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Worldwide Conventions and Business Forum’sLean Six Sigma and Process Improvement in Healthcare      Physician – Hospital P...
Disclosures No financial interests to declare
What does ‘Quality in Healthcare’ mean to you?
Introduction: The Facts   quality has historically been ill-defined in healthcare     definitions not standardized (Center...
What does ‘Quality in Healthcare’ mean to patients?
What does ‘Quality in Healthcare’ mean to patients?  depends on whom you ask . . .   AHRQ: Understanding Health Care Quali...
What does ‘Quality in Healthcare’ mean to patients?clinical skill  feeling secure the doctor is prescribing the right reme...
What does ‘Quality in Healthcare’ mean to patients?service  doctors that dont see patients at record breaking speed  house...
What does ‘Quality in Healthcare’ mean to patients?service  when a doctor takes additional time to more fully analyze  alt...
What does ‘Quality in Healthcare’ mean to patients?service  patient-centric healthcare - everything must be around the  pa...
What does ‘Quality in Healthcare’ mean to patients?financial  able to select the insurance plan that is best for me  avail...
What does ‘Quality in Healthcare’ mean to patients?1. Patients see it as a patient-provider relationship that helps  them ...
Do quality processes of care = quality outcomes?                        orDoes adherence to performance measures actually ...
1. Hyperglycemic control after open-heart surgery   2001: NEJM (2001;345:1359-67)     randomized prospective study of 1,54...
2. Beta-blockade before open-heart surgery (NQF, STS)   2002: JAMA (2002;287:2221-7)     study of 630,000 CABG patients   ...
3. Timing of antibiotics for CAP   2003: Infectious Diseases Society of America guidelines     antibiotics within 4 hours ...
Can the pursuit of quality hinder the arrival?          the law of unintended consequences stinting   limiting access to c...
Quality in Healthcare it is here to stay (are ACOs?) transparency, and the desire for it, will not go away better to embra...
Value-Based Purchasing: Milestones  health insurance through employment (WWII)  establishment of Medicare (LBJ, 1965)  DRG...
What does VBP mean to Medicare? “The overarching goal of these initiatives is to transform Medicare from a passive payer o...
What does VBP mean to Medicare? 6 quality goals   effective   safe   timely   efficient   patient-centered   equitable
What does VBP mean to Medicare? hospitals will be scored in three quality domains     processes of care     Reporting Hosp...
What does VBP mean to Medicare? future    readmissions    hospital-acquired conditions
Value-Based Purchasing: % dollars at risk
Is ‘quality’ the ultimate goal, or is it ‘value’?   competition on the wrong level   advantages of a ‘value’ approach   mo...
Are we getting value?
The Triple Aim in Healthcare (IHI)   Improve the health of the population   Enhance the patient experience (access, satisf...
Why Health Care Reform?  three basic goals     increase access     decrease the rate of cost escalation     improve qualit...
Getting your organization engaged in quality   physicians / providers     education   residents     VO TO , HCAHPS, HSQ Co...
What is the role of the physician in ‘quality’?
Engaging physician in quality initiatives    understand how they see the world    outline expectations of the organization...
Cultures in Conflict!Expert Culture (docs)                     Collective Culture (hosp)an individual’s success is a resul...
Strongest characteristic of physicians   desire for autonomy   competitive core
Understanding physicians: autonomy   focus in medical school: personal responsibility for   patient outcomes   accountabil...
Understanding physicians: competitive spirit   in simulations, do not seek win-win solutions   are hesitant to seek cooper...
Understanding physicians: competitive spirit   when working with mixed groups (attending,   residents, students), perform ...
How do you get quality to work for you?   measure it: gather data   convert it into information (what does it mean)   tran...
How do you get quality to work for you?   track it and gather more data on performance   incentivize compliance     extrin...
data that is MEANINGFUL  important to physicians and patientsdata that is RELEVANT  being recorded and reported by outside...
Outlining expectations   the importance of communication   the need for consistency (builds trust)   link rewards with beh...
How to build trust   create shared visions and goals   recognize common principles   recognize differences, but emphasize ...
How to build trust   openly discuss the disadvantages of not collaborating   celebrate wins along the way   share: informa...
