Discovering a Common Purpose: Creating Physician Engagement

© 2014 Health Catalyst
www.healthcatalyst.com
Proprietary and Confidential
www.healthcatalyst.comProprietary and Confidential
March 11, 2015
Physician Engagement
Bryan T. Oshiro, MD Chief Medical Officer, Health
Catalyst

Learning Objectives
• To describe the importance of physician engagement
in quality improvement (the “why”)
• To describe the challenges and barriers to truly have
physicians lead quality improvement (the “what”)
• To identify strategies to enhance physician
engagement (the “how”)

Best in the World!
• Most American hospitals and physicians provide safe
and effective care for the vast majority of patients, the
vast majority of the time
• Where did Italian Prime Minister Silvio Berlusconi go
when he needed a heart operation in 2011? the
Cleveland Clinic.
• When the late King Hussein of Jordan needed
treatment for lymphoma, where did he go?
• Western medicine’s ability to save and extend life,
and to improve the quality of life for the ill and injured
is nothing short of miraculous

But are We?
• 1999 IOM estimated 48,000 to 98,000 die in U.S.
hospitals for preventable errors.
• Up to 40% of all maternal deaths in the U.S. may
be preventable (Berg 2005)
• More people die from hospital-based preventable
medical injuries than from breast cancer or AIDS or
MVA
• Injuries drive direct health care costs totaling $9-$15
billion per year
Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108(5):1073-1083.

American health care
"gets it right”
54.9%
of the time.
McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to
adults in the United States. N Engl J Med; 2003;2635-2645

Where do we rank in health
and wellness world wide on the
social progress index?
Respondents - 184
A. Top 10 – 4%
B. 11-25 – 22%
C. 26-50 – 54%
D. >50 – 21%

7
Social Progress Index: 2014
Health and Wellness
#71

8
Life Expectancy at Birth: 1970
and 2011 OECD Health Statistics 2013

9
You get what you pay for!?
Per capita health expenditure, 2011
Source: OECD Health Statistics 2013, http://dx.doi.org/10.1787/health-data-en;
WHO Global Health Expenditure Database.
Average: $3,322
USA: $8,508

U.S. Healthcare Spending

Preventable Complications
Unnecessary Treatments
Inefficiency
Errors
Services
That
Add
Value
40%
Waste
60%
Value
All Services
Add
Value
100%
Value
Future
Now
What We Pay For…
11

Healthcare Revolves Around
Physicians
Opening line…
“The words “alignment” and
“coordination” have been tossed
about as the government and the
healthcare industry wrestle to
provide more value for every
healthcare dollar spent. Under
those words, every strategy to fix
the problem revolves around one
thing: physicians.”
HealthLeader's Media Breakthroughs. Aligning Hospitals and Physicians toward Value.
Dec. 2009. In collaboration with PricewaterhouseCoopers.

Engagement matters
• 75-85% of the decisions that drive quality and cost
are determined by physicians
• Gallup reported at one health system,
outpatient volume increased +17.5 for
engaged physicians in the top quartile for
improved engagement.
• Disengaged physicians in the bottom quartile,
their outpatient volume declined -11.7%.

Gallup Business
Journal “ what the
doctor ordered”
Sept 8, 2005

The Challenge
• Almost every aspect of physicians’
lives is changing or seems
uncertain
 Autonomy
 Income
 Social stature
• Physicians are going through
something akin to the stages of
grief
 Most are beyond denial
 Many are stuck at anger
• How do we get physicians to play a
positive constructive role in the
needed change?
15

Systems Issues
• Physicians are too busy
• Physicians are not compensated for their help
• Poor knowledge management support
• Malpractice issues
• Lack of meaningful measurements
• Poor data analytic support
16

Barriers to Strong Physician
Engagement
• Physicians feel overwhelmed and ill-equipped
and have limited understanding of how their
behavior contributes to healthcare waste and
inefficiency
• Providers and payors focusing only on
employment
• Organizations over-weight the importance of
compensation to influence MD behavior
• MD have poor understanding of risk-based
payment models
17
Source: McKinsey Physician Survey, 2011

18
Respondents - 207
A. Not willing – 8%
B. Somewhat willing – 79%
C. Very willing – 13%
Our doctors are ___ to participate in QI at my
hospital or clinic?

