1. Influencing lead clinicians
Dr David I Gozzard
Associate Medical Director
Mersey Internal Audit Agency

2. Outline Introduction Importance of building the case for improvement
A strategy for clinical engagement
Building clinical improvement teams

3. Introduction

4. The Problem?
“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 1998
In Davies H. et al. Healthcare professionals’ views on clinician engagement in quality improvement. A literature review. The Health Foundation, 2007

5. 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

6. Importance of Building the Case for Improvement

8. STANDARDS
COMPLIANCE
(or PERFORMANCE)
IMPROVEMENT

9. 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:
Deciding on topics
Measuring delivered care against standards
Acting on the findings
Sustaining improvements – re-audit

10. HEALTH CARE SYSTEMS
Every system is perfectly designed to achieve exactly the results it gets

11. The “Process” of Healthcare
133 People to take care
of the patient
The Patient

12. Avedis Donabedian (1919 – 2000)
Outcome
Process
Structure

13. AUDIT AND IMPROVEMENT Prototype Pilot Adapt and Spread
Audit as Initiator and Scrutiny
Prototype
Pilot
Adapt and Spread
Audit
Audit
Improvement project

14. A Strategy for Clinical Engagement

15. Engaging Doctors in Quality and Safety
1. Discover Common Purpose:
Improve Patient Outcomes
Reduce hassles and wasted time
Understand the organisations culture
Understand the opportunities and barriers
6. Adopt an Engaging Style:
Involve doctors from the beginning
Make physician involvement visible
Work with the real leaders
Work with early adopters
2. Reframe Values and Beliefs:
Build trust within each quality initiative
Communicate candidly and often
Value physicians time with your time
Make Physicians partners not customers
Promote both system and individual responsibility for quality
Engaging Doctors in Quality and Safety
3. Segment the Engagement Plan:
5. Show Courage:
Provide backup all the way to the board
Are you going to mention the “compact” that some hospitals have tried? I don’t know of anything like that in the UK but it is a good example of management and clinicians reaching a “common purpose”.
Use the 80/20 rule
Identify and activate champions
Educate and inform leaders
Develop project management skills
Identify and work with “laggards”
4. Use “Engaging” Improvement Methods
Standardise what is standardisable and no more
Generate light, not heat, with data
Make the right thing easy to try and easy to do
© 2007 Institute for Healthcare Improvement

16. The Doctors’ Quality Agenda
Physician-led, evidence-based, data-driven
Better outcomes
When all was said and done, how did my patient do?
Professional reputation
Personal sense of excellence
Less wasted time
Hassles
Bottlenecks and delays
Rework
My day was going well until…
No problem with this slide.

17. Waiting for delays and backups in patient flow
Personal “Muda”
Documenting care
Waiting for delays and backups in patient flow
Locating patient records and referral letters
Serving on committees
Certifying the medical necessity for equipment and ambulances
Managing patients’ pharmaceutical needs with repeat prescriptions
Interacting with social services

18. Engaging Doctors in Quality and Safety
1. Discover Common Purpose:
Improve Patient Outcomes
Reduce hassles and wasted time
Understand the organisations culture
Understand the opportunities and barriers
6. Adopt an Engaging Style:
Involve doctors from the beginning
Make physician involvement visible
Work with the real leaders
Work with early adopters
2. Reframe Values and Beliefs:
Build trust within each quality initiative
Communicate candidly and often
Value physicians time with your time
Make Physicians partners not customers
Promote both system and individual responsibility for quality
Engaging Doctors in Quality and Safety
3. Segment the Engagement Plan:
5. Show Courage:
Provide backup all the way to the board
Are you going to mention the “compact” that some hospitals have tried? I don’t know of anything like that in the UK but it is a good example of management and clinicians reaching a “common purpose”.
Use the 80/20 rule
Identify and activate champions
Educate and inform leaders
Develop project management skills
Identify and work with “laggards”
4. Use “Engaging” Improvement Methods
Standardise what is standardisable and no more
Generate light, not heat, with data
Make the right thing easy to try and easy to do
© 2007 Institute for Healthcare Improvement

19. 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
That word “physicians” again.

