The Path to Physician Integration


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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… ƒ Service Excellence focused on the Patient Experience ƒ Performance Measurement & Management ƒ 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? ƒ ƒ ƒ ƒ

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. ƒ 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? ƒ Vision of Achieving top 10% status in Quality ƒ Key Elements of Strategy ƒ Achieve Service Excellence ƒ Measure Performance ƒ Engage Physicians ƒ 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: ƒ ƒ ƒ ƒ ƒ

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 ƒ Focus Group / World Café ‐ April 21 2010: ƒ External Facilitation ƒ 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: ƒ Hewitt Survey ƒ World Café

TOH Expectations of Physicians: ƒ Peer of Peer – World Café ƒ Professionalism – Service Excellence – Dr. Turnbull (Chief of  Staff)  ƒ 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 ƒ Quality ƒ Alignment ƒ Professionalism Department Derived ƒ Practice standards ƒ Academic Standards Physician Development derived ƒ Peer standards ƒ Personal Development

ƒ ƒ ƒ ƒ ƒ ƒ

Critical incident Adverse events Complaints Patient Safety Learning System Audit Medicolegal

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Taking Action ‐ Integrate Strategic  Accountabilities to Medical Governance  Engagement  ƒ Rewards and recognition  ƒ Physician Advocacy and the Engagement Agreement ƒ Leader development ƒ Quality Leader Program Accountability ƒ MAC and Departments: ƒ policy development ƒ formative review systems for leaders and staff ƒ performance metrics 27

Re‐Measure:  Next Steps in Physician Engagement ƒ 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)  ƒ Assess successes, failures and remaining gaps ƒ Build plans based on new survey results ƒ 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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