engaging physicians in leading quality...
TRANSCRIPT
EngagingPhysiciansinLeadingQualityImprovement
Carol Peden, MB ChB, MD, MPH Felipe Osorno, MSCEP Kaveh Houshmand Azad, MSCIE
Keck Medicine of USC University of Southern California Los Angeles
Disclosures CarolPedenisashareholderinFidelityHealthandaFellowandFacultyofIHI.Wehavenootherrelevantfinancialrela;onshipswiththeproductsorservicesdescribed,reviewed,evaluatedorcomparedinthispresenta;on.
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CarolPeden,MBChB,MD,MPHFelipeOsorno,MSCEPKavehHoushmandAzad,MSCIE
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OBJECTIVESOFTHISSESSION
1-Tounderstandhowtodevelopastrategyandframeworktocreateaprogramforphysiciansinleadershipandqualityimprovement2-Tounderstandhowtoimplementaframeworktoenablephysicianstoleadqualityandperformanceimprovementprojects3–Tolearnfromsuccessstoriesfromourphysicianqualityandimprovementprogram,aswellaslessonslearned
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KeckMedicineofUSC
3Hospitals
619Beds
60+Clinics
4,000+Employees
1300FacultyandScien;sts
9000ClinicalTrials
900Residents
$1.6BNetRevenue
Bornin2009
5 Source:UHC,Q32016–Q22017
2.96KeckMedicalCenterofUSCCMI
2.78CityofHope
2.46MoffiQCancerCenter
2.50ClevelandClinic
2.53Univ.ofMarylandMedicalCenter
2.43StanfordHealth
2.27UCLAHealth(RonaldReagan)
2.34MayoClinic
2.11UCSFMedicalCenter
1.92JohnsHopkinsMedicine
Weseesomeofthe
sickestpa]entsinthena]on
2.72SylvesterCancerCenter
CMI=CaseMixIndex
Innovation at Keck
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CharlesHeidelberger,firstassociatedirectorforbasicresearchatUSCNorrisComprehensiveCancerCenterandof5-Fluorouracil,themostwidelyusedcancerchemotherapydrug
FirstFDA-ApprovedHigh-IntensityFocusedUltrasoundSurgicalAbla]onforKidney&
ProstateCancer
FirstImplantableAr]ficialRe]natoRestoreVisionfromRe]ni]sPigmetosa
FirsttoTreatUncontrolledEpilepsywithFDA-ApprovedResponsiveNeuros]mula]onSystem
FirsttoOfferBronchialThermoplastyOutpa]entTreatmentforSevereAsthma
FirsttoEstablishRela]onshipofCancerandEpigene]cDNAMethyla]on
Keck’s Revenue Growth – An Academic Start Up • Revenuehastripledin6years–reached1.6Bin2017• 30%growthinthelast2fiscalyears
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$460M$550M
$620M
$790M
$1.15B
$1.31B
$1.5B
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
2010 2011 2012 2013 2014 2015 2016
Los Angeles Health Care • SignificantMedi-cal(37%ofLACountyand33%ofCA)andMedicarepa;entpopula;on
• LosAngelesisoneoftheleastconsolidatedhealthsystemsintheUS• Markeddemographicdiversity
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Health Spending Per Capita Per State 2014 (most recent data)
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Source:KaiserFamilyFoundaOonhPps://www.kff.org/other/state-indicator/health-spending-percapita
From a For-Profit Hospital to an Academic Medical Center in a changing healthcare world
• Challenges!
• Culture
• Developingdatainfrastructure
• LiQleimprovementinfrastructure
• Rapidgrowthanddevelopingsystems
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Who we are? • CarolPeden,Physician–anesthesiologistandintensivist30yearsfront-lineclinicalexperience,IHIFellowandFaculty,experienceofdesigningandleadingQIprojectsandcurriculaaroundtheworld.
• FelipeOsorno,MITChemicalEngineer,6yearsinconsul;ngatMcKinsey,LeanandSixSigmaTrained,experienceandpassionincrea;ngsystemstoempowerfrontlinestafftoimprovevalue.