Report cards   a.k.a. performance updates   to align behaviors (financial incentives with quality)   individual performanc...
Reinforcing expectations: compensation
Common ground = interdependency   How? develop collaborative partnerships      safety      quality      workflow      sche...
The Balanced Circle                        customer                         service         operational   patient     fina...
Effective clinical leadership raises the performance of  health care organizations       hospitals with the highest clinic...
To promote clinical leadership   establish appropriate incentives   identify, train, and mentor   create the environment (...
“Doing more of what you are        already doing and expecting a different result is a sign of insanity.”              Alb...
Physician Hospital Partnerships The Rules Of Engagement
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Physician Hospital Partnerships The Rules Of Engagement

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Physician Hospital Partnerships The Rules Of Engagement

  1. 1. Worldwide Conventions and Business Forum’sLean Six Sigma and Process Improvement in Healthcare Physician – Hospital Partnerships: The Rules of Engagement Robert Lancey, MD Chief of Cardiac Surgery Co-Director, Heart Care Institute Bassett Healthcare Network Clinical Associate Professor of Surgery Columbia University
  2. 2. Disclosures No financial interests to declare
  3. 3. What does ‘Quality in Healthcare’ mean to you?
  4. 4. Introduction: The Facts quality has historically been ill-defined in healthcare definitions not standardized (Center of Excellence?) patients not standardized (risk-adjusted) care not standardized (evidence-based medicine) meaning not standardized
  5. 5. What does ‘Quality in Healthcare’ mean to patients?
  6. 6. What does ‘Quality in Healthcare’ mean to patients? depends on whom you ask . . . AHRQ: Understanding Health Care Quality Doing the right thing (getting health care services you need) At the right time (when you need them) In the right way (using the appropriate test or procedure) To achieve the best possible results Avoiding underuse (not screening for high blood pressure) Avoiding overuse (performing unnecessary tests) Eliminating misuse (medications with dangerous interactions) AHCA Quality is defined as the combination of care and services that meet or exceed customer needs and expectations.
  7. 7. What does ‘Quality in Healthcare’ mean to patients?clinical skill feeling secure the doctor is prescribing the right remedy the doctor understands the problem, offers solutions and treatments, if needed OUTCOME; will it improve my quality of life best possible outcomes dedication to quality of life both acute and preventative care trust that the provider knows, or can determine the problem, and then do his/her best
  8. 8. What does ‘Quality in Healthcare’ mean to patients?service doctors that dont see patients at record breaking speed house calls same for any service organization: turnaround time, communication being able to ask any questions having a good supporting cast (nurse, techs, etc) who worked together to focus on the patient needs the opportunity to meet with an experienced practitioner that is willing to spend time with you to analyze, discuss, and follow up on your diagnosis and treatment
  9. 9. What does ‘Quality in Healthcare’ mean to patients?service when a doctor takes additional time to more fully analyze alternative explanations and discusses any concerns you have with warmth and empathy skilled, accurate, confident, and compassionate doctors and nurses respectful administration and customer facing organization patient & patient family focused operations understanding patient needs and compassion communicate and interact to improve patient health reduce wait time and spend more time with patients rather than filing paperwork
  10. 10. What does ‘Quality in Healthcare’ mean to patients?service patient-centric healthcare - everything must be around the patients’ needs and convenience COMPASSION! high availability, high accuracy, low aggravation it would be a pleasant surprise if the doctor spent more than 10 minutes with me before he/she has to run to the next appt
  11. 11. What does ‘Quality in Healthcare’ mean to patients?financial able to select the insurance plan that is best for me available insurance that provides peace of mind free-market for insurance - with subsidies provided to certain demographics based on incomeother no more pharma ads
