OA Main- Creating Partnerships with Physicianslesson 4

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OA Main- Creating Partnerships with PhysiciansLesson 4

Presented by [Dr. Clint MacKinney, Emergency Dept. Physician and member of RUPRI]

(1-hourcall) [09-12-2013]

Alex Mitchell:I’d like to welcome everyone to today’s call, Creating Partnerships with Physicians. This is the fourth of five learning sessions that are part of the statewide initiative to improve and sustain quality of care provided by critical access hospitals. Stratis Health with support from the Minnesota Department of Health and Office of Rural Health and Primary Care is proud to host and offer this free programming to all 79 of Minnesota’s critical access hospitals.

Instead of going into great depth about our presenter today I’m going to pass it over to Dr. Clint MacKinney.

Clint, can you provide an introduction and go from there?

Clint MacKinney:I certainly can, Alex, thanks very much and welcome everyone to this conference. I’m hoping all of you have some lunch and can eat a little bit while you’re with us.

I am a rural family doctor. I live just outside St. Cloud in St. Joseph. I work in the ER in Little Falls and in fact, right after this call I’ll be running up there to finish a shift I’m starting late where I’ll end up being until tomorrow morning. I also am really lucky to work part-time with the University of Iowa, College of Public Health. I work closely on a project identifying rural health innovations, both in healthcare delivery and finance. As part of that project, Jennifer Lundblad, present CEO of Stratis Health also works with me.

I’ve done quite a bit of work over my career outside clinical medicine, discussing the challenges of non-physicians working with physicians. Mary Wakefield, the head of HERSA, always talks about Clint, you and your frat brothers at the AMA… nonetheless, physicians are often a unique breed and sometimes it helps to know a little about their background and ways we can best work with them together.

With that let me setup this talk a little bit for you if I could. There are a lot of changes going on in healthcare as you are all aware, some of them being very good especially around quality. I’ve done a lot of consulting work with rural hospitals and it’s always dismayed me that the quality improvement director as a point five FTE seems to be in a closet in the basement for his/her office.

What I’d like to think is that with some of the changes that are going on in healthcare right now, we’re elevating quality improvement officers. We should be speaking of QIOs as quality improvement officers that are on the same level as a CFO, and in the C suite, because increasing the quality, and when I say quality, clinical quality and the patient experience are being elevated to a level of finance that we’ve never really seen before.

This is a potentially exciting time, but we need to have physicians on board as we do this. Now, with that construct setting up that quality is going to be increasingly important and increasingly the finances of hospitals are going to be dependent upon quality as we see utilization and fees being ratcheted down, the way we will claw back some of that revenue for our hospitals is through delivering exceptional quality, exceptional patient care and therefore be competitive.

With that setup, let me get started with this. It’s a little harder that we’re not on a webinar so what I’ll do is to ask you to see the title slide on your computers. Again on your computer skip two slides, if you’re not familiar with this particular book don’t run right out and buy it. Go the NationalAcademy’s of Science website at NAS.edu and download the executive summary.

Every healthcare professional should have this kind of thinking in the back of their heads. In this particular book is where we laid out the very first six aims for the healthcare system, that it should be safe, effective, patient-center, timely, efficient and equitable. There has been an update to that, so we’ll move to slide three and that is something you may be more familiar with, which is the triple aim.

Admittedly the triple aim is getting a lot of use and some people would argue over use, but I’m a simple kind of guy and I resonate with the demand for the health system to improve the experience and quality of care for our individual patients, improve the health of our communities and also use resources wisely. I have to admit too that maybe some of you who are interested in quality are a little bit of Berwickiens. Don Berwick is here at IHI and later at CMS to help move this concept of triple aim forward.

I’d like to argue that one of the reasons we’re seeing a lot of healthcare reform change is because we aren’t delivering value in healthcare that all of us on this call know we’re capable of.

On slide four, this is pretty simple and I’m not a mathematician but I understand addition and division and I think this is a simple way of looking at how we can start thinking about value in healthcare. Value in healthcare is the clinical quality that we provide, plus the experience we provide for our patients the patient experience divided by per capita cost. Therefore obviously if we want to improve the value in healthcare we increase the quality and experience and decrease the cost or we do all three at once.

Look how this matches to the Institute of Medicine’s aim for the healthcare system…

• It should be safe, that’s quality.
• It should be effective, that’s quality.
• It should be patient-centered, that’s the experience.
• It should be timely, that’s the experience.
• It should be efficient, that’s the cost part.