20. Reframing Managers’ Values, Habits, Beliefs…
FROM TO
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
The NHS has almost done away with the term “administrator” and the usage is now in favor of “managers”. However, the sentiments are the same. In the UK we have paid clinical directorships. The medical director tends to be a board level executive position whilst clinical directors head a department.

21. Reframing Doctors’ Values, Habits, Beliefs…
FROM TO
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
The Medical Executive Committee has largely been replaced by a hospital management committee of managers and doctors (usually clinical directors in partnership. This tends to be the day-to-day management committee of the hospital. The Hospital Board oversees the management of this group. Any standardization is probably agreed through clinical governance procedures to agree clinical policy. Consequently all hospitals will have a clinical governance (or sometimes an integrated governance) committee.

22. Engaging Doctors in Quality and Safety
1. Discover Common Purpose:
Improve Patient Outcomes
Reduce hassles and wasted time
Understand the organisations culture
Understand the opportunities and barriers
6. Adopt an Engaging Style:
Involve doctors from the beginning
Make physician involvement visible
Work with the real leaders
Work with early adopters
2. Reframe Values and Beliefs:
Build trust within each quality initiative
Communicate candidly and often
Value physicians time with your time
Make Physicians partners not customers
Promote both system and individual responsibility for quality
Engaging Doctors in Quality and Safety
3. Segment the Engagement Plan:
5. Show Courage:
Provide backup all the way to the board
Are you going to mention the “compact” that some hospitals have tried? I don’t know of anything like that in the UK but it is a good example of management and clinicians reaching a “common purpose”.
Use the 80/20 rule
Identify and activate champions
Educate and inform leaders
Develop project management skills
Identify and work with “laggards”
4. Use “Engaging” Improvement Methods
Standardise what is standardisable and no more
Generate light, not heat, with data
Make the right thing easy to try and easy to do
© 2007 Institute for Healthcare Improvement

23. “There is no such thing as improvement in general”
Joseph Juran

24. “There is no such thing as clinical engagement in general”
Harvard Faculty

25. 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?
There are two positions at the executive management level that are clinical - the medical director – i.e. my post, and the nursing director. Both are hugely influential in steering colleagues along strategic routes. There don’t tend to be department heads or committee heads in the UK involved in the management process. Clinical Directors are the main individuals.

26. 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

27. Segmenting and developing Clinicians to achieve improvement
Develop ability
Cultivate Willingness
Leadership
Engagement
Participation
Support
Control
Benefit
Focus
Relief
Skill
Professionally and clinically competent Clinicians
Professional
Clinical
Speciality & Improvement areas

28. Engaging Doctors in Quality and Safety
1. Discover Common Purpose:
Improve Patient Outcomes
Reduce hassles and wasted time
Understand the organisations culture
Understand the opportunities and barriers
6. Adopt an Engaging Style:
Involve doctors from the beginning
Make physician involvement visible
Work with the real leaders
Work with early adopters
2. Reframe Values and Beliefs:
Build trust within each quality initiative
Communicate candidly and often
Value physicians time with your time
Make Physicians partners not customers
Promote both system and individual responsibility for quality
Engaging Doctors in Quality and Safety
3. Segment the Engagement Plan:
5. Show Courage:
Provide backup all the way to the board
Are you going to mention the “compact” that some hospitals have tried? I don’t know of anything like that in the UK but it is a good example of management and clinicians reaching a “common purpose”.
Use the 80/20 rule
Identify and activate champions
Educate and inform leaders
Develop project management skills
Identify and work with “laggards”
4. Use “Engaging” Improvement Methods
Standardise what is standardisable and no more
Generate light, not heat, with data
Make the right thing easy to try and easy to do
© 2007 Institute for Healthcare Improvement

29. Standardization: Improving Your Performance
“Standard of Care”
“Standard of Care”
Dr. A
Dr. E
Dr. D
Dr. C
Dr. B
Dr. A
Dr. B
Dr. C
Dr. D
Dr. E
Protocol
Procedure
Protocol
Procedure
Ability to identify defects, learn, improve --LOW
Ability to identify defects, learn, improve --HIGH
Reliability =
60-90% or less
Reliability =
99% or more

