Critical Path Network: Physician buy-in helps PI team reduce LOS

Data credibility, physician champion key elements

Winning physician buy-in, one of the toughest challenges in any process improvement (PI) endeavor, was the key to success in a PI project undertaken by Peninsula Regional Medical Center in Salisbury, MD. The project, which targeted clinical PI in pneumonia, realized a reduction in average length of stay (LOS) from 5.7 days to five days between 2001 and 2003, along with significant drops in resource utilization.

"We try to build credibility with our physicians," notes Thomas P. Lawrence, MD, MBA, vice president for medical affairs and premier physician ambassador at the 370-bed regional tertiary care center that serves Maryland’s Eastern Shore and nearby sections of Delaware and Virginia. "Most important of all, you have to be credible with your data."

Hospital data, in general, often have been incorrect, and physicians, therefore, are very suspicious, Lawrence observes. "Unfortunately, they are looking for perfection, which is almost unattainable," he notes.

To help address that resistance, Peninsula decided to use Premier Inc.’s Perspective clinical benchmarking database. Internet-accessible, Perspective has 525 hospitals enrolled to comprise its clinical resource comparative database.

"What Premier provided was believable enough, and by beginning to change the culture, we showed the physicians that we needed direction, not perfection," Lawrence says.

Peninsula’s strategy for garnering physician support is three-pronged:

  1. Engage physicians in dialogue.
  2. Align their goals with the organization.
  3. Celebrate and recognize their contributions.

The pneumonia initiative grew out of a tradition of improvement begun at Peninsula in the 1990s, adds Donna Thompson, RN, BSN, director for clinical quality improvement support.

"It began with the development of clinical pathways — the first one I recall was a med/surg hip clinical pathway," she says. "It was a multidiscipline team effort, and we developed a template for future pathways."

Peninsula began working with Premier a number of years ago. "When we saw the clinical comparative database Premier had, it was a natural for us to use for our quality improvement initiative because it was a robust database and we could benchmark ourselves to many other, similar organizations," Lawrence says.

Peninsula is a bit unique, he notes; it is a complex organization, but it is not a teaching institution, and yet it is rural. Still, it was able to get about a dozen other organizations within the database that were fairly similar.

"This made it easier for our physicians to see information that was relative to them," Lawrence points out.

"They were even similar in terms of volume of ED [emergency department] visits per year — and we have over 60,000," Thompson adds.

Peninsula presented the undertaking to the physicians as an education collaborative. "We explained we were not going to use the data in a punitive fashion," Lawrence says.

Once the benchmarks were identified, Perspective was used to conduct an opportunity assessment, which identified the greatest opportunity either by cost per case or by LOS.

"That’s what led to pneumonia," he explains. "We could certainly come up with 10 or 20 clinical conditions [to benchmark], but we verified that there was a lot of low-hanging fruit in pneumonia, and it was a high-volume admitting diagnosis."

Peninsula already had a pneumonia pathway team in place, so with a few additions, it was ready to get to work. The process, which is a template now for all PI efforts, has six basic steps:

1. Forum.

To begin to get buy-in, you have to take the initiative to the medical staff leadership committee, to see if the staff would support it. In this case, it was the resource utilization committee.

2. Clinical opportunity assessment.

This involves winning staff agreement that this would be a good opportunity around which to form an initiative.

3. PI issues directed to ad hoc teams.

Once there is consensus, the initiative is sent to the appropriate team.

4. Ad hoc team action plan review.

The current pathway is reviewed, a gap analysis is conducted, and then the pathway is tweaked based on what has been learned.

5. Approved plan to pertinent department.

The team reviews the new plan, tweaks it some more, then goes back to the forum that initiated the process to ask them if the changes make sense. Then it’s on to the department of medicine, where physicians are educated about the new plan and buy-in is gained.

6. Remeasure and review.

The results are checked, after which they are posted on a PI board and in clinically important units, so patients and employees in the units can see them.

The process involved several important changes. "We got together a group of physicians and redid the whole formulary, looking at the cost of drugs and evidence-based literature on drugs for non-ICU [intensive care unit] vs. ICU patients, and incorporated it into the doctor’s actual order sheet, so there would be no guesswork," Thompson says. "We used a check box kind of format — the meds were right there with the dosage — which was more user-friendly for the physicians."

In addition, Joint Commission on Accreditation of Healthcare Organizations core measure indicators were incorporated on the order sheet to remind the physicians what they needed for the hospital to be compliant — i.e., blood cultures, antibiotics, oxygen assessments.

"We found we were spending significantly more money on respiratory therapy than in other places, and more on blood gases than on O2 saturation," Lawrence says. "We adjusted our standard so that we were 100% compliant with the core measure and significantly reduced expenses on blood gases. Also, we were doing more PT than our benchmark group. That seemed to be more expensive; but when we checked the literature, we decided it was an appropriate expense and it has helped us with decreased LOS."

None of this could have been accomplished, Lawrence says, without physician buy-in. And a key element in winning that buy-in, he says, is having a physician champion. "Without that, it’s a pretty tough sell. You need someone who’s supportive, a good communicator, a good listener, and can talk about his or her peers."

If the end result you are looking for is to grow corn, says Lawrence, "a lot of tilling of the soil is needed." That starts with education of the medical staff leadership. "They need to know what it means in today’s age to be a good physician," he explains.

At Peninsula, physicians receive leadership training from an outside consultant, as well as attend national meetings about quality, costs, and outcomes.

"Unless PI is linked to lot of hard work around medical staff development, it can be sitting out there as something you have limited success with," Lawrence asserts, adding that there is an economic incentive to quality today. "More payers are going to pay for performance," he says. "The good news is that this not only does not compromise care, but it improves it."