Engaging Physicians in Leading Quality Improvementapp.ihi.org/FacultyDocuments/Events/Event-2930/...Engaging Physicians in Leading Quality Improvement Carol Peden, MB ChB, MD, MPH

EngagingPhysiciansinLeadingQualityImprovement

Carol Peden, MB ChB, MD, MPH Felipe Osorno, MSCEP Kaveh Houshmand Azad, MSCIE

Keck Medicine of USC University of Southern California Los Angeles

Disclosures CarolPedenisashareholderinFidelityHealthandaFellowandFacultyofIHI.Wehavenootherrelevantfinancialrela;onshipswiththeproductsorservicesdescribed,reviewed,evaluatedorcomparedinthispresenta;on.

2

CarolPeden,MBChB,MD,MPHFelipeOsorno,MSCEPKavehHoushmandAzad,MSCIE

3

OBJECTIVESOFTHISSESSION

1-Tounderstandhowtodevelopastrategyandframeworktocreateaprogramforphysiciansinleadershipandqualityimprovement2-Tounderstandhowtoimplementaframeworktoenablephysicianstoleadqualityandperformanceimprovementprojects3–Tolearnfromsuccessstoriesfromourphysicianqualityandimprovementprogram,aswellaslessonslearned

4

KeckMedicineofUSC

3Hospitals

619Beds

60+Clinics

4,000+Employees

1300FacultyandScien;sts

9000ClinicalTrials

900Residents

$1.6BNetRevenue

Bornin2009

5 Source:UHC,Q32016–Q22017

2.96KeckMedicalCenterofUSCCMI

2.78CityofHope

2.46MoffiQCancerCenter

2.50ClevelandClinic

2.53Univ.ofMarylandMedicalCenter

2.43StanfordHealth

2.27UCLAHealth(RonaldReagan)

2.34MayoClinic

2.11UCSFMedicalCenter

1.92JohnsHopkinsMedicine

Weseesomeofthe

sickestpa]entsinthena]on

2.72SylvesterCancerCenter

CMI=CaseMixIndex

Innovation at Keck

6

CharlesHeidelberger,firstassociatedirectorforbasicresearchatUSCNorrisComprehensiveCancerCenterandof5-Fluorouracil,themostwidelyusedcancerchemotherapydrug

FirstFDA-ApprovedHigh-IntensityFocusedUltrasoundSurgicalAbla]onforKidney&

ProstateCancer

FirstImplantableAr]ficialRe]natoRestoreVisionfromRe]ni]sPigmetosa

FirsttoTreatUncontrolledEpilepsywithFDA-ApprovedResponsiveNeuros]mula]onSystem

FirsttoOfferBronchialThermoplastyOutpa]entTreatmentforSevereAsthma

FirsttoEstablishRela]onshipofCancerandEpigene]cDNAMethyla]on

Keck’s Revenue Growth – An Academic Start Up • Revenuehastripledin6years–reached1.6Bin2017•  30%growthinthelast2fiscalyears

7

$460M$550M

$620M

$790M

$1.15B

$1.31B

$1.5B

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

2010 2011 2012 2013 2014 2015 2016

Los Angeles Health Care •  SignificantMedi-cal(37%ofLACountyand33%ofCA)andMedicarepa;entpopula;on

•  LosAngelesisoneoftheleastconsolidatedhealthsystemsintheUS• Markeddemographicdiversity

8

Health Spending Per Capita Per State 2014 (most recent data)

9

Source:KaiserFamilyFoundaOonhPps://www.kff.org/other/state-indicator/health-spending-percapita

From a For-Profit Hospital to an Academic Medical Center in a changing healthcare world

• Challenges!

• Culture

• Developingdatainfrastructure

•  LiQleimprovementinfrastructure

• Rapidgrowthanddevelopingsystems

10

Who we are? • CarolPeden,Physician–anesthesiologistandintensivist30yearsfront-lineclinicalexperience,IHIFellowandFaculty,experienceofdesigningandleadingQIprojectsandcurriculaaroundtheworld.

•  FelipeOsorno,MITChemicalEngineer,6yearsinconsul;ngatMcKinsey,LeanandSixSigmaTrained,experienceandpassionincrea;ngsystemstoempowerfrontlinestafftoimprovevalue.