30. Typical Approach to Standardizing Clinical Processes
Design
Design
Design
Design
Approve
Conference Rooms
Real World
Implement
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; (Available on

31. A Better Way to Standardize Clinical Processes
Refine the Design for the Local Setting Using Small Tests of Change
Design
Approve
(if necessary)
Conference Rooms
Real World
Test and
Modify
Test and
Modify
Test and
Modify
Implement
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; (Available on

32. 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?” OK

33. Engaging Doctors in Quality and Safety
1. Discover Common Purpose:
Improve Patient Outcomes
Reduce hassles and wasted time
Understand the organisations culture
Understand the opportunities and barriers
6. Adopt an Engaging Style:
Involve doctors from the beginning
Make physician involvement visible
Work with the real leaders
Work with early adopters
2. Reframe Values and Beliefs:
Build trust within each quality initiative
Communicate candidly and often
Value physicians time with your time
Make Physicians partners not customers
Promote both system and individual responsibility for quality
Engaging Doctors in Quality and Safety
3. Segment the Engagement Plan:
5. Show Courage:
Provide backup all the way to the board
Are you going to mention the “compact” that some hospitals have tried? I don’t know of anything like that in the UK but it is a good example of management and clinicians reaching a “common purpose”.
Use the 80/20 rule
Identify and activate champions
Educate and inform leaders
Develop project management skills
Identify and work with “laggards”
4. Use “Engaging” Improvement Methods
Standardise what is standardisable and no more
Generate light, not heat, with data
Make the right thing easy to try and easy to do
© 2007 Institute for Healthcare Improvement

34. 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.

35. Engaging Doctors in Quality and Safety
1. Discover Common Purpose:
Improve Patient Outcomes
Reduce hassles and wasted time
Understand the organisations culture
Understand the opportunities and barriers
6. Adopt an Engaging Style:
Involve doctors from the beginning
Make physician involvement visible
Work with the real leaders
Work with early adopters
2. Reframe Values and Beliefs:
Build trust within each quality initiative
Communicate candidly and often
Value physicians time with your time
Make Physicians partners not customers
Promote both system and individual responsibility for quality
Engaging Doctors in Quality and Safety
3. Segment the Engagement Plan:
5. Show Courage:
Provide backup all the way to the board
Are you going to mention the “compact” that some hospitals have tried? I don’t know of anything like that in the UK but it is a good example of management and clinicians reaching a “common purpose”.
Use the 80/20 rule
Identify and activate champions
Educate and inform leaders
Develop project management skills
Identify and work with “laggards”
4. Use “Engaging” Improvement Methods
Standardise what is standardisable and no more
Generate light, not heat, with data
Make the right thing easy to try and easy to do
© 2007 Institute for Healthcare Improvement

36. 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!)
No problem with this slide.

37. See the world one patient at a time
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” OK

38. How would you use the diffusion of innovation theory to influence?
Show a working example!
Prove it!
Mention it!
Change the rules!
No need!

39. Principles for Working with Doctors
Involve them at the beginning
Identify and work with the
real leaders
early 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 OK

40. Building Clinical Improvement Teams

41. Clinical Audit Root cause analysis Quality improvement
Do we have the skills?
Clinical Audit
Root cause
analysis
Quality
improvement
Money
Resource
5 whys
Fishbone diagrams
Process mapping
Identifying issues
Prioritisation
Setting standards
Data collection
Analysis
Action plans
Clinical consensus
Leadership
Enthusiasm
Motivation
Evidence base for assuring commissioners and/or patients

42. QI Expertise
Buy or Build?

43. Two Aspects of QI
Knowledge
Application
(based upon experience)

44. References
Davies H. et al. Healthcare professionals’ views on clinician engagement in quality improvement. A literature review. The Health Foundation, 2007
Clinical Audit: A Simple Guide.
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; (Available on

45. 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; (Available on