Transcript Really Good Doctors

The Very Best Doctors
Wellstar Physicians’ Group
Annual Meeting, Marietta, Georgia
March 8, 2007
James L. Reinertsen, M.D.
[email protected]
307 353 2294
In Wellstar, who would be the very
best doctor for me if I needed…
• …ongoing primary care for diabetes and
hypertension?
• …a colon resection?
Why do you recommend
that particular physician?
Commonly cited attributes of
“best doctors”
• Superb diagnostician
– “She finds the zebra in a herd of horses.”
• Great technical skills
– “If someone’s hands must be in your belly, his are the
hands you want.”
• Excellent bedside manner
– “I’ve never had a patient come back to me unhappy with
him”
• Impressive pedigree
– “Besides, she trained at Hopkins”
Uncommonly cited attributes of
“best doctors”
• Reliable for common conditions
– “Over 50% of her diabetics have HbA1c’s less
than 7!”
– “His surgical site infection rate is an order of
magnitude better than a typical surgeon’s.”
• Accessible and “easy to use”
– “You can see her the same day you call”
– “His office team works like a Swiss watch”
Similar story for “best hospitals”
Questions for this evening
• Which of these views of “best doctor” is
prevalent
– in our profession?
– among regulators, health plans, and policy types?
• Is it possible for “Dr. Zebra Good-Hands” and
“Dr. Easy Access-Reliable” to be one and the
same person?
• What does a medical group practice have to do
with any of this?
Tensions between two views of quality
Regulators and payors
• Public reporting and P4P
– CMS Core Measures
– HealthGrades
– NCQA Physician Diabetes
Recognition
– CMS/Premier
– BTE
• Focus on process,
reliability of EBM
• Measure what is available
Physicians
• Professional reputation
–
–
–
–
Diagnostic acumen
Technical magic
Bedside manner
Good judgment
• Focus on outcomes,
stories, legends,
relationships
• Value what is
unmeasurable
Are these two views compatible?
Yes, partly:
To the extent that performance measures of
process are strongly predictive of
outcomes, then the regulatory/payer
perspective aligns with physicians’
perspective.
Do process measures drive outcomes?
Pro
• Accumulating evidence for
predictive relationship for
many measures
– VAP and Ventilator Bundle
• By and large, what gets
measured improves
• High return if we improve
from current baseline
• We have to start somewhere
• Our customers demand
some sort of accountability
Con
• Uneven relationship of
individual measures to
outcomes
– HbA1c versus BP control
• Difficulty in attribution to
individual physicians
• Diminishing returns at high
reliabilities?
• Unmeasured but important?
• “Burden” of improvement
conflicts with time needed
to be a good doctor
Question Two:
Can you do it all?
(Is it realistic for you to aspire to be
“Dr. E. Z. Reliable-Goodhands?”)
Back to basics: what doctors do
• Address the three timeless needs of patients
– Explain the current situation
• What is happening to me? Why?
– Predict the future
• What is going to happen to me? When?
– Change my future
• If that’s what’s going to happen to me, can you change it for
the better? How?
• Perform two core processes:
– Transforming and translating information
– Building relationships capable of supporting healing
Critical requirements for building healing
relationships and transforming information
Time and Touch
Some common time-stealers
•
•
•
•
•
•
•
Documenting so that you can get paid
Finding information needed for care
Making things work when the system doesn’t
Asking permission to deliver care
Redoing work someone has already done
Managing your backlog of patients
Custom-crafting work you could do as a team
Jody’s Question
Other examples of physicians creating
time to be better doctors
• Park Nicollet Clinic: 239 standing order sets +
computerized patient record = 1-2 hours saved per
doctor per day. (David Abelson)
• Methodist (Mpls) GI Lab: 30 patients per day to 64
patients per day in same space, same number of
physicians, increased time in critical aspects of
colonoscopy, and 1 hour total time less per day for
each doctor. (David Wessner)
• Austin (TX) physicians: “Open access made my life
better, and improved chronic disease process
measures without even trying.” (Mark Murray)
The good news: We don’t have to invent
new knowledge to get time back.
Just use the knowledge we already have.
•
•
•
•
•
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Systems theory
Flow management
Reliability science
Lean production systems
Rapid cycle improvement
…
Levels of Reliability in Health Care (Amalberti, Nolan)
Chaos
Processes are
largely
custom-crafted
each time
10-1
Standard
specs,
checklists,
training,
trying hard
10-2
Standard
process;
redundancy,
habits and
patterns…
Each doctor
writes
individual
orders, gives
to RN
Preventing,
treating acute
and chronic
disease in US
5 people
describe 5
processes;
feedback on
compliance
Typical MD
group
working
hard
5 people
describe 1
process; RN
managed
prevention
bundle
10-3
Obsession
with Failure:
Prevent
Mitigate
Redesign
External
approval
necessary
for certain
orders
Best MD
ADEs per
group
1000 doses
performance in best
hospitals
10-5
Loss of
identity
Equivalent
actor
Safety in
anesthesia
Conclusion: Physicians have the
opportunity to give ourselves back
a lot of time. What we do with the
time is up to us. If we use it wisely,
we have the chance of becoming
“Dr. E. Z. Reliable-Goodhands”
Question 3:
What does any of this have to do
with physician group practice?
With regard to quality, group practices
should be in a position to…
• Choose to work on something important,
rather than simply react to external requests
• Practice the science of medicine as a group,
and the art of medicine as individuals
• Create a “system” in which each individual
doctor has the opportunity to be “Dr. E.Z.
Reliable-Goodhands”
Why?
• Public Practice: the common medical record
• Opportunity to select physicians with shared
values
• Opportunity to remake the physician “compact”
• Opportunity to build other common systems:
core work processes, staff training, disease
registries, advanced access…
• Opportunity to influence the external
environment
1. Discover Common Purpose:
6. Adopt an Engaging Style:
1.1 Improve patient outcomes
1.2 Reduce hassles and wasted time
1.3 Understand the organization’s culture
1.4 Understand the legal opportunities and
barriers
6.1 Involve physicians from the
beginning
6.2 Work with the real leaders
6.3 Work with early adopters
6.4 Make physician
involvement visible
6.5 Build trust within each
quality initiative
6.6 Communicate candidly,
often
6.7 Value physicians time
with your time
5. Show Courage:
2. Reframe Values and Beliefs:
Engaging
Physicians
in Quality
and Safety
5.1 Provide Backup all the way
to the Board
4. Use “Engaging” Improvement
Methods
4.1 Standardize what’s standardizable, and no more
4.2 Generate light, not heat, with data
4.3 Make the right thing easy to try
4.4 Make the right thing easy to do
2.1 Make physicians partners,
not customers
2.2 Promote both system and
individual responsibility for
quality
3. Segment the
Engagement Plan:
3.1 Use the 20/80 Rule
3.2 Identify and activate champions
3.3 Educate and inform structural
leaders
3.4 Develop project management
skills
3.5 Identify and work with
“laggards”
© 2007 Institute for Healthcare Improvement
Questions for discussion:
• Is the primary driver of your quality work
external requirements, or internal aspirations?
• How much of your wasted time every day is a
self-inflicted wound?
• If you could save time by practicing science as
a team, why aren’t you? Or are you?
• Is computerization going to solve these
problems for you, or make them worse?