  12. 12. What does ‘Quality in Healthcare’ mean to patients?1. Patients see it as a patient-provider relationship that helps them reach their goal of health, quality of life2. Patients have little understanding of what actually constitutes the ‘right care’ or the correct treatment3. From their perspective it is based on having a close relationship with their medical provider that is based on trust
  13. 13. Do quality processes of care = quality outcomes? orDoes adherence to performance measures actually lead to better outcomes? few studies have supported this others studies in fact question it (the law of unintended consequences) 1. hyperglycemic control after open-heart surgery 2. beta-blockade before open-heart surgery 3. timing of antibiotics for community acquired pneumonia
  14. 14. 1. Hyperglycemic control after open-heart surgery 2001: NEJM (2001;345:1359-67) randomized prospective study of 1,548 ICU patients intensive insulin therapy led to lower mortality, infections, RF adopted by CMS and SCIP as quality metric 6 a.m. blood sugar of < 200 mg/dL on post-op mornings 1 & 2 no evidence of benefit of either timing or level tighter control leads to hypoglycemia up to a two-fold increase in mortality
  15. 15. 2. Beta-blockade before open-heart surgery (NQF, STS) 2002: JAMA (2002;287:2221-7) study of 630,000 CABG patients mortality benefit with β-blocker (3.4% vs. 2.8%) if unmatched NO benefit when matched 2006: MaVS study, Am Heart J (2006;152:983-90) prospective study of patients with known heart disease no difference in cardiac events more hypotension, bradycardia in β-blocked patients POISE study in Lancet (2008;371:1839-47) largest randomized trial (> 8000 patients) with / at risk for CAD lower MI rate, but higher death and stroke rates (15 vs. 8 + 5) STS National Meeting, 2010 12,855 patients undergoing CABG (known heart disease) no difference in mortality, stroke, or MIs
  16. 16. 3. Timing of antibiotics for CAP 2003: Infectious Diseases Society of America guidelines antibiotics within 4 hours of arrival if admitted with pneumonia based on unpublished analysis of old Medicare data (not RCT) senior author sat on consensus panel adopted by CMS and JCAHO as quality metric and tracked result over-diagnosis of pneumonia antibiotics given without knowing in order to be in compliance eventually changed to 6 hours
  17. 17. Can the pursuit of quality hinder the arrival? the law of unintended consequences stinting limiting access to care that improves quality but costs more quicker-sicker discharge discharging patients earlier than clinically indicated cherry-picking treating only healthier patients steering avoiding sicker patients
  18. 18. Quality in Healthcare it is here to stay (are ACOs?) transparency, and the desire for it, will not go away better to embrace it and become part of the process, because what matters is . . . What ‘Quality in Healthcare’ mean to payers!
  19. 19. Value-Based Purchasing: Milestones health insurance through employment (WWII) establishment of Medicare (LBJ, 1965) DRGs (Yale, 1982) the ‘Quality Cure’ (McClellan and Cutler, 1995) pay-for-participation value-based purchasing
  20. 20. What does VBP mean to Medicare? “The overarching goal of these initiatives is to transform Medicare from a passive payer of claims to an active purchaser of quality health care for its beneficiaries.” “We have worked with stakeholders to define measures of quality in almost every setting. These measures assess structural aspects of care, clinical processes, patient experiences with care, and, increasingly, outcomes.” “CMS views value-based purchasing as an important step to revamping how care and services are paid for, moving increasingly toward rewarding better value, outcomes, and innovations instead of merely volume.” from Medicare Program; Hospital Inpatient Value-based Purchasing Program [CMS 3239-P], released January 2011
  21. 21. What does VBP mean to Medicare? 6 quality goals effective safe timely efficient patient-centered equitable
  22. 22. What does VBP mean to Medicare? hospitals will be scored in three quality domains processes of care Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) AMI, Heart Failure, Pneumonia, Surgical Care Improvement Project Healthcare Associated Infections patients’ perspectives of care Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey outcomes 30-day mortality measures for AMI, HF, PN
  23. 23. What does VBP mean to Medicare? future readmissions hospital-acquired conditions
  24. 24. Value-Based Purchasing: % dollars at risk
  25. 25. Is ‘quality’ the ultimate goal, or is it ‘value’? competition on the wrong level advantages of a ‘value’ approach more consistent with integrated approach keys to taking a ‘value’ approach
  26. 26. Are we getting value?
