planning is setting the course for the future
Defining an overarching vision
Identifying strategies and actions to execute the vision
Setting goals
Allocation of resources
Guidelines
Include physician leaders that are reasonably well aligned
Promote clinical excellence and patient-centered care as the shared agenda
Physicians involved in strategic planning become the communication vessel to other key stake holders
16 ©Jay Kaplan, M.D. & Studer Group 2013
Tactic #2: Committed Ongoing Communication Between Senior Leaders & Physicians
Regular meetings with medical staff and senior hospital leadership
Regular agenda item at MEC/Dept. meetings
New physician breakfasts
Conduct small physician “focus groups” on possible strategic initiatives
If needed, develop a “Physician Advisory Group” (PAG) to provide direct access and advice to the CEO
Who Do You Speak With First?Build Critical Mass
Importance
Engagement
1st Priority
3rd Priority
2nd Priority
Tactic #3: Survey Your PhysiciansKeeping It Simple
1. What are the 3 things which you most love about practicing medicine in this environment?
2. What are the 3 things which you most dislike about your current practice?
3. What suggestions/solutions do you have for those issues mentioned in #2?
17 ©Jay Kaplan, M.D. & Studer Group 2013
What Are The Issues?Hospital PracticeWhat Are The Issues?Hospital Practice
More on Hospital Practice Issues…More on Hospital Practice Issues…
Tactic #4: Develop a Physician Satisfaction Team
Goal: Improve Physician Satisfaction
Tasked to create visible response to physician issues
Reports to CEO
Accountable to improve physician satisfaction
Invite physician membership
Empower to act quickly and decisively
18 ©Jay Kaplan, M.D. & Studer Group 2013
Physician Satisfaction Action Plan
Tactic #5: Set Standard Expectations forRounding on Physicians/Stoplight Report
WHY: Establishes sincere communication between leadership and physiciansWHO: Senior leaders, Physician Leaders, Administrative directorsWHEN: Schedule a time at physician’s convenience
HOW: “One on one”, with a rounding logWho is doing a great job?What is going well? What is not working for you?Do you have the tools/equipment you need?Anything you need for me to do for you right now?Review of current efforts underway and outcomes
Simplified . . . 3 Steps
“Do you have everything you need to provide excellent care to your patients?”
“I want to be responsive….Let me update you since we last talked…”
As a reminder our current focus on quality/the patient experience/teamwork is . . . I am asking all of the medical staff to . . . (wash hands, sit down, round collaboratively)
19 ©Jay Kaplan, M.D. & Studer Group 2013
Physician Rounding Pocket Card - sample
Wins
Care Quality
Efficiency
Appreciation
Responsiveness
Focus/Fix/Follow-Up
Document What You Are Doing -Stoplight Report
20 ©Jay Kaplan, M.D. & Studer Group 2013
Recommend and Set Expectations for the Implementation of Tools to Improve Communication
5 Physician Wow’s
Got Chart
Bedside Questions for Your Physician
Patient Visit Guide
Tactic #6: Help Physicians Practice
The 5 Physician Wow’s
Telephone log
Having information available when calling or returning calls to physicians
Patient locator log
Having open computers for physician documentation
At least one thank-you card sent weekly to a physician
Got Chart Date:
Before you call, did you: Ensure you are calling the appropriate physician (primary, consulting?)Check: Are there standing orders to cover this situation?Review physician preferences for when and where to call?Check: Does anyone else need the physician?See and assess this patient yourself?Read the most recent MD progress notes and notes from the nurse who worked the prior shift?
When you call: Have at hand: Chart, Recent Assessment (current and past lab results with times tests done), lists of meds, code status and most recent vital signs.Enter the complete 7-digit phone number when paging.Identify yourself, the unit, the patient, room number, and the diagnosis.Be clear about the reason for the call.Document whom you spoke to, time of call, and summary of conversation.
21 ©Jay Kaplan, M.D. & Studer Group 2013
Dear Doctor:
•My diagnosis?
•Tests for today
•New medications?
•Requirements for going home?
•Other questions?
Physician Note Pad
Patient Visit Guide
What is the primary reason for your visit
today?
What is the one thing we need to focus on to assure an excellent
visit?
Recommendations/ Instructions
Follow Up Care
Post-Visit Care – How will I learn about my test
results
We are committed to providing you with
excellent care
Tactic #7: Physician Recognition
22 ©Jay Kaplan, M.D. & Studer Group 2013
Organizational Acknowledgement
Tactic #8: Give Physicians Feedback & Then Training to Help Them Succeed
Credible Individualized Data
Skills training - General Medical Staff Education
Physician Leadership Academy
Define Physician Champions
Shadow Rounding with Individual Physicians
Physician Access to Quality of Care or Performance Data
Source: Physicians’ Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care; Anne‐Marie J. Audet, Michelle M. Doty, Jamil Shamasdin, & Stephen C. Schoenbaum; May 2005
1 physician in 3 receives any data about performance. 1 physician in 5 receives data pertinent to clinical
outcomes. 1 physician in 4 receives patient survey data.
1 physician in 3 receives any data about performance. 1 physician in 5 receives data pertinent to clinical
outcomes. 1 physician in 4 receives patient survey data.
23 ©Jay Kaplan, M.D. & Studer Group 2013
Self –Test for Physicians
Self –Test for Physicians
Crucial Communications
“May I Speak Freely?”
“My purpose in talking with you is …”(a mutual goal)
“When you … I feel . . . ” (action you are giving feedback on – something they can change)
“I imagine that …” (positive intent/benefit of the doubt)
“And because we both want …” (common goal)
“I need …” (specific alternative behavior requested)
Affirm him or her as a person
24 ©Jay Kaplan, M.D. & Studer Group 2013
What You Can Ask Physicians to Do to Help You
For Our Patients
Sit down and use key words
Touch all the bases in communication - AIDET®
Collaborative Rounding
Follow up phone calls
For Our Staff
Colleague as Customer/Partner
Collaborate/Appreciate/Respect/Educate
Say “Thank You” more
Medical Practice Execution FrameworkEvidence-Based LeadershipSM
Standardization AcceleratorsMust Haves®
Performance Gap
Objective Evaluation
System
Leader Development
Foundation
STUDER GROUP®:
Behavior Standards
Rounding for Outcomes
AIDET®
30/90 Meetings
Physician Selection Toolkit
Select Pre & Post Visit calls
Re-recruit high and middle/solid performers
Burnout
Development Opportunities
Coffee Cup Conversations
Processes that are consistent and standardized
Process Improvement
PDCALean/Six Sigma BaldrigeFrameworkSupport Cards
Software
Aligned Goals Aligned Behavior Aligned Process
Create process to assist leaders and physicians in developing skills and leadership competencies necessary to attain desired results
Physician Feedback System
Align MD goals to system goals
Rev 4.8.11
“Physicians go where they are welcomed, remain where they are respected and grow where they
are nurtured.”
Bill Leaver, CEO Iowa Health Systems
Bill Leaver CEO, Trinity Health Systems
Summary
25 ©Jay Kaplan, M.D. & Studer Group 2013
Thank you.Jay Kaplan MD, [email protected]
No one said it was going to be easy . . .