That leaves one out and that’s equity. Equity means justice, and if there’s anyone on the call that believes our system is perfectly just and equitable please work with me in the ER for a couple nights and I’ll show you the inequities in our current healthcare system.

This also works for the triple aim, in that we have better care for our patients, better health for our communities and populations and we start doing it at lower cost. This is the value equation.

Now let’s move into the thinking of how we get to this value in healthcare while engaging physicians.

Let me introduce you to Commodore Oliver Hazard Perry. Does everyone remember the War of 1812 history, the Battle of Lake Erie? Commodore Perry says, “We have met the enemy and they are ours”, but in this particular talk we have a different philosopher we need to concentrate on and that’s Swamp Possum Pogo, the American Philosopher who said, “We have met the enemy and he is us.” We is us when we start talking about physicians. Physicians is us, we is us.

We have some evils. We have Mike Myers, Dr. Evil and then here’s the culture of healthcare. If you can’t articulate these I bet you can feel them in your bones.

• We have steep hierarchy’s.
• We rely on authority for our resources. Autonomy, doing things on our own is prioritized.
• We rely on memory and we have very feeble teamwork.
• We have a sense, especially amongst physicians, of this Iron Man mentality… I can do this by myself.
• We deny that we’re human and when we do inevitably fail we have a punitive approach to that process.

I was talking to a physician recently who had just gone through peer review. I asked her, “Did you feel really energized about your profession? Did you feel excited to see the next patient, to go out there and do a better job after this process of peer review?” She looked at me like I was from Mars. Of course not. Even though we call it peer review, it’s still done in a punitive way and we need to move past that. This is our culture.

Let’s move to the next slide, why not quality improvement? These are the things we’ll hear about as push-back, even if we’re not just working in healthcare. Get ready for these, know that they’re coming and be ready not to be deflated when you hear them.

• We’re too busy.
• We can’t afford it.
• We’re already doing something different, why are you bugging me now?
• I’m sorry, we’re already in the top 10% it’s okay to have those two ventilator acquired pneumonia’s, because that’s the top 10% in Minnesota.
• We have to have more resources.
• We have to have more people and more time.
• I don’t want to do that, I don’t get paid for it.

Let’s go to the next slide, why not quality improvement right here in our hospitals?You’ll hear these as well.

• The airline industry doesn’t apply to us, even though they’re in the business of safety. They’re in the business of satisfying their customers, even though Jennifer Lundblad and I got in at midnight last night on a flight from Washington.

• Patients are heterogeneous one size does not fit all. We’re not an airline taking care of masses of people.

• This is all about relationships not numbers I take care of an individual patient.

• Process improvement, what is that exactly? What are you talking about with PDSA, I don’t get that?

• We can’t do this kind of thing because we aren’t a teaching hospital or, we are a teaching hospital but we don’t do those kinds of things.

• Strict rules will anger doctors.

We have something missing and this is where I think we can all step up to the plate and ask, why not quality improvement in our own organizations? This has to come, not just from physicians or quality improvement officers, but it needs to come from senior leadership like CEOs and the Boards. This is how these behaviors, these individuals and these governess processes are the ones that will start making a difference in the organization.

Let me tell you a quick story of a little hospital in western Tennessee that I visited several years ago. When you walked into the hospital it was really apparent because of posters and what people said that this place was all about quality. I was talking with an elderly lab director, who had a little 4x4 office on the hall, but right in front of her office was her current QI project and I believe it was something like reducing urine culture contamination.

It was a quick little one paragraph summary of the process and a quick Excel spreadsheet showing what they had done, just the kind of thing you wanted to see. We were also talking about productivity among her lab personnel and she was pulling out spreadsheets showing me the productivity of the lab personnel while they were doing work that was billable versus work that was not quality control things for their machines.

I stopped for a moment and said how do you find the time to do this? She’s a working lab tech as well and she leans out of her office, points down the hall to the CEOs office and says this is my job. This is what I do here. It wasn’t something that was added on it was something she did.

That was a leadership decision that quality is what you do it’s not what we do after hours or as extra work. So there are some leadership things that can happen that make quality improvement easier. Blame-free culture, we all learn and share from mistakes. We all are expected to participate in quality (performance improvement) because I think this should go hand in hand.

