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Engaging Physicians in       Quality and Performance             Improvement                  Wendy M. Novicoff, Ph.D.    ...
ACGME Competency Related to                 Quality    •   According to the ACGME, to be qualified as competent physicians...
Definition of Quality    “ the degree to which health care services       for individuals and populations       increases ...
How Can Performance    Improvement Impact Quality?    Three distinct parts:    • Using data and statistics to measure    •...
Bringing in EBM and                         Guidelines    • If we know a specific clinical process is a      “best practic...
The Purpose of EBM and        Practice Guidelines    “The purpose of Evidence-Based    Medicine and practice guidelines is...
Definition of Clinical                      Guidelines    Clinical guidelines are “systematically    developed statements ...
How is This Accomplished?    Define best medical practice         Determine why variation occurs                         M...
Financial Rationale for EBM?    ↑ Costs                                       Present                                     ...
Evidence-Based Medicine                                  ↓↓     involves managing processes of care                       ...
Supporters of EBM    • Standards will reduce costs, reduce      variability, and increase access to care    • Means to mea...
Critics of EBM    • Evidence is not always available or strong      enough to make sound guidelines    • Loss of autonomy ...
Adherence to Guidelines    • Asthma example: surveys showed low      compliance with guidelines (between 35%      and 68%)...
Barriers to Adherence    • Lack of awareness of guideline    • Lack of familiarity with guideline    • Lack of agreement w...
Causes of Practice Variation     Complexity of modern medicine     Insufficient evidence base for most     treatment choic...
Quality Improvement in                 Reducing Variation    25                          LCL    UCL   25                  ...
Examples of Variation                    in Health Care    • Time needed to get test results to MD’s    • Actual time that...
Must Break the “Cycle of                  Fear”                                            Fear                           ...
Lessons from Brent James    1. The core problem is variation in clinical practice.    2. Real benefits accrue when inappro...
Lessons from Brent James    5. “Control” is a central issue.    6. Implementing process management requires a       partne...
How are Quality Problems              Handled?    • Problem: Last month Dr. Smith’s      patients had the highest complica...
How are Quality Problems              Handled?    • Problem: The Billing Office is overwhelmed      by complaints about er...
How are Quality Problems              Handled?    • Problem: a patient is upset because she had      to wait 4 hours in th...
10 Ways to Sell Change    •   Perceived advantage (WIIFM)    •   Compatible with current practice    •   Simplicity of usa...
Stakeholder Analysis        Key             Strongly   Moderately             Moderately Strongly                         ...
Three D’s Matrix    Approach                          Examples    Data                              Charts, graphs, statis...
Preparing the                           Organization©   All Rights Reserved.
Elements for Successful                 Projects    • High frequency events (hourly, daily,      weekly)    • Established ...
But What Is Really Needed?    • Support from      Management    • Sponsor    • Owner    • The “right” team©     All Rights...
Problems In Project                         Identification    • Having a predetermined solution    • Trying to make “every...
Adding Structure©   All Rights Reserved.
Integration with Existing                    Methods    • Most institutions have existing programs      – do not dismiss p...
Guiding Principles    • GPs give a framework for all project      work    • Example primary guiding principle: a      qual...
Pick the Right Project Leaders    • These are often not the people you      assume they will be:      – Prior training can...
Required Training at All                    Levels    • All leadership (managers and above)      required to attend two-ho...
Support Systems and                   Communication Plans    • All trainees given two support people in addition to      t...
Project Examples©   All Rights Reserved.
Comprehensive              Improvement in               Orthopaedics             Outpatient Clinics©   All Rights Reserved.
Major Areas for Improvement    •   Patient safety    •   Access/scheduling    •   Clinic throughput    •   Nurse triage   ...
Prioritization – The Pay-Off                   Matrix           high                         Jewels             High    PA...
Measureable Impacts So                  Far…    • Average wait time on the phone (Call Center) has      been reduced from ...
Improving Compliance     with Core Measures©   All Rights Reserved.
Tell ‘Em Like It Is©   All Rights Reserved.
A Little Competition Never              Hurts…                  Physician names go here – for ALL to see©   All Rights Res...
