Dr. Cohn keynoting NE MGMA

I recently had the honor to keynote the annual New England Medical Group Management Association (MGMA) meeting. My topic was “Changing the Landscape via Authentic Physician Engagement.”  Four of the ten steps I covered to engage physicians to improve care include:

1) Encourage practicing physicians to articulate future clinical priorities

2) Include doctors who are users of radiology, anesthesiology, pathology, and emergency services to draw up contract specifications and monitor performance

3) Establish a hotline for process improvement issues

4) Have the Chief Information Officer and programmers round periodically with physicians

The most memorable discussion question was:

“How do we get doctors to talk with one another?”
I suggested that they build on times when doctors talked with one another and improved their practice environment.  Having a physician champion in the practice convey the message may work better than having the message come from the practice manager.  Hearing that team-building and conflict management are not taught in most medical schools, residencies, and fellowships prompted a participant to ask, “When will these vital communication skills be taught in medical school?”

A hospital CEO said, “We need to recognize our interdependence, that we all have a job to do to care for our communities.”

One of the best ways that I know to engage physicians is to talk with their staff members, the people doctors listen to, so that we can find out not only when they are free but also what drives them: what inspires and frustrates them, when are they so absorbed in what they are doing that they lose track of time, what about their families and outside interests makes them unique human beings.  Perhaps by becoming more personal, we can depersonalize our differences and recognize our common heritage: that we chose careers in healthcare to make a difference in patients’ and families’ lives.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

©2012 Healthcare Collaboration. All Rights Reserved.

The People Doctors Listen to is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

As I wrote in Collaborative Engagement, engaged workers strongly agree with the following statements:

• This organization really inspires the very best in me
• I am willing to put in a great deal of effort beyond what is normally expected to help this organization be successful
• I talk up this organization to my friends as a great organization to work for

(Achieving Breakthrough Engagement: Lessons from High-Performing Organizations. 2007. Washington: The Advisory Board Company, p.3.)

Engaged workers:

• Exceed expected level of effort
• Are inspired to do their best work
• Feel part of the greater work community
• Make meaningful contributions through their work
• Are personally motivated to help their organization succeed

(Achieving Breakthrough Engagement: Lessons from High-Performing Organizations. 2007. Washington: The Advisory Board Company, p.14)

They liked the idea embodied in Appreciative Inquiry, of building on the goodwill engendered by previous efforts, such as preparing for a Joint Commission visit that went well and their move to a new hospital facility.

The goal they share is to build on the efforts of physician champions to move the majority of practicing physicians from renters to owners, rekindling their passion for medicine despite disruptive changes in their lives. They liked the story of the orthopedic surgeon I worked with in the pogo epiphany, who moved beyond blame-storming when he realized that every time that he pointed a finger, three others pointed back at him.

I know that they will engage, collaborate, and succeed. They make me proud to be a fellow-physician.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

©2012 Healthcare Collaboration. All Rights Reserved.

Engage, Collaborate, and Succeed is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

The CEOs Dilemma

Last week, I had the pleasure of teaching a case discussion at the Harvard School of Public Health, entitled (A) Physician-Led Planning: The CEO’s Dilemma and (B) The Physicians’ Response. 

Of the approximately 60 Masters in Public Health students, about 2/3 were physicians learning additional skills, such as systems thinking, that bode well for the future of US healthcare.  Our ability to provide outstanding care depends on our ability to understand the context in which we are working and to leverage one anothers’ talents.

The case is about a hospital’s struggle to survive in an increasingly competitive marketplace and its journey to entice practicing physicians to improve care for its community.   Very briefly, a new CEO (the 3rd  in 6 years) faced deteriorating margins, an outmoded physical plant, years of inadequate investment in health information technology, and the need to develop robust service lines in the face of a disenchanted, disengaged medical staff who split admissions among several nearby hospitals.