• KavehHoushmandAzad,MScIndustrialEngineering,10yearsofexperienceinhealthcareperformanceimprovement
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Getting Physicians Engaged in Improvement
• Whythisprogramforusnow?• GrowthandInfrastructure• Valueinhealthcare• Transforma;onalchange• Theissuesallhealthcareorganiza;onsarefacing
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We are all facing similar challenges
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End-to-End
BundlesV VALUE
Changesinreimbursement
models
Risingsupplyandlaborcosts
Wasteininternalprocesses
Varia]onamongproviders
Needforchange
Burnout
WestetalLancet2016;388:2272-81SalyersetalJournalofGeneralInternalMedicine201614
Strategies to reduce physician burnout
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hPps://newsnetwork.mayoclinic.org/discussion/mayo-clinic-reversing-physician-burnout-using-nine-strategies-to-promote-well-being/
• Acknowledgingandassessingtheproblem• Recognizingthebehaviorsofleadersthatcanincreaseordecreaseburnout
• Usingasystemsapproachtodeveloptargetedinterven;onstoimproveefficiencyandreduceclericalwork
• Cul;va;ngcommunityatwork• Usingrewardsandincen;vesstrategically• Assessingwhethertheorganiza;onsac;onsarealignedwiththestatedvaluesandmission
• Implemen;ngorganiza;onalprac;cesandpoliciesthatpromoteflexibilityandwork-lifebalance
• Providingresourcestohelpindividualspromoteself-care
• Suppor;ngorganiza;onalscience(Studythefactorsinyourownins;tu;onthatcontributetotheproblem,andinvestinsolu;ons.)
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Achieving The Quadruple Aim
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ImprovedPa]entOutcomes
LowerCostofCare
ImprovedPa]entExperience
ImprovedCareGiverExperience
Why not a multidisciplinary team approach? • Culture• Nomedicalschooltraining(todate)inQIatUSC
• Time• LiQleestablishedinfrastructure• Needtorapidlydevelopacohortofleaderswhocouldthenworkwiththeirteams
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CultureofImprovement
DataAvailabilityandTransparency
BuildingCapabili]es
System-WideImprovement
Specialty-LevelImprovement
EngagedPhysicians
Our System-Wide Strategy
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hPp://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
ModelforimprovementdevelopedbyAssociatesinProcessImprovement
• Approachfromboth“Lean”and“ModelforImprovement”• Usingbackgroundresearchandtheteam’sexperience
Designing the program
LeanThinking
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hPps://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_0.pdf
hPps://paOentsikkerhed.dk/content/uploads/2016/02/psskatalog_uk_www.pdf
hPps://www.rcplondon.ac.uk/projects/learning-make-difference-ltmd
Experience and Learning
The “Secret Sauce”
AmericanJournalofMedicalQuality2017.
• “Earlyengagementofaphysicianleader–whocanlisten,engage,andleadothercolleagues–tobeanearlyadopter”
• “Theymustbeequippedwiththetrainingandtoolstoleadothers,requirededicatedprotected;me,andtheautonomytocoordinateandimplementchanges”
• “Theengagedphysicianleaderrequirestrainingingovernance,leadershipandmedicaleconomics…andmentorship”
EPOCH Aim and Theory
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EPOCHTrial:EnhancedPeri-Opera;veCareforHigh-riskPa;ents£1.5M/90Hospitals
Front-line clinical staff will be enabled
to achieve improvements in care for patients
undergoing Emergency Surgery
which will lead to improved outcomes
Evidencebased
interven;ons
Measurement&datafeedback
Mo;va;onandfocus
Communityofprac;ce
QIskillstraining
MDTapproach
Ethnography and physician engagement “Becausehistoricallyweassurgeonswouldfinishanemergencyandouenleavetheopera;ngtheatretowritetheopera;onnotes,andthenouentheconsultantwouldleave,andtheregistrarmightcomebacktoseewhatisgoingon,butouenyouwould…findoutthenextmorningwherethepa;enthadgone.Whereasthisnow,gevngusintomoreofacultureof:‘Isthispa;enthighrisk?Shouldtheygotointensivecare?Whatisourplanofmanagement?Doweextubate?’Thosekindofthingsareconversa;onsIthinkweshouldhave’.”(SurgicalFellowHospital2)
23 EPOCHTrialSociologyofHealthandIllness2017;39:1314-1329
How to make change happen
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What does engagement really mean to physicians? 1. Respectformycompetencyandskills2. Feelingthatmyopinionsarevalued3. Goodrela;onshipswithmymedicalcolleagues4. Goodwork/lifebalance5. Avoiceinhowmy;meisstructuredandused6. Faircompensa;on7. Goodrela;onshipswithnon-clinicalstaff8. Abroadersenseofmeaninginmywork9. Avoiceinclinicalopera;onsandprocesses10. Opportuni;estoexpandmyskillsandlearnnewskills
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From:IncreasingPhysicianEngagement:startwithwhat’simportanttophysicians.RobertStarkThejournalofmedicalpracOcemanagement2014;30:171-5
How was our program developed?
