How to achieve QI cooperation from health system physicians
How to achieve QI cooperation from health system physicians
Protocol program worked for this 5-hospital system
Trying to get physicians to beef up data reporting and follow clinical pathways and protocols can be tough in the best of times. But in an era when the health care system is fragmented and some people seem worried about everything but the patient, that task could be nearly impossible.
Thomas Collins, EdD, president and CEO of the five-hospital MemorialCare health system in Southern California, didn’t let negative reactions from physicians about any idea mooted by health system management stop him from creating a clinical map and protocol program for MemorialCare. And he was successful, even though the system doesn’t directly employ any of its 1,250 physicians and Collins wanted to have 85% of the patients that go to system hospitals treated under one of the clinical maps.
The idea isn’t new; one of the models Collins worked with initially came from the Mayo clinic. "But they employ their physicians, so it’s not the same," he points out.
The quality initiative has performed beyond expectations since its inception in 1993. Some 850 physicians voluntarily participate in the system, and about 70% of patients — 76,000 inpatients and outpatients — are cared for under one of the 27 protocols and clinical maps that currently exist.
There have been positive clinical results of the program, too. The median time for delivering IV thrombolytic drugs to chest pain patients is eight minutes faster than the national median, and the system’s rate of complications for simple pneumonia is nearly 43% lower than state and national rates.
"People talked about physician/hospital relationships, buying and selling, and golden para-chutes and Wall Street," Collins explains. "But it seemed to me that the missing link in all those discussions was the patient."
While that seems like a selfless, altruistic reason for implementing a quality program, he admits there is sound business reasoning behind the initiative, too. "There is a large oversupply of hospitals and doctors. We are a commodity and needed a way that would differentiate ourselves from others so that patients want to choose us."
Making it the doctor’s prescription
Hatching an idea is easy. Getting it to work is something else entirely. Collins held a series of lunch discussions with about six physicians at each hospital to determine how to put the patient back in the equation, and the idea of creating protocols that would bring continuity and excellence of care to all MemorialCare patients, regardless of payer source, was a hit.
But Collins didn’t want the project to appear like a directive from above, so he hired a facilitator and sent 32 physicians on a two-day retreat to work on a plan. "I didn’t participate. If it had legs, I wanted it to happen because they saw this as an opportunity."
Physicians liked the idea in principle, but getting them to agree to gather and report data required some salesmanship. Collins says that one way he swayed them was to insist that physicians who had superior outcomes would be identified in MemorialCare literature and patient information materials. "That they are associated with MemorialCare — and that their expertise is aggressively communicated to the market — gives them a positive business result from participating," says Collins.
After the retreat, a steering committee of 15 physicians took on the task of developing the program. There are three sections: initiative development teams, marketing, and information services.
A third of the physicians at MemorialCare are involved in those teams and the study groups that determine which conditions and procedures should be included in the maps and protocols. There are also three administrative staff to support their efforts. "But the administration leadership leaves them on their own to come to an agreement," he says. "It has to be a clinical conclusion that they reach."
There is no shortage of clinical protocols available to use, and Collins admits that what the physicians do isn’t "earthshaking or revolutionary. But we are able to take existing protocols and literature and come to a conclusion about how our physicians will care for our patients."
Even more difficult than getting physicians to accept the idea of the protocol is getting them to use it and report their figures, says Collins. But he adds that the rate of use and reporting goes up if the physicians feel a sense of ownership in the program.
Selecting procedures
The next step for the physicians on board was deciding which areas to tackle. "We knew we had to start based on utilization," explains Clyde Wesp, MD, MA, chairman of the quality task force for MemorialCare. "And the utilization couldn’t just be based on patients, but on how many groups of physicians it might touch, too. Chest pain can affect ED physicians, internists, and cardiologists, so we could get a lot of people involved in putting together a map. Right away, we get a good bang for our buck."
The obvious protocols included chest pain, routine care of the newborn, vaginal births, and mammography. "With that, we were touching about 50,000 patients a year," says Wesp. Eventually, those maps spawned other ones: Mammography led to breast pathology, and chest pain led to cardiac catheterization and management of myocardial infarctions.
Common DRGs also were ripe for attention. "We looked at orthopedics and what were the most common diagnoses and procedures," Wesp says. "Total hip and knee replacements are done at all those facilities. And that’s a good thing to tackle because the procedures have a defined beginning, middle, and end to them."
Once the target was set, Wesp and his colleagues looked for physicians who did a lot of the designated procedures. "We would talk to outcomes managers or clinical nurse specialists, and get them to tell us who might be receptive to us, asking them to be on our team."
Without that interest, you end up with an uninterested body in the meetings who has nothing to contribute, he adds.