• KavehHoushmandAzad,MScIndustrialEngineering,10yearsofexperienceinhealthcareperformanceimprovement

11

Getting Physicians Engaged in Improvement

• Whythisprogramforusnow?• GrowthandInfrastructure• Valueinhealthcare• Transforma;onalchange• Theissuesallhealthcareorganiza;onsarefacing

12

We are all facing similar challenges

13

End-to-End

BundlesV VALUE

Changesinreimbursement

models

Risingsupplyandlaborcosts

Wasteininternalprocesses

Varia]onamongproviders

Needforchange

Burnout

WestetalLancet2016;388:2272-81SalyersetalJournalofGeneralInternalMedicine201614

Strategies to reduce physician burnout

15

hPps://newsnetwork.mayoclinic.org/discussion/mayo-clinic-reversing-physician-burnout-using-nine-strategies-to-promote-well-being/

•  Acknowledgingandassessingtheproblem•  Recognizingthebehaviorsofleadersthatcanincreaseordecreaseburnout

•  Usingasystemsapproachtodeveloptargetedinterven;onstoimproveefficiencyandreduceclericalwork

•  Cul;va;ngcommunityatwork•  Usingrewardsandincen;vesstrategically•  Assessingwhethertheorganiza;onsac;onsarealignedwiththestatedvaluesandmission

•  Implemen;ngorganiza;onalprac;cesandpoliciesthatpromoteflexibilityandwork-lifebalance

•  Providingresourcestohelpindividualspromoteself-care

•  Suppor;ngorganiza;onalscience(Studythefactorsinyourownins;tu;onthatcontributetotheproblem,andinvestinsolu;ons.)

15

Achieving The Quadruple Aim

16

ImprovedPa]entOutcomes

LowerCostofCare

ImprovedPa]entExperience

ImprovedCareGiverExperience

Why not a multidisciplinary team approach? • Culture• Nomedicalschooltraining(todate)inQIatUSC

•  Time•  LiQleestablishedinfrastructure• Needtorapidlydevelopacohortofleaderswhocouldthenworkwiththeirteams

17

18

CultureofImprovement

DataAvailabilityandTransparency

BuildingCapabili]es

System-WideImprovement

Specialty-LevelImprovement

EngagedPhysicians

Our System-Wide Strategy

19

hPp://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

ModelforimprovementdevelopedbyAssociatesinProcessImprovement

•  Approachfromboth“Lean”and“ModelforImprovement”•  Usingbackgroundresearchandtheteam’sexperience

Designing the program

LeanThinking

20

hPps://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_0.pdf

hPps://paOentsikkerhed.dk/content/uploads/2016/02/psskatalog_uk_www.pdf

hPps://www.rcplondon.ac.uk/projects/learning-make-difference-ltmd

Experience and Learning

The “Secret Sauce”

AmericanJournalofMedicalQuality2017.

•  “Earlyengagementofaphysicianleader–whocanlisten,engage,andleadothercolleagues–tobeanearlyadopter”

•  “Theymustbeequippedwiththetrainingandtoolstoleadothers,requirededicatedprotected;me,andtheautonomytocoordinateandimplementchanges”

•  “Theengagedphysicianleaderrequirestrainingingovernance,leadershipandmedicaleconomics…andmentorship”

EPOCH Aim and Theory

22

EPOCHTrial:EnhancedPeri-Opera;veCareforHigh-riskPa;ents£1.5M/90Hospitals

Front-line clinical staff will be enabled

to achieve improvements in care for patients

undergoing Emergency Surgery

which will lead to improved outcomes

Evidencebased

interven;ons

Measurement&datafeedback

Mo;va;onandfocus

Communityofprac;ce

QIskillstraining

MDTapproach

Ethnography and physician engagement “Becausehistoricallyweassurgeonswouldfinishanemergencyandouenleavetheopera;ngtheatretowritetheopera;onnotes,andthenouentheconsultantwouldleave,andtheregistrarmightcomebacktoseewhatisgoingon,butouenyouwould…findoutthenextmorningwherethepa;enthadgone.Whereasthisnow,gevngusintomoreofacultureof:‘Isthispa;enthighrisk?Shouldtheygotointensivecare?Whatisourplanofmanagement?Doweextubate?’Thosekindofthingsareconversa;onsIthinkweshouldhave’.”(SurgicalFellowHospital2)

