Adequate physician participation is crucial for many quality improvement initiatives, so quality professionals always look to include them more. Though challenging sometimes, the effort pays off in better quality, outcomes, and patient safety.
Encouraging more physician participation and engagement amounts to changing the culture of an organization, says Scott E. Buchalter, MD, vice president for strategy and quality officer at the University of Alabama at Birmingham (UAB). He was chief of staff for 11 years, during which he came to understand that physicians often do not have the training and knowledge necessary to work most effectively as a member of a team, particularly when it comes to quality improvement efforts.
“They need the knowledge and tools not just to deliver proper care but also to understand how to change and measure processes appropriately,” Buchalter says. “Quality improvement, or the science of managing processes, requires a different way of looking at and using data. It’s more of a real-time way to approach the processes that we use to deliver care.”
Expectations for physician involvement were different in the past, and many are just now providing physicians the skills and data necessary to contribute to quality improvement efforts, he says.
“If we don’t have those competencies in our physicians and their engagement in these quality efforts, we won’t get to the clinical outcomes and cost improvement that we want,” he says.
UAB teaches these skills in its Quality Academy, which offers the Graduate Certificate for Healthcare Quality and Safety. (See the story in this issue for more on the Quality Academy.)
Need Enough Participation
Not every physician must be an expert in quality improvement or heavily involved in quality initiatives, Buchalter notes. But there must be enough participation to make a difference.
“You do have to have a critical mass of physicians and others who are expert enough that the culture starts to change and you can spread the use of these improvement tools throughout an organization,” he says. “That is what we didn’t have before, that participation level and expertise, rather than just one or two physicians who are especially interested in quality but can’t change things on their own.”
Healthcare organizations should strive for 100% participation in quality improvement efforts, Buchalter says. That does not mean everyone is equally skilled in quality improvement science or that everyone participates to the same extent, he explains.
“It means that everybody, top to bottom, can know something about the details of improving care, what that means, and how you do it,” Buchalter says. “A tiered approach allows us to address the various levels of people involved, their time constraints, and what role they can play on a team. Over time, we are creating a larger and larger group of doctors and others who are knowledgeable and effective in using quality improvement science and improving outcomes.”
Hospital Structure Helps
A hospital’s organizational structure also can encourage physician engagement, notes Fameka Leonard, RN, MSN, LSSGB, director of quality management at UAB Hospital. The hospital saw improved physician participation when it added a chief medical officer position and a more defined structure for physician engagement.
“We have been moving more toward a model in which the physician is not just the leader of the care team, but also their participation is critical to any process improvement at the hospital,” she says.
Physician engagement has been critical to the work of the hospital’s clinical effectiveness arm, called UAB Care, she notes. UAB Care studies patient populations to search for opportunities to optimize care through standardized, evidence-based processes, and those teams always are led by a physician, Leonard says.
“Putting those physicians in the driver’s seat makes those efforts much more successful, rather than someone else coming up with a plan and telling them that they’re going to do it this way from now on,” Leonard says. “Physicians are not unique in preferring to be involved from the start in determining how they are going to do their jobs and what produces the best results. They want to be part of making the decisions that will affect them.”
Choose Right Physicians
Recruiting the right physicians as champions for a quality improvement effort or cheerleaders for quality improvement overall can be critical to success, Leonard says. She cautions, however, that you don’t always want to go straight to the top. The physician with the best title, seniority, and authority isn’t always the best choice, she says.
For example, the division director for a clinical department may be a highly esteemed researcher who has little daily involvement with the clinical processes that are being addressed, she says. Getting that person on board may make little difference, Leonard says, and in many cases that senior physician will be happy to let someone more directly involved take the lead.
“There are formal leaders and informal leaders, and sometimes it’s those informal leaders that you really want to get on your side,” Leonard says. “You have some people who really energize their colleagues and peers, but they may not be the formal leader or the physician highest up in the chain of authority. It can be a mistake to make a beeline to the boss who doesn’t really care all that much, rather than the one who has a dog in that fight and can get out there every day and motivate the people who are most affected by a change in practice.”
Use Competitive Instincts
Transparency and competitiveness are the best strategies for motivating physicians to change their behavior, Leonard says. Until individual physicians are held accountable for their own performance, it is too easy for them to say, “We’re not doing well as a department, and we all should try to improve.” Providing each physician’s performance scores to the whole department provides far better results, she says.
“Physicians are very competitive and want to do their best, so when you show them their performance on a particular measure and they’re at the bottom, they tend to make changes,” Leonard says. “When their colleagues know about the low scores, they can be very motivated to bring them up.”
Physician leadership can be key to making clinical processes work efficiently and effectively, says Bill Denton, RN, MBA, chief operating officer with Novia Strategies, a consulting company in Poway, CA. He has led surgical departments, large, complex academic medical centers, and often works with hospitals seeking to improve their operating room performance and processes. He says putting a physician in charge can make all the difference.
