INFLUENCINGLEAD CLINICIANS

Dr David I GozzardAssociate Medical Director

Mersey Internal Audit Agency

Outline

1. Introduction

2. Importance of building the case for improvement

3. A strategy for clinical engagement

4. Building clinical improvement teams

Introduction

“Quality has been used as a weapon in the fight against limits to healthcare funding. In one corner of the ring stands the clinician, outraged that a paper pushing manager concerned with throughputs and efficiency does not understand or care that quality of care is adversely affected by cost cutting. In the other corner stands the manager, convinced that quality is the last refuge of the medical scoundrel – a convenient, vague and all embracing term used to block any attempts to question or change clinical behaviour”

Buchan 1998In Davies H. et al. Healthcare professionals’ views on clinician engagement in

quality improvement. A literature review. The Health Foundation, 2007

The Problem?

The Paradigm

• Clinicians’ primary professional focus is their own practice.

• At best, clinicians have little time to spare for quality agendas of their

organisations.

• At worst, relationships are strained because the clinicians’ quality

agendas conflict with those of their organisations.

• Very little happens without a clinician order

Importance of Building the Case for Improvement

STANDARDS

COMPLIANCE

(or PERFORMANCE)

IMPROVEMENT

WHAT IS CLINICAL AUDIT?

“Clinical audit is a quality

improvement cycle that involves

measurement of the effectiveness

of healthcare against agreed and

proven standards for high quality,

and taking action to bring practice

in line with these standards so as

to improve the quality of care and

health outcomes.”

New Principles of Best Practice in Clinical Audit, Jan 2011

Clinical Audit is a continuous cycle of:1.Deciding on topics2.Measuring delivered care against standards3.Acting on the findings4.Sustaining improvements – re-audit

HEALTH CARE SYSTEMS

Every system is perfectly designed to achieve exactly the results it

gets

The “Process” of Healthcare

The Patient133 People to take careof the patient

Avedis Donabedian (1919 – 2000)

AUDIT AND IMPROVEMENT

Prototype PilotAdapt and

Spread

Improvement project

AuditAudit

Audit as Initiator and Scrutiny

A Strategy for Clinical Engagement

Engaging Doctors in

Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

3. Segment the Engagement Plan:

4. Use “Engaging” Improvement Methods

5. Show Courage:

6. Adopt an Engaging Style:

• Improve Patient Outcomes• Reduce hassles and wasted time• Understand the organisations culture• Understand the opportunities and barriers

• Make Physicians partners not customers

• Promote both system and individual responsibility for quality

• Use the 80/20 rule• Identify and activate champions• Educate and inform leaders• Develop project management

skills• Identify and work with “laggards”

• Standardise what is standardisable and no more• Generate light, not heat, with data• Make the right thing easy to try and easy to do

• Provide backup all the way to the board

• Involve doctors from the beginning• Make physician involvement visible• Work with the real leaders• Work with early adopters

• Build trust within each quality initiative

• Communicate candidly and often

• Value physicians time with your time

© 2007 Institute for Healthcare Improvement

The Doctors’ Quality Agenda

Physician-led, evidence-based, data-drivenBetter outcomes

When all was said and done, how did my patient do?Professional reputationPersonal sense of excellence

Less wasted timeHasslesBottlenecks and delaysReworkMy day was going well until…

Personal “Muda”

Documenting careWaiting for delays and backups in patient flowLocating patient records and referral lettersServing on committeesCertifying the medical necessity for equipment and ambulancesManaging patients’ pharmaceutical needs with repeat prescriptionsInteracting with social services

Engaging Doctors in

Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

3. Segment the Engagement Plan:

4. Use “Engaging” Improvement Methods

5. Show Courage:

6. Adopt an Engaging Style:

• Improve Patient Outcomes• Reduce hassles and wasted time• Understand the organisations culture• Understand the opportunities and barriers

• Make Physicians partners not customers

• Promote both system and individual responsibility for quality

• Use the 80/20 rule• Identify and activate champions• Educate and inform leaders• Develop project management

skills• Identify and work with “laggards”

• Standardise what is standardisable and no more• Generate light, not heat, with data• Make the right thing easy to try and easy to do

• Provide backup all the way to the board

• Involve doctors from the beginning• Make physician involvement visible• Work with the real leaders• Work with early adopters

• Build trust within each quality initiative

• Communicate candidly and often

• Value physicians time with your time

© 2007 Institute for Healthcare Improvement

Common Agenda: Keys to Success

Frame the quality challenge in terms that are important to doctors

“Reduce Needless Deaths, Readmissions, Nosocomial Infections, Hassles…”