The questions we discussed involved:

• What are the risks of the structured dialogue approach that the CEO was considering, creating a Medical Advisory Panel  (MAP) of his top physicians, regardless of their irascibility?
• What are the potential benefits?
• What are the alternative approaches, and how do they compare in terms of risk and benefit?
• If he decided to go ahead with the MAP approach, what criteria should he use in choosing the MAP co-chairs?
• How else might he want to influence the MAP strategic planning process?

We had a lively discussion, in which the majority of the students voted in favor of undertaking the Medical Advisory Panel.  During the B case discussion of the physician response to the MAP process, I pointed out that the early meetings were painful, as physicians learned to talk with fellow physicians and confront one another in a respectful manner under the guidance of an experienced facilitator. 

However, within six months, the physicians came to consensus:

• focusing on the development of four service lines: cardiovascular, oncology, complex medicine (for example, renal failure), and complex surgery (for example, spine surgery and laparoscopic bariatric surgery)
• setting up multidisciplinary task forces to improve engagement of healthcare professionals, medical-surgical nursing interactions, clinical information systems, and marketing

Although many will contend that these physician-driven recommendations are not truly strategic planning, the value of having a consensus of physician champions owning the top strategic priorities cannot be overstated:

• The hospital developed a reputation of being physician-friendly, leading to additional physicians coming to the CEO to establish new services
• The MAP spirit became contagious, with the Medical Executive Committee becoming a more collaborative environment that drew upon physician panelists and presenters who had been groomed during the MAP process.  As one physician noted:

We failed to do the work it takes to maintain the marriage…. MAP was the start of the process, but fulfillment will require an epidemic of cooperation between clinicians and administration.

In subsequent years:

• A major insurer awarded this hospital distinction centers for spine surgery and  knee and hip replacement
• HealthGrades gave this hospital Cardiac Care and Coronary Intervention Excellence awards for outcomes in the top 5-10% among US hospitals
• They achieved Magnet designation for excellence in nursing
• Their cancer center achieved the highest accreditation award from the American College of Surgeons
• They became a Thomson Reuters top hospital
• They achieved 38% market share in their primary zip code

What do you think?

• Is this case believable
• Are the issues at this hospital similar to ones that you confront where you work
• Do you know physician champions where you work who could respond to the challenges of clinical priority setting

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

Although I earned a teaching stipend for facilitating the class discussion, I have not received compensation for writing this content.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Strategic Planning is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

• This organization really inspires the very best in me
• I am willing to put in a great deal of effort beyond what is normally expected to help this organization be successful
• I talk up this organization to my friends as a great organization to work for
  (Achieving Breakthrough Engagement: Lessons from High-Performing Organizations. 2007. Washington: The Advisory Board Company, p.3.)

Engaged workers:

• Exceed expected level of effort
• Are inspired to do their best work
• Feel part of the greater work community
• Make meaningful contributions through their work
• Are personally motivated to help their organization succeed
  (Achieving Breakthrough Engagement: Lessons from High-Performing Organizations. 2007. Washington: The Advisory Board Company, p.14)

We began with a discussion of time wasters in which people feel disengaged (meetings rose to the top of that list) and ended with a discussion of the organization’s strengths, challenges, opportunities, and threats.  I was impressed with the engaged body language and respectful listening in the group breakout sessions as well as the quality of their insights.

Group discussion of strengths, challenges, opportunities, and threats

Presentation of group insights

My previous post on Collaborative Engagement seemed more antagonistic than this one.  Perhaps it relates to the double meaning of engagement, a pleasant experience, as in engaged to be married and a negative, engaging the enemy.

A strategic approach to increasing engagement lies in the development of a collaborative physician-hospital compact that delineates shared expectations

What do you think?

• How many providers meet the aforementioned definition of engagement where you work
• What can we do to increase providers’ feelings that their organization  inspires the  best in them
• Is the above process a journey worth taking

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

Although I received compensation for facilitating the medical staff retreat, writing this content is totally of my own volition.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Engagement: An Overdue Update is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

If you want to learn more about how her hospital improved reliability in the area of cardiac medications, please read on.

