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The Path to Physician Integration: Strategies & Tactics That Get Results Dr. Jack Kitts, President & CEO Dr. Jim Worthington, VP Medical Affairs, Quality & Performance The Ottawa Hospital October 10th 2012
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TOH – One Hospital on Three Sites
TOH is an academic medical centre affiliated with the University of Ottawa and the Ottawa Hospital Research Institute 2
Where Have We Come From? Three Phases of Development Chaos of the Merger New Direction & Stabilization In Search of Excellence
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The Ottawa Hospital Vision “To provide each patient with the world‐class care, exceptional service and compassion that we would want for our loved ones”
The Ottawa Hospital Goal Top 10% performance in quality and patient safety in North America
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Achieving Top Performer Status… Service Excellence focused on the Patient Experience Performance Measurement & Management Physician Engagement & Accountability
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The Reality Physicians are conflicted between accountability to the patient and a system that lacks sufficient resources. And this conflict is permanent…
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How we currently pay for health care
$ for showing up and doing something
$ for actually performing well
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Fact: Physicians are losing credibility “National polls indicate that Canadians have less and less faith in the competence of their physicians, while pollsters say Canada’s doctors are perceived to be motivated primarily by financial self‐interest” (CMAJ 2009; DOI: 10.1503/cmaj.109‐3021)
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Leading Change “… the image of physicians has been tarnished, although …there is still residual, if not considerable, respect for doctors within the Canadian populace …I think we have to stand up and reclaim that sense of moral high ground, and we have to start to speak for the public interest, and be seen as advocating for that” (Dr. Jeffrey Turnbull, CMA President ‐ CMAJ 2010 DOI:10.1503/cmaj.109‐3341)
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Why are we not capable of change?
It’s the culture. It’s not about the patient ‐ it’s about the provider. We are not wired to work in teams. More healthcare is seen to be better. When we do less, even when less is actually better…someone loses. We cannot measure costs or quality for each patient.
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The Challenge 1. Will physicians engage in, and lead change? 2. Will physicians truly focus on the patient? 3. Will physicians embrace and model professionalism?
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Why Engagement? Vision of Achieving top 10% status in Quality Key Elements of Strategy Achieve Service Excellence Measure Performance Engage Physicians Engagement is associated with many positive outcomes Are TOH Physicians Engaged ?
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How is Engagement Defined? • Engagement is the measure of a physician’s emotional and intellectual commitment to an organization. SAY
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STAY - STRIVE
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Engagement to What? • Engagement to an organizational vision and Top 10% Quality Plan • Engagement to a process directed towards improving an outcome, Quality Plan • Engagement to direct provision of service, Departmental/Physician level • NOT the same things, different tactics focus on each of the above
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Engagement Strategy Present State
Vision/Core Values
Milestones •Process change •tactics
Outcomes •Benchmark in values aligned metrics
Physician Engagement
Engagement Agreement Values Vision Survey •Development •Communications
•Survey results •Focus Groups •Communications
•Statement of mutual undertakings •Alignment of Values •Engaged decision making •Leadership structure •Leader development •Communications
•Alignment • Quality of care • Professionalism • Hospital direction •Accountability agreements •Roles and Responsibilities •Performance measurement •Performance appraisal •Credentials redesign
•Engagement index 15
Are TOH Physicians Engaged? Baseline Survey –Aon Hewitt Index 2009 Measure the proportion of physicians fully engaged to the organization goals and vision and identify opportunity areas for enhancement
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Understanding Survey Results Aon Hewitt Nov 2009 Assessed multiple drivers of Engagement / indices TOH Opportunities for enhancing organizational engagement greatest within:
Administration / Management / Communications Resources/Allocation / Decision making Systemic Processes / Balance / Health and Wellbeing Performance Appraisal / Recognition Work Climate / Environment
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Building Insight Consulting the Medical Staff Focus Group / World Café ‐ April 21 2010: External Facilitation drill down the issues and themes identified by Aon Hewitt survey framed within the hospitals 4 values
Objective – develop a representative set of physician expectations of the Hospital as well as their expectations of their peers , aligned within organizational values – an Agreement or Compact
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Developing Mutual Expectations Physician Expectations of TOH: Hewitt Survey World Café
TOH Expectations of Physicians: Peer of Peer – World Café Professionalism – Service Excellence – Dr. Turnbull (Chief of Staff) Corporate – Senior Management Team
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Affirming our Aligned Mutual Expectations
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Taking Action, Strategic Theme and Tactic Engagement to Organization – New Vision is to provide each patient with … – Value Statements – Engagement Agreement Departmental/Divisional Tour.
