To keep doing things the same way results Annual Meeting Presentations/General Sessions...Eligible Professionals Included 2013 2015 payments Groups ≥ 100 2014 2016 payments Groups

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


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


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


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%


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)


“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.


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


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


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


= 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.”


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.


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 . . .


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)


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


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


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?


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


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)


Physician Rounding Pocket Card - sample

Wins

Care Quality

Efficiency

Appreciation

Responsiveness

Focus/Fix/Follow-Up

Document What You Are Doing -Stoplight Report


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.


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


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.


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


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


Thank you.Jay Kaplan MD, [email protected]

No one said it was going to be easy . . .

To keep doing things the same way results Annual Meeting Presentations/General Sessions...Eligible Professionals Included 2013 2015 payments Groups ≥ 100 2014 2016 payments Groups

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