Applying High-Reliability Principles to Improve Cardiac Outcomes

Case Presentation

After discussing quality outcome scores for their institution, leaders at a community hospital system decided to take action. Physicians were not routinely following protocol for ordering aspirin (ASA), beta blockers, and angiotensin-converting enzyme inhibitors (ACEI) on admission and discharge. The doctors claimed the data were wrong. Was it a performance issue or a data integrity problem?

A review of the institution’s cardiac medication outcome data showed that the issues were multi-factorial. The organization had set a benchmark for performance on cardiac medication administration at 90% compliance, but composite performance scores were 76%.  The Vice President of Quality voiced concern that despite improvement methods, no movement in scores occurred.

The hospital assembled a team of cardiologists, primary care doctors, nurses, pharmacists, information technology experts, a project leader, and a finance approver. The team set a goal to achieve 95% compliance by the end of the 9-month project cycle. They applied the following five principles of high reliability organizations to their new approach. High reliability organizations* (HRO) are those that can perform relatively error-free, complex operations consistently over long periods of time:

Sensitivity to operations – Hospital leaders assumed that poor compliance with cardiac medication standards was the result of poor ordering practices by the physicians. However, chart reviewers only agreed on abstraction of charted data 42% of the time. They developed standard review procedures for chart abstracters. Physician experts at each system hospital reviewed data and coached individual physicians on documentation accuracy of admission diagnoses to improve data integrity.

Deference to expertise – The team engaged experts at all levels of the cardiac medication delivery system to standardize protocols. Physicians peer-reviewed charts for diagnosis, intervention, documentation accuracy, and protocol compliance. Individual physicians received information regarding their performance and reviewed aggregate data at monthly medical staff meetings. Their focus on correcting care and process issues resulted in improved compliance with evidence-based protocols for cardiac medication administration and improvement in care outcomes.

Reluctance to simplify- The project team employed the Six Sigma process: Define, Measure Analyze, Improve, Control (DMAIC) to solve complex problems. They analyzed data to make fact-based decisions, identified errors and roadblocks, and made changes by piloting solutions. When the team encountered process problems, such as lack of standardization of the patient discharge process, they used a technique known as Work-Out to solve complex problems where the causes are evident. The streamlined discharge process, which included protocols for cardiac medication ordering, was piloted on one nursing unit then implemented hospital-wide.

Resilience – The project manager was responsible for ongoing analysis and reporting of outcome data. A physician council appointed by the Board of Trustees was entrusted with oversight of the process. A monthly dashboard tracked compliance with medication ordering, administration to patients, and chart reviews. The cardiac medication dashboard was incorporated in the quarterly quality report to the Board. Reviews conducted over the next 18 months showed that the process was capable of accurately capturing data, and ongoing focus on the process of ordering and administering cardiac medication showed continued improvement in performance.

Preoccupation with failure: Before the project began, caregivers and hospital leadership accepted defects in the system as physician error. At the conclusion of the 9-month project cycle, the steps of the medication delivery system were streamlined, which led to better information, greater understanding of the care needs of cardiac patients, improved cardiac medication administration, and better relationships between hospital leadership, physicians, and the rest of the care team. The institution exceeded its goal by achieving an overall cardiac medication compliance score of 97.3% by the end of the project cycle, an improvement that they have sustained over time.

Addendum

Although comparisons with other industries have their limitations, the progress that commercial airlines have made in safety over the past 30 years has been remarkable, averaging one fatality per million flights. HRO’s differ from other organizations in that they are able to demonstrate safe outcomes consistently over time. This time-based performance has been attributed to a culture shift present within an HRO. It is the creation of this culture that HRO’s aim to explicitly foster.

HRO’s are organized to acknowledge certain fundamental realities. Chief among these are that teamwork does not come naturally to people and that errors, no matter how much planning is invested for prevention, will happen and that an organization must therefore be prepared for recovery after such events.