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Taking Action, Strategic Theme and Tactic • Engagement to Process directed to Quality Plan goals – Annual Strategic Priorities – Quality Plan
Developed with input from Medical Departments
– Medical Advisory Committee Scorecard, focused subset of above plans with specific department targets
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Taking Action, Strategic Theme and Tactic • Engagement to direct provision of care – Measurement Systems and Reporting • TOH data warehouse • Atlas of clinical activity for departments • NSQIP • Patient Safety Learning System, links to M&M rounds Metrics • Enables review at department/division/physician level
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Taking Action, Strategic Theme and Tactic Physician well being and recognition – Physician Integration Committee, pages, one number to call for DI, IPADS – Medical Staff Association, re‐energized • Physician of the Year Award • Compass Award, Living Our Values • Physician and resident Professionalism Award • Physician Leader Award • Annual Reception for new Physicians
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Taking Action, Strategic Theme and Tactic Physician Development – 360 review for each physician – LDI – Physician Management Institute, CMA courses delivered at TOH – Focus on Female MD Leadership – Quality and Patient Safety Physician Leadership Program – EMBA
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Taking Action Accountability – Outcome based Anticipated
Unanticipated
Hospital Derived Quality Alignment Professionalism Department Derived Practice standards Academic Standards Physician Development derived Peer standards Personal Development
Critical incident Adverse events Complaints Patient Safety Learning System Audit Medicolegal
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Taking Action ‐ Integrate Strategic Accountabilities to Medical Governance Engagement Rewards and recognition Physician Advocacy and the Engagement Agreement Leader development Quality Leader Program Accountability MAC and Departments: policy development formative review systems for leaders and staff performance metrics 27
Re‐Measure: Next Steps in Physician Engagement Receive results of the 2012 Hewitt Physician Engagement Survey ( preliminary – response rate increase from 59 to 68% , proportion of fully engaged increased by 16% over baseline , 8 point absolute increase) Assess successes, failures and remaining gaps Build plans based on new survey results Focus on Physician well‐being, performance review, decision making and communications
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Re‐measure – Results QP Metrics Satisfaction with Pain Management Inpatient ‐ Satisfaction with Pain Management ‐ % Yes, definitely April 2010 to May 2012
2012/13 MAY YTD = 87.7%
100% 95% 90% 85%
FY 11/12 Target = 83%
FY 12/13 Target = 85%
80% 75% 70% 65% 60% 55%
Nurse & Resident Pain Management Training introduced
50%
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Antimicrobial Stewardship GIM
ICU
DDD/ 1000pt
‐25%
‐13%
DDD Restricted Agents
‐43%
‐40%
*400K in annual savings from Pharmacy Budget *Decreased C. Diff on specific units 30
Re‐measure – Results QP metrics Hand Hygiene Compliance (Moment 1) Hand Hygiene Compliance ‐ Moment #1 April 2010 to March 2012
2012/13 SEPTEMBER YTD = 89.5%
100% 90% 80%
March = 90.9% Target = 80%
70% 60% 50% 40% 30% 20%
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Re‐measure – Results QP metrics HSMR 160
Hospital Standardized Mortality Ratio April 2011 to May 2012
2012/13 MAY YTD = 82.4%
140 120 100
FY 11/12 Target ≤ 100% FY 12/13 Target ≤ 86%
80 60 40 20 0
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Re‐Measure – Results QP metrics Overall Rating of Care ‐ % Excellent 70%
Inpatient ‐ Overall Rating of Care ‐ % Excellent January 2010 to July 2012
2012/13 JULY YTD = 47.2%
Ontario Teaching Hospitals 90th %ile = 63.7% 60% FY 12/13 Target = 46%
50% 40%
FY 11/12 Target = 41%
30% 20% 10%
Patient Satisfaction Scorecard launched Patient Rounding introduced
Post Visit Phone Calls implementation begins
Hourly Rounding & Bedside Shift Report introduced
0%
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Summary 1. Identify, support, mentor emerging physician leaders (champions) 2. Create a clear vision with clear expectations of each member of the medical staff 3. Align goals and processes 4. Measure performance and benchmark results 5. Insist on personal accountability
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