The surgery department highlights the need for good processes, Denton says. He headed the surgical department of a hospital with 70 operating rooms, and he compares that to starting each day with 70 weddings that must be carried out simultaneously in the same facility, followed by more later in the day. A problem or breakdown in the process of one surgery can produce a ripple effect that upsets many more.
Physicians were motivated to keep the hospital ORs running smoothly because any glitch could cost them time and money, Denton says. The hospital sought to improve its processes with the creation of an OR Executive Committee, and other hospitals have followed suit. The committee is similar to the OR committee required by The Joint Commission but different in a key way.
Members of the TJC’s committee are appointed and often are department chairs, Denton notes. The committee is more problem-oriented, identifying issues such as cases not starting on time or turnover taking too long and then instructing someone to fix those problems. The OR Executive Committee, however, is more of a task force that identifies the problems but also develops a solution.
Give Authority to Committee
The committee is comprised of a nurse leader, an administrator, and several physicians, Denton explains.
“The administration should hand pick the people on this committee, looking for people they can work with and have a relationship with, not necessarily the chair of the department,” Denton says. “The CEO comes to this group and tells them they are in charge of setting the rules and regulations for the OR. The committee is told that the hospital will never make an end run on the committee or grant exceptions to the rules it sets.”
A common problem addressed by an executive OR committee is the delay caused by surgeons not starting their procedures on time. If the hospital provides data that a doctor is not showing up on time for his 7 a.m. surgeries and that’s throwing off everyone after him, this committee decides how to deal with him, Denton explains.
The committee could decide, for instance, that after arriving late a certain number of times the physician loses his 7 a.m. privileges and must take a much later time slot, which inconveniences him and his patients.
“If a nurse leader in the OR says that, the physician is just going to brush it off. The same happens if an administrator tells them,” Denton says. “But when it’s a physician executive committee, their peers don’t have any sympathy for the doctor who can’t show up on time like everyone else, and this committee has the authority to actually do something about it. The doctor who can’t adhere to the process realizes that and improves.”
Good Data Required
The executive committee has a formal process for warning physicians, sometimes two notifications and a third hand-delivered warning that action will be taken, Denton says. In some cases, the committee determines that the real issue is a process failure within the hospital that prevents the surgeon from beginning on time, such as diagnostic imaging that’s not delivered in a timely manner.
If the same problem went to the traditional physician committee with department heads who are not motivated to improve processes, egos and departmental turf battles could overshadow efforts to find a solution, he says.
The committee needs a steady flow of reliable and usable data from the hospital, Denton says.
“Physicians rely on data and they respond very well if you give them the kind of data they need to solve problems and improve processes,” Denton says. “If you have the right physicians on the committee and not just the department heads who are appointed without much thought, they can take that data and do something meaningful with it.”
SOURCES
- Scott E. Buchalter, MD, Vice President, Strategy & Quality Officer, University of Alabama at Birmingham. Telephone: (205) 996-5732. Email: [email protected].
- Bill Denton, RN, MBA, Chief Operating Officer, Novia Strategies, Poway, CA. Telephone: (866) 747-4200.
Email: [email protected]. - Fameka Leonard, RN, MSN, LSSGB, Director of Quality Management, University of Alabama at Birmingham Hospital. Telephone: (205) 934-0189. Email: [email protected].
UAB’s Quality Academy Teaches QI Skills
To encourage greater involvement in quality efforts and provide the necessary skills for physicians and others, UAB created the Graduate Certificate for Healthcare Quality and Safety five years ago. The program is known as the Quality Academy.
About one-third of participants are physicians, and the rest are nurses and administrators, says Scott E. Buchalter, MD, vice president for strategy and quality officer at the UAB. They work together over the course of a semester, studying quality improvement and patient safety. (More information on the UAB certificate program is available online at: http://bit.ly/2ocURc9.)
“They emerge as experts, relatively speaking, in quality and patient safety, so they can then go out and lead others in their hospitals,” he says. “That still leaves thousands of caregivers, technicians, residents, pharmacists, and others who also need to understand methodologies for improvement in their own areas, even if they are not experts, so we created the Mini-Quality Academy for them.”
The mini program is a half-day program that UAB provides monthly for about 50 employees. About 800 employees have been through the mini-academy over the past several years, learning the core basics of improvement science, quality improvement, and patient safety.
“They are not experts like those who go through the Quality Academy, but they absolutely know enough to participate in care delivery activities and quality improvement efforts as a meaningful contributor,” Buchalter says. “A fair number of them go on to complete the full Quality Academy.”
For those interested in going beyond the quality certificate program, UAB also offers a master’s degree in healthcare quality and safety, one of the few available in the country. Completing the Quality Academy puts the student about halfway toward the master’s degree, Buchalter notes.
Adequate physician participation is crucial for many quality improvement initiatives, so quality professionals always look to include them more. Though challenging sometimes, the effort pays off in better quality, outcomes, and patient safety.
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