23 EPOCHTrialSociologyofHealthandIllness2017;39:1314-1329

How to make change happen

24

What does engagement really mean to physicians? 1.  Respectformycompetencyandskills2.  Feelingthatmyopinionsarevalued3.  Goodrela;onshipswithmymedicalcolleagues4.  Goodwork/lifebalance5.  Avoiceinhowmy;meisstructuredandused6.  Faircompensa;on7.  Goodrela;onshipswithnon-clinicalstaff8.  Abroadersenseofmeaninginmywork9.  Avoiceinclinicalopera;onsandprocesses10. Opportuni;estoexpandmyskillsandlearnnewskills

25

From:IncreasingPhysicianEngagement:startwithwhat’simportanttophysicians.RobertStarkThejournalofmedicalpracOcemanagement2014;30:171-5

How was our program developed?

SPO

NSO

RS

HIP

DES

IGN

HealthSystemLeadership

ValueImprovementOffice(“LeanTeam”)+CenterforHealthSystemInnova;on

DepartmentChairs

ValueImprovementOffice(“LeanTeam”)+CenterforHealthSystemInnova;on

SELE

CTI

ON

DEL

IVER

Y

Why it was designed this way? •  Tohelpcliniciansunderstandthecomponentsofvalue•  Toequipthemwithimprovementsciencetools•  Toprovideleadershipdevelopment•  Toeducateonchangemanagementconcepts•  Toprovidebasicsonorganiza;onalstrategyandgoals•  Todemonstratehowtouseandinves;gateins;tu;onaldatae.g.Vizient•  Tohelpfosterresearchandpublica;oninqualityimprovement•  Tosupportselec;onanddevelopmentofaprojectonwhichtoapplytheseskills

27

Program Structure

28

Day

1Day

2

Day

3Day

4

§  QualityandLeanIntroduc]on

§  SystemThinking§  A3andPDSA§  ProjectSelec]on

§  ValueStreamMap§  RunCharts§  RootCauseAnalysis

§  ChangeManagement§  Innova]on§  StakeholderAnalysis§  Leadership

§  Publica]on§  Benchmarking§  Sustainability

AdultLearningprinciplesIncludinggameandsimula;ons

1:1coachingsessions

DataSupport

Introduction to the program

29

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

•  Selec;ngandscopingpoten;alprojects

•  Selec;ngandcalcula;ngprojectmetric(s)

QIPIday2QIPIday3

•  Formingprojectteams•  Mappingprocesses•  RootCauseAnalysis

•  Developingcountermeasures•  Implemen;ngcountermeasuresCommunica;ngtheprojectwithotherstakeholders

•  Re-measuringprojectmetrics•  Makingnecessaryadjustments•  Finalizingthepresenta;on

QIPIday1

Jul17

Aug17

Sep17

Oct17

Nov17

QIPIday4

Ongoingcoachinganddatasupport

CohortSelec]on

Sharingtheresultandlearnings

Educating and Inspiring our Staff - QIPI

30

Crea;ngacollabora;veandposi;veoff-siteexperienceFastpacedlearningandapplica;onoftoolsInvitedguestspeakerstoenrichthelearningexperienceOpportuni;esforpublica;ons

Crea;ngacollabora;veandposi;veoff-siteexperience

Fastpacedlearningandapplica;onoftools

Opportuni;esforpublica;ons

Invitedguestspeakerstoenrichthelearningexperience

Summary of successful projects

31

Dr.BrigneyDeClerckImprovingEMRU;liza;on/efficiency

indermatologyclinics

Dr.ArmandDorianAppropriate“Pa;entStatus”

Determina;onat;meofAdmission

Dr.JayHudginsImprove%oftransfusedcasesvs.

typeandscreenorders

Dr.BenjaminEmanuelImprovedoor;metoCT/MRI;mefor

strokepa;ents

Dr.JehniS.RobinsonImprovepa;entcycle;meinFamily

Medicineclinic

Dr.NaomiSchechterImprovingpa;enttransferstoNorris

Radia;onOncology

Dr.MichaelJohnsImprovePa;entthroughputin

OHNSclink

32

Recognitions and presentations

Other QI physician engagement projects at KMUSC • CareDeliveryRedesignAmul;disciplinaryapproachleadbyhealthcareadministratorswithengagedphysicians,andsupportedbytheValueImprovementOffice•  SurgicalQualityImprovementOfficersAphysicianledprogram,fundedbytheDepartmentofSurgerywithnominatedsurgicalandanesthesiologyleads,supportedtoworkontheirownimprovementprogramswithfinancialcompensa;on.QIMentoringanddataanaly;cssupportprovided.