SPO
NSO
RS
HIP
DES
IGN
HealthSystemLeadership
ValueImprovementOffice(“LeanTeam”)+CenterforHealthSystemInnova;on
DepartmentChairs
ValueImprovementOffice(“LeanTeam”)+CenterforHealthSystemInnova;on
SELE
CTI
ON
DEL
IVER
Y
Why it was designed this way? • Tohelpcliniciansunderstandthecomponentsofvalue• Toequipthemwithimprovementsciencetools• Toprovideleadershipdevelopment• Toeducateonchangemanagementconcepts• Toprovidebasicsonorganiza;onalstrategyandgoals• Todemonstratehowtouseandinves;gateins;tu;onaldatae.g.Vizient• Tohelpfosterresearchandpublica;oninqualityimprovement• Tosupportselec;onanddevelopmentofaprojectonwhichtoapplytheseskills
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Program Structure
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Day
1Day
2
Day
3Day
4
§ QualityandLeanIntroduc]on
§ SystemThinking§ A3andPDSA§ ProjectSelec]on
§ ValueStreamMap§ RunCharts§ RootCauseAnalysis
§ ChangeManagement§ Innova]on§ StakeholderAnalysis§ Leadership
§ Publica]on§ Benchmarking§ Sustainability
AdultLearningprinciplesIncludinggameandsimula;ons
1:1coachingsessions
DataSupport
Introduction to the program
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Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
• Selec;ngandscopingpoten;alprojects
• Selec;ngandcalcula;ngprojectmetric(s)
QIPIday2QIPIday3
• Formingprojectteams• Mappingprocesses• RootCauseAnalysis
• Developingcountermeasures• Implemen;ngcountermeasuresCommunica;ngtheprojectwithotherstakeholders
• Re-measuringprojectmetrics• Makingnecessaryadjustments• Finalizingthepresenta;on
QIPIday1
Jul17
Aug17
Sep17
Oct17
Nov17
QIPIday4
Ongoingcoachinganddatasupport
CohortSelec]on
Sharingtheresultandlearnings
Educating and Inspiring our Staff - QIPI
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Crea;ngacollabora;veandposi;veoff-siteexperienceFastpacedlearningandapplica;onoftoolsInvitedguestspeakerstoenrichthelearningexperienceOpportuni;esforpublica;ons
Crea;ngacollabora;veandposi;veoff-siteexperience
Fastpacedlearningandapplica;onoftools
Opportuni;esforpublica;ons
Invitedguestspeakerstoenrichthelearningexperience
Summary of successful projects
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Dr.BrigneyDeClerckImprovingEMRU;liza;on/efficiency
indermatologyclinics
Dr.ArmandDorianAppropriate“Pa;entStatus”
Determina;onat;meofAdmission
Dr.JayHudginsImprove%oftransfusedcasesvs.