Not “Reduce LOS” or “Improve Productivity”Measure and display the results on important things—show them that together, you’re actually making these things better

Reframing Managers’ Values, Habits, Beliefs…

• Doctors are important customers

• Doctors make care decisions, we run the finances and facilities

• The patient is the only customer

• Doctors are our partners in running the system

FROM TO

Reframing Doctors’ Values, Habits, Beliefs…

• I must have complete autonomy for everything

• I am personally responsible for the patients I take care of directly

• I need autonomy for the art of medicine, but I share it with other physicians for the science of medicine

• I am responsible for the care given broadly throughout the system that I am part of, including my own patients

FROM TO

Engaging Doctors in

Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

3. Segment the Engagement Plan:

4. Use “Engaging” Improvement Methods

5. Show Courage:

6. Adopt an Engaging Style:

• Improve Patient Outcomes• Reduce hassles and wasted time• Understand the organisations culture• Understand the opportunities and barriers

• Make Physicians partners not customers

• Promote both system and individual responsibility for quality

• Use the 80/20 rule• Identify and activate champions• Educate and inform leaders• Develop project management

skills• Identify and work with “laggards”

• Standardise what is standardisable and no more• Generate light, not heat, with data• Make the right thing easy to try and easy to do

• Provide backup all the way to the board

• Involve doctors from the beginning• Make physician involvement visible• Work with the real leaders• Work with early adopters

• Build trust within each quality initiative

• Communicate candidly and often

• Value physicians time with your time

© 2007 Institute for Healthcare Improvement

“There is no such thing as improvement in general”

Joseph Juran

“There is no such thing as clinical engagement in general”

Harvard Faculty

Questions

• Which doctors must be engaged in this initiative, if it is to succeed? (And which doctors are not relevant at all?)

• Who is on our short list of potential champions for this initiative? How will we select one or two champions? What is our plan to support them?

• What will be the role of the formal leaders: Clinical Executive Management, Department Heads, and Clinical Directors in this initiative?

• Does a doctor need to be the “project leader” for this initiative? If so, how will we train and support that doctor so that the project will be effectively led?

• Which doctors are likely to vocally oppose and potentially derail this initiative? How could we mitigate that risk?

Table Exercise

Consider a quality initiative that you are either engaged in or

are planning to start.

Some doctors are likely to vocally oppose and potentially derail

this initiative.

How could we mitigate that risk?

List 3 approaches

10 minutes

Leadership

Engagement

Participation

Develop ability

Cultivate Willingness

Segmenting and developing Clinicians to achieve

improvement

Speciality & Improvement areas

Control

Benefit

Relief

Support

Focus

Skill

Professionally and clinically competent

Clinicians

ClinicalProfessional

Engaging Doctors in

Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

3. Segment the Engagement Plan:

4. Use “Engaging” Improvement Methods

5. Show Courage:

6. Adopt an Engaging Style:

• Improve Patient Outcomes• Reduce hassles and wasted time• Understand the organisations culture• Understand the opportunities and barriers

• Make Physicians partners not customers

• Promote both system and individual responsibility for quality

• Use the 80/20 rule• Identify and activate champions• Educate and inform leaders• Develop project management

skills• Identify and work with “laggards”

• Standardise what is standardisable and no more• Generate light, not heat, with data• Make the right thing easy to try and easy to do

• Provide backup all the way to the board

• Involve doctors from the beginning• Make physician involvement visible• Work with the real leaders• Work with early adopters

• Build trust within each quality initiative

• Communicate candidly and often

• Value physicians time with your time

© 2007 Institute for Healthcare Improvement

Standardization: Improving Your Performance “Standard of Care”

Dr.

A

Dr.

E

Dr.

D

Dr.

C

Dr.

B

ProtocolProcedure

ProtocolProcedureProtocol

Procedure

ProtocolProcedure Protocol

Procedure

ProtocolProcedureProtocol

Procedure

ProtocolProcedureProtocol

Procedure

ProtocolProcedure

Reliability =60-90% or less

Ability to identify defects, learn, improve --LOW

Dr.

A

Dr.

E

Dr.

D

Dr.

C

Dr.

B

Reliability =99% or more

Ability to identify defects, learn, improve --HIGH

ProtocolProcedure

ProtocolProcedure

“Standard of Care”

Typical Approach to Standardizing Clinical Processes

Source: Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available on www.IHI.org)

Design Design Design Design Approve

Conference Rooms

Real World

Implement

A Better Way to Standardize Clinical Processes

Design

Test and Modify

Test and Modify

Implement

Approve (if necessary)

Test and Modify

Conference Rooms

Real World

Source: Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care(Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available on www.IHI.org)

Refine the Design for the Local Setting Using Small Tests of Change

Questions

Are you trying to standardize too much?

