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

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

Introduction

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

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

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

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

Avedis Donabedian (1919 – 2000) Outcome Process Structure

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

A Strategy for Clinical Engagement

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

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.

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

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

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.

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.

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.

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

“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? 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.

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

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

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

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

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; 2008. (Available on www.IHI.org)

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; 2008. (Available on www.IHI.org)

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

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

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: 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

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.

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

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

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

Building Clinical Improvement Teams

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

QI Expertise Buy or Build?

Two Aspects of QI Knowledge Application (based upon experience)

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. http://www.hqip.org.uk/assets/Guidance/HQIP-Clinical-Audit-Simple-Guide-online1.pdf 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)