33

34

Recipe for Care Delivery Redesign Steps:1.  AlignonBurningPlaxorm

2.  Iden;fyKeyOpportuni;es3.  GaugeReadiness&BuildCoreTeams

4.  EngageinCri;calReview

5.  CreateEnvironmentforChange

6.  FacilitateCross-Collabora;on7.  Sustain,Share,&Expand

KeyIngredients:q PhysicianChampionsq Mid-LevelProvidersq AlliedHealth

Professionalsq AncillaryServicesq Administra;veSupportq Execu;veEngagementq DataTransparencyq SharedVisionfor

Success

35

1.AlignonBurningPlaiorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkAssessCurrentStateandBenchmarkEngageClinicalLeadersinthe“Why?”CreateASharedVision

Q+S+A $

OurSharedChallenge:

36

1.AlignonBurningPlaxorm

2.Iden]fyKeyOpportuni]es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkUseDatatoDiscoverGapsIden;fyExis;ngImprovementsinProgressSelectFocusCohort

37

1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkAssessReadinessforChangeIden;fyChampionsinKeyAreasAskWhoElseShouldBeInvolved

38

1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri]calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkCombineClinicalandFinancialDataCri;callyReviewEveryDay,EveryCareDecisionIden;fyProcessFailuresAcrossDisciplines

39

1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkAssembleImpactedStakeholdersCreateSafeSpacetoShareEncourageDifficultDiscussions

40

1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora]on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkShareFindingsfromCri;calReviewsIden;fyCross-Func;onalTeamsLaunchShort-andLong-termImprovements

41

1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkMonitorandSharePerformanceLearnfromSuccessesandFailuresCreateOrganiza;onalAwareness

42

1.AlignonBurningPlaxorm

2.Iden;fyKeyOpportuni;es

6.FacilitateCross-Collabora;on

7.Sustain,Share,&Expand

3.GaugeReadiness&BuildCoreTeams

4.EngageinCri;calReview

5.CreateEnvironmentforChange

Steps

KeyIngredientsatWorkShareFindingsfromCri;calReviewsIden;fyCross-Func;onalTeamsLaunchShort-andLong-termImprovements

Department of Surgery Quality Officers Program •  SupportedandfundedbyChairofSurgery•  Financialincen;ve•  SignificantdataandQIsupport• Onemee;ngamonthofgroup•  SomeQItraining•  Focusondevelopmentofleaders•  Financialcalcula;onstojus;fyROI• Celebra;onofsuccess

43

DOS Quality Officers Desired Outcome

44

Forumtosharequalitydata&ini]a]ves

Engage,mentor,&trainofficersonquality&

performanceimprovement

Leadandimplementquality&performanceimprovement

projectwithinthedivisionandscaletootherdivisions

1 2 3

Performance Improvement Process

45

IDENTIFICATIONOFPROJECT

Regulations

QualityOutcomes

CostOperationalInefficiencies

Research

INVESTIGATION STRATEGY IMPLEMENTATION AUDIT/MODIFY/ITERATE REPORT

QualityOutcomes

CostOperationalInefficiencies

Research

Value=QualityCost

ProcessforPerform

anceIm

provement

(1yearTim

efram

e)

1 month 2-4 months 2 months 3-6 months 1 month

Using measurement and local data…to inform and drive improvement

• ProcessandOutcomedata• Crea;ngabuzz,acampaign,energy–thewishtobepartofsomething