MD Willingness to Change:
Removing Waste from Healthcare System
19

Physicians Likely to Change (%)
20

Stages of Engagement
Aversion Apathy Engaged

Audience participation
Which stage best describes the engagement level
of the majority of physicians in your organization?
Respondents - 204
a. Aversion – 12%
b. Apathy – 40%
c. Engaged – 22%
d. Unsure or not applicable – 26%
22

Levels of Physician Engagement
• Confidence: Physicians believe that the
hospital can always be trusted to consistently
deliver on it’s promises.
• Integrity: Physicians believe that the hospital
always treats them fairly and will satisfactorily
resolve any problems that might occur.
• Pride: Physicians feel good about using the
hospital and hospital use reflects upon them.
• Passion: Physicians view the hospital as
irreplaceable and as an integral part of their
lives and their practice of medicine.
23
Gallup Business Journal “ what the doctor ordered” Sept 8, 2005

The best lever to engage physicians
in QI is to?
Respondents - 206
A. Place doctors in leadership positions – 33%
B. Employ them – 10%
C. Create financial incentives – 27%
D. None of the above – 30%
24

Weber’s Motives of Social Action
• Shared purpose
• Appealing to self-interest
• Earning respect
• Embrace tradition
25

Proprietary and Confidential 26

Discover Common Purpose
• We’re going to do what’s best for the patient
 Primary focus of your aims
• Reduce hassles and wasted time
• Understand the organization’s culture
 Improvement Readiness Assessment
 If possible, learn from efforts in other areas
• Understand the legal opportunities and barriers
27

Reframe Values and Beliefs
• Make physicians partners, not customers
 Make them part of the decision making
• Promote both system and individual
responsibility for quality
 Personal responsibility for quality is powerfully
engrained in physicians
28

Audience Participation
How well do you feel the physician and health
system goals are aligned in your organization?
Respondents - 181
a. Not aligned – 8%
b. Somewhat aligned – 53%
c. Moderately aligned – 35%
d. Very aligned – 4%
29

Segment the Engagement Plan
• Identify and activate champions
• Educate and inform structural leaders
 Show them the evidence and be transparent
about the data
 Develop project management skills
• Provide support and education
• Engage the physicians’ intellect
 Allow for review of improvement ideas or tests
of change
30

Proprietary and Confidential 31
Innovators
early
adopters
early
majority
laggards
(never adopters)
* Adapted from Rogers, E. Diffusion of Innovations. New York, NY: 1995.
late
majority
Innovators. Recruit
innovators to re-
design care delivery
processes (like
Revere)
Early adopters. Recruit
early adopters to chair
improvement and to lead
implementation at each site.
(key individuals who can
rally support)
TheChasm
N = number of individuals in group
N
N = number needed to influence group
(but they must be the right individuals)

Less Effective Approach to improvement:
“Punish the Outliers”
# of
Cases
Current Condition
• Significant Volume
• Significant Variation
# of
Cases
Option 1: “Punish the Outliers” or
“Cut Off the Tail”
Strategy
• Set a minimum standard of quality
• Focus improvement effort on those
not meeting the minimum standard
Mean
Focus on
Minimum
Standard
Metric
Excellent OutcomesPoor Outcomes Excellent OutcomesPoor Outcomes
1 box = 100 cases in a year

Effective Approach to improvement:
Focus on “Better Care”
Excellent OutcomesPoor Outcomes
# of
Cases
Current Condition
• Significant Volume
• Significant Variation
Excellent Outcomes
# of
Cases
Option 2: Identify Best Practice
“Narrow the curve and shift it to the right”
Strategy
• Identify evidenced based “Shared Baseline”
• Focus improvement effort on reducing
variation by following the “Shared Baseline”
• Often those performing the best make the
greatest improvements
Mean
Focus on
Best Practice
Care Process
Model
Poor Outcomes
1 box = 100 cases in a year

Use “Engaging” Improvement
Methods
• Standardize what is standardizable no more
• Use data sensibly
 Focus on system performance first
• Make the right thing easy to try
 Agile project management
• Make the right thing easy to do
34

Build Trust
• The focus must be on the patient
• Talk about an actual preventable patient safety case.
• Build trust within each quality initiative
• Communicate often and candidly
• Create a communication pathway: M&M,
Grandrounds, department meeting, quality meetings
etc.
• Address concerns and issues in a timely and obvious
manner
• Identify and overcome barriers to engagement
35

Show Courage
Provide backup
all the way to
the board
36

Adopt an Engaging Style
• Involve physicians from the beginning
• Work with the real leaders and early adoptors
• Choose messages and messengers carefully
• Make physician involvement visible
• Build trust within each quality initiative
• Communicate candidly, often
• Value physicians’ time with your time
37

Audience participation
Which do you feel would be the most important to
increase your physician engagement?
Respondents - 186
a. Cultivate a healthy and safe culture for physicians
– 6%
b. Create a shared vision – 41%
c. Create a support structure and align resources –
33%
d. Listen to physicians concerns and answers
concerns in a timely fashion – 17%
e. Unsure or not applicable – 3%
38

Summary
• People resist loss not change
• Create a shared vision: Keep the patient as the “North
Star”
• Identify real leaders, early adopters
• Create a support structure and align resources
• Try to surface and mitigate real AND perceived loss
• Create trust: Deliver on Your Promises!
39

On the Journey Together
40

Questions?
41

Discovering a Common Purpose: Creating Physician Engagement

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