Given the key position occupied by physicians in the medical super-structure, if healthcare is to become an HRO, doctors must be a major presence in any culture of reliability. As this case showed, finger-pointing on both sides needs to give way to a data-driven climate of inquiry.

The enabling features of organizations that foster highly reliable teams include:

-  a culture of trust, shared values, safety, and risk-mitigating communication processes

-  communication that provides opportunities for discussion and improvement

-  distributed decision-making, in which all team members share accountability

-  communication that is frequent, specific, accurate, problem-solving, and based on mutual respect

Rather than have safety imposed upon us, let’s start now to incorporate the principles that high-reliability organizations embody.

Ellen Guarnieri has over twenty five years of comprehensive healthcare experience in roles that ranged from staff nurse to CEO of a leading New Jersey Hospital. She is currently the President and CEO of Comprehensive Healthcare Strategies, focusing on organizational planning and redevelopment. Ellen can be reached at Eguarnie@comcast.net.

*Reference

Weick KE, Sutcliffe, KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001.

©2012 Healthcare Collaboration. All Rights Reserved.

Applying High-Reliability Principles: Guest Ezine by Ellen Guarnieri is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.

The most common response was hammer, followed by gun, and then chain saw.  For a number of reasons, I felt fortunate to get out of the room alive.

I can understand the fascination with tools and building a toolkit.  It offers a readily comprehensible framework for the question, “What do you do,” i.e., ”I fix problems.”  We value problem-solvers.  They rise through an organization to become its senior leaders.

For a different way of looking at tools, I salute Chris Warner, who wrote High Altitude Leadership and has led over 150 international mountaineering expeditions.  He lists Danger #3 for high-altitude climbers as Tool Seduction:

Cho Oyu has become such a popular mountain, that the same level of infrastructure that is built on Everest is applied to climbs on this peak.  Each tent is equipped like a hotel room with sleeping bags, ministoves, bags of food, and bottles of oxygen.

Climbers waited for the storm cycle to play out… Precious time was wasted because Sherpas needed to move even more gear into place…. And when the tiny window finally opened, a small handful of us, those not needing all sorts of tools and comforts, snuck to the summit.  The largest groups watched helplessly from base camp.

An overdependence on Sherpas, tools, and infrastructure can limit talented climbers.  Similarly, a parade of consultants packing the latest tools and theories can bog down progress and distract companies from focusing on vital issues.  Of course, tools are important.  But in critical moments, even the best tools break or fail in some other way- yet you must still survive.  The problem isn’t with the tools; it’s in how you relate to them.

Tools offer hope, and they make people feel that they have the right answer.  But a problem occurs when people use tools as crutches for safe answers.  Both dead climbers and dead companies are found grasping great tools.

Act in the face of real fear; subjugate your personal desires to the greater goal of the group; fight arrogance with humility; seek out and nurture partnerships; be seduced by passion and not by tools.

As I wrote in Collaborative Listening, the most important tool for hospital leaders and physicians to grasp is dialogue.  In “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, I stated that face-face conversations are the only sustainable way that people can deal with complex situations in which predictability is diminished, experience does not guarantee success, and relationships are key.

 Physicians can help because our training prepares us to make major decisions based on limited information.  When lives are at stake, we often do not have time to obtain perfect information and have to rely on our clinical intuition.  Act-learn-adapt, or as we say in surgery, “Ready, fire, aim,” characterizes clinical practice.

What do you think?

• Do we use tools as crutches
• Are there tools other than dialogue that improve physician-hospital relations reliably
• Can you fathom extensions of act-learn-adapt into administrative situations

 As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

©2012 Healthcare Collaboration. All Rights Reserved.

Collaborative Tools to Facilitate Physician Engagement: Post 84 is an original post from Kenneth Cohn, Healthcare Collaboration. If you enjoyed this post, be sure to follow Ken on Twitter, Facebook or Google+.