4The 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 1998In Davies H. et al. Healthcare professionals’ views on clinician engagement in quality improvement. A literature review. The Health Foundation, 2007
5The ParadigmClinicians’ 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
9WHAT 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 2011Clinical Audit is a continuous cycle of:Deciding on topicsMeasuring delivered care against standardsActing on the findingsSustaining improvements – re-audit
10HEALTH CARE SYSTEMSEvery system is perfectly designed to achieve exactly the results it gets
11The “Process” of Healthcare 133 People to take careof the patientThe Patient
16The Doctors’ Quality Agenda Physician-led, evidence-based, data-drivenBetter outcomesWhen all was said and done, how did my patient do?Professional reputationPersonal sense of excellenceLess wasted timeHasslesBottlenecks and delaysReworkMy day was going well until…No problem with this slide.
17Waiting for delays and backups in patient flow 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
19Common 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 betterThat word “physicians” again.
20Reframing Managers’ Values, Habits, Beliefs… FROM TODoctors are important customersDoctors make care decisions, we run the finances and facilitiesThe patient is the only customerDoctors are our partners in running the systemThe 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.
21Reframing Doctors’ Values, Habits, Beliefs… FROM TOI must have complete autonomy for everythingI am personally responsible for the patients I take care of directlyI need autonomy for the art of medicine, but I share it with other physicians for the science of medicineI am responsible for the care given broadly throughout the system that I am part of, including my own patientsThe 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.
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
25QuestionsWhich 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.
26Table ExerciseConsider 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 approaches10 minutes
27Segmenting and developing Clinicians to achieve improvement Develop abilityCultivate WillingnessLeadershipEngagementParticipationSupportControlBenefitFocusReliefSkillProfessionally and clinically competent CliniciansProfessionalClinicalSpeciality & Improvement areas
29Standardization: Improving Your Performance “Standard of Care”“Standard of Care”Dr. ADr. EDr. DDr. CDr. BDr. ADr. BDr. CDr. DDr. EProtocolProcedureProtocolProcedureAbility to identify defects, learn, improve --LOWAbility to identify defects, learn, improve --HIGHReliability =60-90% or lessReliability =99% or more
30Typical Approach to Standardizing Clinical Processes DesignDesignDesignDesignApproveConference RoomsReal WorldImplementSource: 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
31A Better Way to Standardize Clinical Processes Refine the Design for the Local Setting Using Small Tests of ChangeDesignApprove(if necessary)Conference RoomsReal WorldTest andModifyTest andModifyTest andModifyImplementSource: 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
32Questions 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
34What 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.
36Adopt 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.
37See the world one patient at a time Doctors…See the world one patient at a timeHave strong, specific, largely unspoken bonds based on shared experiencesOverestimate the risk of changeBehave collegially about knowledge, autonomously about individual patientsAre influenced by credible dataValue “due process”OK
38How would you use the diffusion of innovation theory to influence? Show a working example!Prove it!Mention it!Change the rules!No need!
39Principles for Working with Doctors Involve them at the beginningIdentify and work with thereal leadersearly adoptersDisplay doctor involvement to allDisplay credible results to allDon’t “package” the dataShow that you value their process and their timeOK
41Clinical Audit Root cause analysis Quality improvement Do we have the skills?Clinical AuditRoot causeanalysisQualityimprovementMoneyResource5 whysFishbone diagramsProcess mappingIdentifying issuesPrioritisationSetting standardsData collectionAnalysisAction plansClinical consensusLeadershipEnthusiasmMotivationEvidence base for assuring commissioners and/or patients
43Two Aspects of QIKnowledgeApplication(based upon experience)
44ReferencesDavies H. et al. Healthcare professionals’ views on clinician engagement in quality improvement. A literature review. The Health Foundation, 2007Clinical 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
45References4. 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