Quality Improvement in Healthcare

KevinCrostonMD7 Tips for Physician Engagement

By Dr. Kevin Croston

At North Memorial Health Care, the 512-bed two-hospital health system in Minneapolis where I am Chief Medical Officer and President of the Physician Organization, we recently launched a clinical quality improvement initiative that relies heavily on intelligence generated by our enterprise data warehouse and associated analytics. Our goal is to shift from a personality-centric culture to one that is data-driven, with near real-time data helping our providers make better decisions and improve the quality of outcomes.

Turning our plentiful data into meaningful information represented significant change for our providers, many of whom were wary at first. Fortunately, we have a strong quality improvement culture. And, as a relatively small hospital system, there’s a lot of “us against the world” mentality, which can be useful in driving change.

Ultimately, we did a lot of things right, and the early results have been impressive. Deploying the program first in our Women’s and Newborn’s department, we reduced our rate of potentially dangerous, elective early-term deliveries by 75 percent in just six months. The percentage of all deliveries that were elective pre-39-week surgeries plummeted from 1.2 percent to just 0.3 percent. That result shattered a goal we had set with a key payer, who had offered to pay North Memorial a significant bonus if we achieved a 0.6 percent rate of early-term deliveries.

We also reduced by 35 percent the incidence of chronic lung disease – bronchopulmonary dysplasia (BPD) – for newborns with a gestational age of less than 32 weeks. And we reduced length of stay for newborns over 32 weeks with neonatal respiratory distress syndrome RDS by 36 percent, far exceeding our target of 9 percent.

After achieving these early gains, we expanded the program to nearly every department in the health system, exponentially increasing the risk of provider resistance. In addressing that risk, we learned some important lessons about how to gain the provider support you need, especially from physicians, to make and maintain clinical improvements across a health system.

Tip #1 – Get the Physicians Engaged Early
This is one of the most important things you can do and one of the biggest things we did right. Physicians will buy into a new methodology much more quickly if they are engaged in its development.

To that end, we asked our senior medical staff to work with the senior administrative staff in devising quality improvements. They met weekly to set the strategy and prioritize changes. Bringing senior physicians into the decision-making process early gave them a sense of ownership and control and helped them see the value in what we were doing.

Building a sense of ownership among the physicians was greatly assisted by the data visualization capabilities our Health Catalyst enterprise data warehouse (EDW). We could use the EDW during meetings to answer questions right away, rather than several weeks later after back-and-forth with an IT analyst. Physicians could immediately see, for instance, how their behavior was affecting length of stay and how specific changes in clinical process could improve LOS. Letting them see the result, and having them guide how we got there, made it easier to convince them to make the needed changes.

Bottom line: The more physicians can be made to feel that change was their idea, the faster they’ll get on board.

Tip #2 – Find Champions Among the Medical Leadership
No surprise here. Once the quality improvement team has set the vision, the need to find champions among the medical leadership to evangelize it. That doesn’t mean they’re issuing orders. Instead, they’re promoting it to their colleagues, telling them where the organization is headed and why it will benefit them individually and as part of the team.

The champions should focus on what success will look like. If they can paint an attractive vision, it will help overcome the early fears, and keep everyone on-board through the inevitable bumps and complications that arise in any sort of project of this magnitude.

They should also make it clear that it will not be a direct A to B to C path; instead, it will be one of continuous process improvement. There may be some difficulties or setbacks along the way. In the end, however, they need to make it clear it will be worth the growing pains to get to where the organization wants to go.

Tip #3 – If Your Project Is Large, Choose One Area of Focus
One of the toughest aspects of a large project is getting it started. The scope is so intimidating that you can easily find yourself doing nothing. Since people have short memories, any early enthusiasm you were able to generate will quickly dissipate if no progress is being demonstrated.

To avoid that very real concern it’s best to choose one small area to start – preferably one where there is low risk and high reward. In our case, we started with the pregnancy area and a project to reduce elective deliveries before 39 weeks. We felt it would be relatively easy to execute, as well as easily measurable. And we knew from the research that the annual cost to society associated with pre-term birth was at least $26.2 billion, so improving care in women and newborns was something we felt strongly about.

We knew a success here would yield health benefits to the babies and their mothers and financial benefits to the entire organization. It would also quickly demonstrate that our methodology works, helping to drive future quality improvements. All of which came to pass.

Tip #4 – Build a Broad but Specific Guidance Team
Once you’ve selected your starting point, organize your guidance team. I can tell you from first-hand experience the most critical aspect is to include someone from each area that interacts with the patient.

To lead the OB project, we selected a senior physician and previous member of our board of trustees. We also brought in a couple of nurse experts and a data architect. We had HR and IT resources that we could pull in as needed. The team worked well because we had the right people and each had a well-defined role. For example, one of our clinical directors served as the knowledge manager. The team also set aside a specific weekly meeting time and they all committed to being there every week.

We also saw what happens when it goes the other way. A subsequent initiative with our cardiology group didn’t follow the edict of having specific people in team roles. The cardiologists would rotate participation on the team depending on who had availability, and meeting times were more ad hoc. Moreover, my oversight team didn’t feel empowered to keep this important group of surgeons on track, which amplified the problem.

The lesson: Everyone needs to understand and be committed to the program’s goals, and the organization needs to be willing to stand its ground to inspire that change. No matter how well-intentioned team members are – and believe me our cardiologists had great intentions – without a commitment and oversight it may be impossible to drive the change you want.

Tip #5 – Once You Have the Plan, Follow It
This was an interesting learning experience for us. At North Memorial, we needed to learn how to stick to the discipline of developing simple goals, identifying the baseline, defining what our goals are, where we’re headed and how we’re going to get there, and then sticking to the plan and moving forward.

It is too easy to get caught in the weeds, especially with a project that has many moving parts. When that happens, the project can stall and the people you need most can lose faith. Establishing a solid plan, and then fanatically sticking to it, will help you avoid those pitfalls and maintain the enthusiasm you’ll need to see the project completed and, more importantly, embraced by the organization.

Tip #6 – Make the Results Data-driven
Clinicians are scientists by training, and they like to see measureable evidence of success. The more you can present data to show how the methodology you’re using has driven improvements in overall performance, reductions in error or improved finances, the more they will support the change you’re trying to make.

Once you have the numbers, be sure to communicate your successes as widely as possible across the organization. Use the credibility of your leaders/evangelists to spread the word. You don’t want to be an underground success – you want to share your data with everyone who needs to know.

Tip #7 – Be an Agent for Change
Most of us naturally fear and avoid change. But change can be a positive thing if handled properly. The steps laid out here can help your clinicians overcome the resistance that can slow down valuable improvement projects. If you use them, your organization will benefit both clinically and financially.

Use these steps to help your clinicians overcome the resistance that can slow down valuable projects, and your organization will benefit both medically and financially.

About the author:  Dr. Kevin Croston is Chief Medical Officer and President of Physician Organization at North Memorial Health Care, Robbinsdale, MN. He is a general surgeon who specializes in traumatic injury, Dr. Croston is the health system’s lead physician and oversees North Memorial’s physician organization.  This article was originally published on Health Catalyst and is republished here with permission.