Updating Inpatient                Status©   All Rights Reserved.
Current State    • Rule: Observation patients must be      discharged or reclassified as inpatients within      24 hours  ...
©   All Rights Reserved.
Future State    • Improvements focused on revising standard      operating procedures and institutional policy       – Lim...
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Engaging Physicians in Quality and Performance Improvement

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  1. 1. 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© All Rights Reserved.
  2. 2. 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© All Rights Reserved.
  3. 3. 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© All Rights Reserved.
  4. 4. 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© All Rights Reserved.
  5. 5. 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© All Rights Reserved.
  6. 6. 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 Mauck Health Affairs, 2005© All Rights Reserved.
  7. 7. 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© All Rights Reserved.
  8. 8. 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© All Rights Reserved.
  9. 9. Financial Rationale for EBM? ↑ Costs Present Practice Revenues ↓ Costs ↓ Revenues ↑ Assure best practices Reduce needless variation© All Rights Reserved.
  10. 10. Evidence-Based Medicine ↓↓ involves managing processes of care not managing clinicians© All Rights Reserved.
  11. 11. 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© All Rights Reserved.
  12. 12. 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© All Rights Reserved.
  13. 13. 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%© All Rights Reserved.
  14. 14. 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© All Rights Reserved.
  15. 15. 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© All Rights Reserved.
  16. 16. Quality Improvement in Reducing Variation 25 LCL UCL 25 LCL UCL 20 20 15 15 10 10 5 5 0 0 Data Distribution Data Distribution before process improvement after process improvement© All Rights Reserved.
  17. 17. 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© All Rights Reserved.
  18. 18. Must Break the “Cycle of Fear” Fear “my patients are sicker than yours” Micromanage Kill the messenger wasted activity place blame & resources defensive response Filter the data game the system, change methods, question data© All Rights Reserved.
  19. 19. 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© All Rights Reserved.
  20. 20. 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© All Rights Reserved.
  21. 21. 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.© All Rights Reserved.
  22. 22. 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.© All Rights Reserved.
  23. 23. 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.© All Rights Reserved.
  24. 24. 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© All Rights Reserved.
  25. 25. Stakeholder Analysis Key Strongly Moderately Moderately Strongly Neutral Stakeholder Against Against Supportive Supportive© All Rights Reserved.
  26. 26. Three D’s Matrix Approach Examples Data Charts, graphs, statistics Demonstrate Show how project will positively impact people and processes Demand Negative consequences if actions aren’t followed© All Rights Reserved.
  27. 27. Preparing the Organization© All Rights Reserved.
  28. 28. 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…)© All Rights Reserved.
  29. 29. But What Is Really Needed? • Support from Management • Sponsor • Owner • The “right” team© All Rights Reserved.
  30. 30. 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© All Rights Reserved.
  31. 31. Adding Structure© All Rights Reserved.
  32. 32. 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© All Rights Reserved.
  33. 33. 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© All Rights Reserved.
  34. 34. 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© All Rights Reserved.
  35. 35. 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© All Rights Reserved.
  36. 36. 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© All Rights Reserved.
  37. 37. Project Examples© All Rights Reserved.
  38. 38. Comprehensive Improvement in Orthopaedics Outpatient Clinics© All Rights Reserved.
  39. 39. Major Areas for Improvement • Patient safety • Access/scheduling • Clinic throughput • Nurse triage • Employee satisfaction • Patient satisfaction© All Rights Reserved.
  40. 40. Prioritization – The Pay-Off Matrix high Jewels High PAYOFF Hards Low DROP Hanging Fruit low easy EFFORT hard© All Rights Reserved.
  41. 41. 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.© All Rights Reserved.
  42. 42. Improving Compliance with Core Measures© All Rights Reserved.
  43. 43. Tell ‘Em Like It Is© All Rights Reserved.
  44. 44. A Little Competition Never Hurts… Physician names go here – for ALL to see© All Rights Reserved.
  45. 45. Updating Inpatient Status© All Rights Reserved.
  46. 46. 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© All Rights Reserved.
  47. 47. © All Rights Reserved.
  48. 48. 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© All Rights Reserved.
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