Do your data reports to doctors make things worse?

Do you have endless meetings trying to decide on the “right

answer,” as if this is the one and only opportunity you’ll ever

have to get it right?

Have you ever faced a doctor rebellion after implementing the

“right answer?”

Engaging Doctors in

Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

3. Segment the Engagement Plan:

4. Use “Engaging” Improvement Methods

5. Show Courage:

6. Adopt an Engaging Style:

• Improve Patient Outcomes• Reduce hassles and wasted time• Understand the organisations culture• Understand the opportunities and barriers

• Make Physicians partners not customers

• Promote both system and individual responsibility for quality

• Use the 80/20 rule• Identify and activate champions• Educate and inform leaders• Develop project management

skills• Identify and work with “laggards”

• Standardise what is standardisable and no more• Generate light, not heat, with data• Make the right thing easy to try and easy to do

• Provide backup all the way to the board

• Involve doctors from the beginning• Make physician involvement visible• Work with the real leaders• Work with early adopters

• Build trust within each quality initiative

• Communicate candidly and often

• Value physicians time with your time

© 2007 Institute for Healthcare Improvement

What do you do?

A complaint comes to you from a nurse that a surgical

consultant behaves badly in theatre, shouting at staff and

occasionally throwing surgical instruments. The staff

have been scared to raise this issue but the nurse now

says that several nurses will resign unless “something is

done”. The doctor involved is head of a regional surgical

service.

Engaging Doctors in

Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

3. Segment the Engagement Plan:

4. Use “Engaging” Improvement Methods

5. Show Courage:

6. Adopt an Engaging Style:

• Improve Patient Outcomes• Reduce hassles and wasted time• Understand the organisations culture• Understand the opportunities and barriers

• Make Physicians partners not customers

• Promote both system and individual responsibility for quality

• Use the 80/20 rule• Identify and activate champions• Educate and inform leaders• Develop project management

skills• Identify and work with “laggards”

• Standardise what is standardisable and no more• Generate light, not heat, with data• Make the right thing easy to try and easy to do

• Provide backup all the way to the board

• Involve doctors from the beginning• Make physician involvement visible• Work with the real leaders• Work with early adopters

• Build trust within each quality initiative

• Communicate candidly and often

• Value physicians time with your time

© 2007 Institute for Healthcare Improvement

Adopt an Engaging Style

Involve doctors from the beginning (but don’t make them do everything)

Work with the real leaders (they may not be most senior)

Work with early adopters (they will help you and the improvement)

Make doctors involvement visible (credible and not shameful)

Build trust within each quality initiative (make it part of the way things are done around here)

Communicate candidly, often (if your lips aren't bleeding you haven't communicated enough)

Value doctors time with your time (don’t waste either!)

Doctors…

• See the world one patient at a time

• Have strong, specific, largely unspoken bonds based

on shared experiences

• Overestimate the risk of change

• Behave collegially about knowledge, autonomously

about individual patients

• Are influenced by credible data

• Value “due process”

How would you use the diffusion of innovation theory

to influence?

No need!

Mention it!

Show a working

example! Prove it!

Change the rules!

Principles for Working with DoctorsInvolve them at the beginning

Identify and work with the real leadersearly adopters

Display doctor involvement to all

Display credible results to all

Don’t “package” the data

Show that you value their process and their time

Building Clinical Improvement Teams

Do we have the skills?

Clinical AuditRoot cause

analysisQuality

improvement

•5 whys

•Fishbone diagrams

•Process mapping •Clinical consensus

•Leadership

•Enthusiasm

•Motivation

•Evidence base for assuring commissioners and/or patients

•Money

•Resource•Identifying issues

•Prioritisation

•Setting standards

•Data collection

•Analysis

•Action plans

QI Expertise

Buy or Build?

Two Aspects of QI

1. Knowledge

2. Application(based upon experience)

References

1. Davies H. et al. Healthcare professionals’ views on clinician

engagement in quality improvement. A literature review. The Health

Foundation, 2007

2. Clinical Audit: A Simple Guide. http://

www.hqip.org.uk/assets/Guidance/HQIP-Clinical-Audit-Simple-Guide-o

nline1.pdf

3. Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage

Points for Organization-Level Improvement in Health Care (Second

Edition). IHI Innovation Series white paper. Cambridge, MA: Institute

for Healthcare Improvement; 2008. (Available on www.IHI.org)

References

4. Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging

Physicians in a Shared Quality Agenda. IHI Innovation Series white

paper. Cambridge, MA: Institute for Healthcare Improvement; 2007.

(Available on www.IHI.org)