•  Ini;alQItraining,followup,regularreviewandsharingwithstakeholders

• BasictraininginQItechniques,dataandsupport

46

Sample Project: Increasing Efficiency & Decreasing Length of Stay

in Vascular Surgery • Hypothesis• Projectiden;fiedbysurgeons,engagedAQendingandDivisionChief•  Increasingiden;fica;onandearlymanagementofavoidabledelayswilldecreaselengthofstay–focusonpa;entswithO/Era;o>1day

• OverlappingprojectbetweenSurgicalQualityOfficersandCareRedesign• Results

47

Current Process

48

Proposed New Process for Workflow

49

Surgical Quality Officers; Reflection -what we will do differently in the next

iteration •  InvolveAnesthesiology• Compensa;onlinkedtoaQendance• Projectsmoreclearlylinkedtoorganiza;onalgoals• Moreformal;meinQItraining•  Lessofa‘research”approachtodata,lessretrospec;veanalysis–moreuseofsamplingandruncharts

• GreaterinvolvementofhospitalQIdepartment• Morecelebra;onandpromo;onofsuccess50

We’ve shared our experience …. What does some of the research say….

51

• Askdoctorstolead–mantrais“physician-led,data-driven,evidencebased”• Askdoctorswhattheywanttoworkon• Makeiteasyfordoctorstoleadandtopar;cipate• Recogni;onfordoctorswholead•  Supportformedicalstaffleaderswithcourage• Opportuni;estolearnandgrowGosfeldAG,ReinertsenJL(2010).AchievingClinicalIntegra;onwithHighlyEngagedPhysicians.Unpublishedmanuscriptin“MedicalEngagementtooimportanttobelektochance”ClarkJ.TheKing’sFund2012

52

hPp://www.kingsfund.org.uk/sites/files/kf/medical-engagement-nhs-john-clark-leadership-review2012-paper.pdfhhPps://www.kingsfund.org.uk/sites/default/files/field/field_publicaOon_file/medical-engagement-a-journey-not-

an-event-jul14_0.pdf

Lessons from McLeod Hospital’s Transformation

53

Consider Behavioral Economics

AnnInternMed2016;164:114-119

•  Improvingqualityispartofdoctorsprofessionaliden;ty-tappingintothiscanbeapowerfulmo;vatorforchange

•  Clinicianledqualityimprovementcanleadtogreaterstandardiza;on,moreequitablecare,greaterqualitycontrol,improvedpa;entsa;sfac;onandbeQerpa;entoutcomes

•  QImustbealignedwithresourcealloca;on,supportedbyprofessionaltraining,commissioningandregula;onandintegratedintoservicemanagement

•  QItobesustainablemustbeintegratedwithorganiza;onaldirec;onandresources

54

www.health.org.uk

How do you get clinicians involved in quality improvement?

1.  Consideryourorganiza;onstrackrecord–emphasizewhythisprogramwillsucceed–howisitdifferent?

2.  Givedoctors;meandresourcestoac;velyengage3.  Explana;onsofthepurposeoftheprogramshouldbe

phrasedtoreflectpriori;esandconcernsofclinicians4.  Evidenceofefficacy–localevidencewillhelp5.  Externalexper;sewherepossibletoaddcredibility6.  Localprogramchampions(credibilitywithother

clinicians)7.  Managementinvolvement–inaposi;ontosupport

clinicians

55

MedicalEngagementinorganisaOonwidesafetyandqualityimprovementprogrammes.

ParandetalQualSafHealthCare2010;19:e44

Seven Themes for Medical Engagement

Harness Passion • Whatistheirpassion,whatistheirclinicaldesire?•  Isittobethebestgastroenterologistever–howcanyouhelpthemgetthere?•  Tohavethelowestmortalityforsepsis–howcanyourQIworkgetthemthere?•  AskhowcanIhelpyou..bethebestdoctor…havethebestteam..savethemostpa;ents?

56

In Summary • Wehavedesignedandledanumberofprogramswhichengageanddevelopphysiciansinimprovementleadership

• Wewillmodifythenextroundoftheseprogramsbasedonourexperienceandfeedback

• Wehaveseentangibleimprovements,ROIandjoyinworkincreaseforphysiciansandtheirteams

57

58

THEKECKEFFECT

ENGAGEDPHYSICIANSIMPROVINGTHEQUALITYOFOURCARE

THANKYOU!