Achieving physician buy-in through incentives
Developing physician champion critical
Case managers know all too well that constructing the ideal case management program is likely to pay few dividends without the active participation of physicians. But John Hinton, DO, MPH, vice president of clinical information management at Catholic Healthcare Partners (CHP) in Cincinnati, argues that getting physician buy-in is an often misunderstood task.
Case managers must have a plan for engaging physicians that begins with understanding the current challenge, Hinton says. For example, case managers may be seeking to address the limited adoption of guidelines or failure to meet outcome targets. Other challenges may include increased readmissions or extended length of stay. "The key to motivating physicians is to give them the sense of urgency." The three issues he tries to emphasize throughout CHP’s 31 hospitals are public reporting, patient safety and quality, and making sure both the facility and the physician get appropriate reimbursement. "In order to get appropriate reimbursement, you are going to need appropriate documentation and coding," Hinton adds. "Those are the three things that we can generate that can be beneficial."
Patient safety and reducing medication errors are important and can be achieved through performance improvement, documentation improvement, and an emphasis on evidence-based practices, he says. It’s important to note that none of those factors are financial, Hinton says. "I don’t think financial incentives work. I think financial incentives tend to be demeaning." He tries to appeal to the "higher motives" of physicians, such as liking to teach and practice effective medicine. "Those are two key behaviors that you want to appeal to when working with physicians."
Another critical ingredient to securing physician buy-in is making sure that patient care is fairly well standardized, Hinton says. Because CHP has 31 hospitals in its system, he says he would be concerned, for example, why congestive heart failure might be treated significantly different at one end of the system than at the other. It is important to make sure that physicians not only are using the same pathway but that they are using evidence-based medicine, he explains. "Some of those things we can help through case management and just-in-time information to physicians," he adds.
Hinton says one major emphasis CHP currently is working on is a computerized physician order entry system in part to improve standardization. "This way, you can prompt physicians in a timely fashion based on diagnosis and current best practices about what can be selected by the physician to treat the patient," he says.
According to Hinton, it is a misconception to believe that physicians must be "educated." What they actually require is "awareness" followed by behavior change. "Physicians have had enough education," he argues. "They don’t need to be brought in for educational sessions to be sat down and instructed."
Hinton says case managers should look for "the teachable moment" that arises when an issue comes up on the floor with the patient. He says it is largely a matter of catching physicians when a chart is open and there is a question about what choices should be made about treating or discharge planning for that patient. Physicians are "primed to receive input" when someone is helping them to reduce a barrier, he explains.
In addition, many physicians often are unaware of patterns of care and instead view each patient only as an individual, Hinton says. Because they often don’t see the whole population they are managing, they require feedback on a regular basis regarding the entire population of patients, he says.
For example, case managers might ask a physician whether she realizes she had eight patients in with pneumonia last month and that four of them did not receive their antibiotics until 24 hours later, rather than the standard eight hours. "They need to be helped by someone aggregating that information and letting them know how they are performing and how they are performing in relation to their peers, and how they are performing in relation to their own practice," he asserts.
If a system has five community-acquired pneumonia patients and all five are treated differently, physicians should be prompted to look at how they are assigning antibiotics and the criteria they are using to make the clinical discriminations on treatment, Hinton says. In addition, he says, case managers must educate physicians on what these practices mean in the big picture. "We want to give them an idea of the impact they are having."
In addition to pointing out what is not working, case managers also should emphasize what is working, Hinton says. "If you have physicians who are doing a good job, leave them alone and get out of their way and concentrate on where you have opportunity," he says.
If physicians are performing well and exceeding national standards, they should know that, Hinton adds. "Physicians respond well to praise and encouragement," he says. "But they get very little of it out in the field."
In short, if physicians are not working fully within the guidelines but are doing very well on quality and outcomes, case managers probably should leave them alone, Hinton says. "Work on what we need to do about some of the practices that may not be working as well," he says.
According to Hinton, it also is useful to adopt "a system approach" to behavior and practice change as opposed to targeting individual physicians. "We can work on bad apples, but the new paradigm of quality improvements works on trying to shift the curve and not just cut off the folks at the end of the curve who may be poor performers," he explains.
Case managers should seek out "physician champions" to spearhead their efforts, he says. Hinton emphasizes the difference between "champions" and "heroes." The latter are ordinary people who do extraordinary things at specific points in time, he says. By contrast, he likens physician champions to athletes in training. "Our goal is to develop folks who can do the right thing over and over again repeatedly and not just every once in a while have a breakthrough," he explains.
There are several criteria regarding the type of physicians who make champions, Hinton says. Case managers should look for physicians who are effective communicators, like to teach, and have a high degree of both clinical expertise and humanistic concern, he adds.
Case managers should focus on getting physicians to teach, demonstrate, and be examples for their peers, Hinton says. He points out that people retain 90% of what they teach and diminishing amounts if they are just listening or doing other things. "I think it is important that physicians be fully engaged. You want to appeal to those traits and select physicians with those traits as your core champions."
[For more information, contact:
- John T. Hinton, DO, MPH, Vice President, Corporate Medical Director, Clinical Performance Improvement, Catholic Healthcare Partners, 615 Elsinore Place, Cincinnati, OH 45202. Telephone: (513) 639-2839. E-mail: [email protected].]
Physician Champions Selection
Communication:
- Convey information that provides learning experience
- Express themselves clearly and to the point
- Provide practical information first, then rationale
- Take time to answer questions completely
- Enjoy and are willing to share knowledge
Expertise:
- Like to teach
- Are current and up-to-date with command of medical knowledge
- Demonstrate a high level of clinical expertise
Relationships:
- Caring physicians with high level of humanistic concern
- Treat staff and colleagues as equals
Source: Hiss, Macdonald, et al; University of Michigan, Ann Arbor.
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