  27. 27. The Triple Aim in Healthcare (IHI) Improve the health of the population Enhance the patient experience (access, satisfaction) Reduce / control the cost of care
  28. 28. Why Health Care Reform? three basic goals increase access decrease the rate of cost escalation improve qualityIt all comes down to: VALUE = QUALITY / COST . . . and physicians control QUALITY and (87% of) COST
  29. 29. Getting your organization engaged in quality physicians / providers education residents VO TO , HCAHPS, HSQ Committee nursing staff feedback; HCAHPS surveys ancillary staff operational staff
  30. 30. What is the role of the physician in ‘quality’?
  31. 31. Engaging physician in quality initiatives understand how they see the world outline expectations of the organization seek common ground invest in the physician leaders
  32. 32. Cultures in Conflict!Expert Culture (docs) Collective Culture (hosp)an individual’s success is a result teamwork is paramountof the individual’s knowledge,skills, and ambitionssuccess of the group depends on success of the group depends onhow each individual participates how well they work togetherthe whole is equal to the sum of the whole is greater than thethe parts sum of the partsmotivation for success is motivation for success is theindividual accomplishments and need for acceptance andpower recognition from Atchison & Bujak, Leading Transformational Change, ACHE Health Administration Press, Chicago
  33. 33. Strongest characteristic of physicians desire for autonomy competitive core
  34. 34. Understanding physicians: autonomy focus in medical school: personal responsibility for patient outcomes accountability goes with autonomy focus on, “What is in it for me and my patient?” personal contract with each patient vs. social contract to practice socially responsibly contrary to systems approach (basis of quality improvement)
  35. 35. Understanding physicians: competitive spirit in simulations, do not seek win-win solutions are hesitant to seek cooperation would prefer to have everyone lose rather than give any others a chance to get more than their fair share
  36. 36. Understanding physicians: competitive spirit when working with mixed groups (attending, residents, students), perform even worse why: training is all about competition pre-medical college programs pyramidal residency programs
  37. 37. How do you get quality to work for you? measure it: gather data convert it into information (what does it mean) transfer it to knowledge (evidence-based practices) convert it to action
  38. 38. How do you get quality to work for you? track it and gather more data on performance incentivize compliance extrinsic: reimbursement intrinsic: why it is good for patients why it is good for the organization (Balanced Circle)
  39. 39. data that is MEANINGFUL important to physicians and patientsdata that is RELEVANT being recorded and reported by outside agenciesdata that is RELIABLE quantifiable, risk-adjusteddata that is ACTIONABLE can be modified by improvementsdata that is TIMELY recent
  40. 40. Outlining expectations the importance of communication the need for consistency (builds trust) link rewards with behaviors extrinsic rewards (bonuses for productivity) intrinsic rewards (feedback on patient satisfaction) clarity in goals: the value of report cards
  41. 41. How to build trust create shared visions and goals recognize common principles recognize differences, but emphasize commonalities identify the benefits of collaboration consider barriers and how to overcome them together
  42. 42. How to build trust openly discuss the disadvantages of not collaborating celebrate wins along the way share: information, credit, work, expectations act on data, not opinions focus on the future and not the past
  43. 43. Report cards a.k.a. performance updates to align behaviors (financial incentives with quality) individual performance vs. department-level data vs. national benchmarks physicians are data driven, but . . . use data to shed light, not fire
  44. 44. Reinforcing expectations: compensation
  45. 45. Common ground = interdependency How? develop collaborative partnerships safety quality workflow scheduling patient satisfaction form creative shared business models search for and leverage shared values
  46. 46. The Balanced Circle customer service operational patient financial efficiency care success clinical quality
  47. 47. Effective clinical leadership raises the performance of health care organizations hospitals with the highest clinician participation in management scored 50% higher on important drivers of performance than hospitals with low levels of clinical leadership1 organizations with strong clinical leadership are more successful in performance improvement than those without2 1 Castro et al. A healthier health care system for the United Kingdom, mckinseyquarterly.com, February 2008 2 Managing Change and Role Enactment in the Professionalised Organisation, National Coordinating Centre for NHS Service Delivery and Organisation, 2006
  48. 48. To promote clinical leadership establish appropriate incentives identify, train, and mentor create the environment (highlight the successes) importance of training and mentoring (ex: PLA)
  49. 49. “Doing more of what you are        already doing and expecting a different result is a sign of insanity.” Albert Einstein

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