There’s a graphic you might have seen that quality cannot operate without efficiency. Quality without efficiency is unworkable and efficiency without quality is unthinkable. This will require curiosity, creativity and transparency and it needs all of us working on that.

Let’s move to the next slide now. This is difficult stuff. We think that our jobs as quality improvement officers or physicians that are interested in quality or CEOs is all about PDSA, root cause analysis and setting up that fishbone analysis, it’s just the science of tools, but that’s just the easy stuff. It’s the culture that quality is important, that it’s what we do that’s really hard. That requires changing beliefs and self images.

There’s a professionalism belief system that we’re committed and confident individuals who provide high quality care, but then there’s a quality science which often directly is in conflict with the professionalism culture. That is ‘to err is human’.

We want to foster a new belief system among our clinicians and this isn’t just physicians but all clinicians, that it’s my ethical obligation to my patients requires me to improve quality for all patients.

Here’s one of the worst things, next slide, worst barrier to change and you’ve always heard it this way, because we’ve always done it that way Dr. MacKinney… so let’s make sure those words are completely out of the vocabulary and culture of your organization. Make sure they’re gone.

Let’s talk a bit about medical staff. Here I am, probably having a beer with John Sheehan. John is just retired and is one of the brightest rural healthcare finance guys in the nation. He just thinks in numbers, CPA/MBA. We were sitting there talking about hospital CEOs as doctors and rural healthcare finance people often do and out of the blue John says, “A health leaders most important job is developing and nurturing good medical staff relationships.”

And remember, all of you QIO officers on the call are health leaders. My jaw just dropped open and I said John, “What do you mean?” He said, “Look, when I improve revenue cycles in a hospital I’m tweaking around the edges of the financial performance of the hospital. What happens when a doctor writes or doesn’t write an order or when a quality issue occurs or doesn’t occur in an organization, that’s where the true value of the organization occurs.” So it’s important that we work with these physicians, but it hasn’t been easy.

I’m not going to quote quality improvement officers because I’m sure they’d be kinder. I am going to quote some CEOs from slide 13. Forgive the salty language, but these are direct quotes I’ve heard when working as a consultant with rural hospitals.

This job would be a hell of a lot easier if it weren’t for those damn physicians.

Or, they’ve got pediatric personalities

Or, I’m going to drive that SOB out of town.

One of my favorites which was a hospital in a college town in New England…

We’re going to have this medical staff meeting down at the local hotel I don’t want to get blood on my conference room walls.

I hope all of you are both chuckling, but inside going oh my God, how can we say these kinds of words about people we really need to be working with? Let me contrast that too, and I don’t know if there’s anyone on the call from Deer River, but the CEO there is a buddy of mine and he just said to me, Clint I’m blessed by my physicians. I looked at him and said I don’t even care if you’re lying to me. The point is that we need to work together and this kind of rhetoric isn’t going to help.

Why do we even bother?Here are the reasons why. They provide most of the medical care. I argued that it’s the clinicians that deliver the intrinsic value in healthcare, it’s not the CAT scanner, but it’s the relationship, the face-to-face relationship between nurses and patients, physicians and patients and therapists and patients. That’s the intrinsic value in healthcare.

Physicians are also knowledgeable and influential. They can be exquisitely powerful allies, but alternately if they’re apathetic or worse yet, antagonistic they’ll undermine your QI plan as fast as you can, whatever. Then I joke that without physicians hospitals become pretty expensive hotels.

Let me talk a little about physicians for a moment. The socialization of physicians and I won’t go into it a lot is unique and probably pathological. What I mean is how physicians become who they are. First, they’re selected for a certain personality for getting into medical school. These are often people that have put aside both social opportunities and social graces, and sometimes even income to have a long and arduous process of becoming a physician.

As they do so in the traditional medical school you are rewarded for being aggressive, autonomous and in control, and it continues all through your career.

When I was early in my residency I was on a particularly tough case at 3:00 o’clock in the morning and I stumbled through, fortunately the patient didn’t die and the next morning on rounds at 7:00 o’clock in the morning the attending said to me, ‘good job Clint you didn’t even have to call me.’ Does that make anyone on the call gasp? It does to me now, for two reasons.

1. That I potentially put that patient in jeopardy because of my inexperience and I didn’t call for help.

1. Somebody’s rewarding me for that type of behavior.

That happens all the time. Very individualistic and autonomous. It’s like a fight club and your goal is generating patients and revenue. It’s the hamster wheel of fee for service and this is what we’re programmed to do.