Along with getting physicians involved who are most likely to care for the targeted patient populations, Wesp likes to ensure that there is a balance between types of physicians on the development team. For instance, family practice, internists, and neurologists are all involved in a current effort to develop a clinical map for stroke patients.
In many cases, the people involved aren’t physicians. Nursing staff, physical therapists, and pharmacists are also brought in. "Their job isn’t just to participate in the map development, but to communicate with their peers at their facilities and get input from them," he adds.
The input of nonphysician sources can really add to a protocol’s development, Wesp continues. "With cardiology issues, a pharmacist knows most about all the different drugs, including the clinical and financial benefits of using one over another."
Wesp comes to meetings armed with Internet research and the latest and greatest articles on the topic at hand. "There are a lot of data out there, so I talk to clinical nurse specialists and try to focus on any areas of controversy." With stroke, one issue discussed is the use of tPA (tissue plasminogen activator) for patients and whether the five hospitals in the system could meet the time requirements needed to make that drug effective.
"I have to go in with a big picture," he explains. "I have to look at our ability to manage stroke in a time efficient way, decrease any risk to our organization, and optimize patient care."
To do that, Wesp has to consider many topics, including educating the community to understand the symptoms of stroke, educating paramedics to know if they have a stroke patient, and ensuring the community at large knows a MemorialCare facility is a stroke center.
ED physicians need to know exactly what to do when a potential stroke patient comes into the department, he says. "There has to be a checklist that will enable them to determine quickly that it is a stroke patient and identify the best treatment for him or her. Patients have to be able to get to the CT scan and have certain lab work done quickly. If we can’t do that, and put an order set together, then we can’t achieve our goal. That’s what I have to have in my mind when I go into one of the meetings. Not just whether we should give tPA to patients."
If a facility is having trouble with a particular department — for instance, radiology isn’t staffed 24 hours a day, seven days a week — then the work a team does in the map development phase may give physicians the clout they need to make a change, Wesp says.
MemorialCare works on about six maps per year, and Wesp says it takes about six months to a year to create a protocol and implement it. That includes determining measures of success, deciding what data to use as a benchmark, and making sure that the various hospital systems and processes allow each facility to collect and report appropriate data.
Different maps and protocols will do all of those things differently, he explains. For instance, in the orthopedic population, the tool used to measure outcomes is called the SF36, and it is widely used around the country. But there is more than one tool used to measure outcomes in stroke patients, and Wesp says the physicians will have to determine which outcome measure best suits them and MemorialCare patients.
Benchmarking data differ, too. For cardiac patients, for instance, MemorialCare uses a national registry of myocardial infarction that is supported by Genentech, the San Francisco-based makers of tPA. "But it includes 600,000 patients in the database," he says. "You get to compare yourself with large numbers."
The work doesn’t stop when a map is implemented. There is education of staff, and a re-evaluation of the processes implemented to see if they work as intended. Teams meet about every other month, even after a map is completed. "Things change, and we have to update the maps on a regular basis," says Wesp. "Or something might not be working and may need to be tweaked."
The work also goes on to incorporate new items. For instance, work on vaginal and cesarean births may lead to work on vaginal births after cesareans.
Wesp acknowledges that in a managed care environment, where volume is important to a physician’s financial success, getting doctors to participate in such programs is difficult. "You can’t just ask them to do things differently or throw change at them without a reason. There is an element of salesmanship and influence that you have to use."
But Wesp, who is a practicing pediatrician, says that this initiative is different. "We have decided that form follows function here. The leadership of MemorialCare and the physicians both had a vision of differentiation based on quality. The cultural change has to seep down, but there will be a point where someone will say, Either you believe it and are with us, or you don’t and you go somewhere else.’"
Along with the positive clinical outcomes, Collins says that the quality program has led to an improved mood in the organization and an increase in customers. "There is so much HMO backlash. This is a message of clinical excellence irrespective of your insurance company. We will treat you the same no matter what. And that means our patients are more satisfied, and it means that we are more attractive to consumers. And so are our physicians."
"I think that part of the success of this was that I was careful to go to the doctors first," Collins adds. "But I think if I were doing it over again, I would spend even more time cultivating the relationship and getting the idea across that this isn’t the institutions’ program, but theirs. I went right into the business differentiation strategy and wanted to get the business plan done in a weekend. The facilitator we used told me to slow down and respect the process."
[For more information, contact:
• Thomas Collins, EdD, President and CEO, MemorialCare, Long Beach, CA. Telephone: (714) 378-5529.
• Clyde Wesp, MD, MA, Chairman, Quality Task Force, MemorialCare, Long Beach, CA. Telephone: (714) 378-5574.]
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