typeandscreenorders
Dr.BenjaminEmanuelImprovedoor;metoCT/MRI;mefor
strokepa;ents
Dr.JehniS.RobinsonImprovepa;entcycle;meinFamily
Medicineclinic
Dr.NaomiSchechterImprovingpa;enttransferstoNorris
Radia;onOncology
Dr.MichaelJohnsImprovePa;entthroughputin
OHNSclink
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Recognitions and presentations
Other QI physician engagement projects at KMUSC • CareDeliveryRedesignAmul;disciplinaryapproachleadbyhealthcareadministratorswithengagedphysicians,andsupportedbytheValueImprovementOffice• SurgicalQualityImprovementOfficersAphysicianledprogram,fundedbytheDepartmentofSurgerywithnominatedsurgicalandanesthesiologyleads,supportedtoworkontheirownimprovementprogramswithfinancialcompensa;on.QIMentoringanddataanaly;cssupportprovided.
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Recipe for Care Delivery Redesign Steps:1. AlignonBurningPlaxorm
2. Iden;fyKeyOpportuni;es3. GaugeReadiness&BuildCoreTeams
4. EngageinCri;calReview
5. CreateEnvironmentforChange
6. FacilitateCross-Collabora;on7. Sustain,Share,&Expand
KeyIngredients:q PhysicianChampionsq Mid-LevelProvidersq AlliedHealth
Professionalsq AncillaryServicesq Administra;veSupportq Execu;veEngagementq DataTransparencyq SharedVisionfor
Success
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1.AlignonBurningPlaiorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkAssessCurrentStateandBenchmarkEngageClinicalLeadersinthe“Why?”CreateASharedVision
Q+S+A $
OurSharedChallenge:
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1.AlignonBurningPlaxorm
2.Iden]fyKeyOpportuni]es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkUseDatatoDiscoverGapsIden;fyExis;ngImprovementsinProgressSelectFocusCohort
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1.AlignonBurningPlaxorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkAssessReadinessforChangeIden;fyChampionsinKeyAreasAskWhoElseShouldBeInvolved
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1.AlignonBurningPlaxorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri]calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkCombineClinicalandFinancialDataCri;callyReviewEveryDay,EveryCareDecisionIden;fyProcessFailuresAcrossDisciplines
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1.AlignonBurningPlaxorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkAssembleImpactedStakeholdersCreateSafeSpacetoShareEncourageDifficultDiscussions
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1.AlignonBurningPlaxorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora]on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkShareFindingsfromCri;calReviewsIden;fyCross-Func;onalTeamsLaunchShort-andLong-termImprovements
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1.AlignonBurningPlaxorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkMonitorandSharePerformanceLearnfromSuccessesandFailuresCreateOrganiza;onalAwareness
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1.AlignonBurningPlaxorm
2.Iden;fyKeyOpportuni;es
6.FacilitateCross-Collabora;on
7.Sustain,Share,&Expand
3.GaugeReadiness&BuildCoreTeams
4.EngageinCri;calReview
5.CreateEnvironmentforChange
Steps
KeyIngredientsatWorkShareFindingsfromCri;calReviewsIden;fyCross-Func;onalTeamsLaunchShort-andLong-termImprovements
Department of Surgery Quality Officers Program • SupportedandfundedbyChairofSurgery• Financialincen;ve• SignificantdataandQIsupport• Onemee;ngamonthofgroup• SomeQItraining• Focusondevelopmentofleaders• Financialcalcula;onstojus;fyROI• Celebra;onofsuccess
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DOS Quality Officers Desired Outcome
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Forumtosharequalitydata&ini]a]ves
Engage,mentor,&trainofficersonquality&
performanceimprovement
Leadandimplementquality&performanceimprovement
projectwithinthedivisionandscaletootherdivisions
1 2 3
Performance Improvement Process
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IDENTIFICATIONOFPROJECT
Regulations
QualityOutcomes
CostOperationalInefficiencies
Research
INVESTIGATION STRATEGY IMPLEMENTATION AUDIT/MODIFY/ITERATE REPORT
QualityOutcomes
CostOperationalInefficiencies
Research
Value=QualityCost
ProcessforPerform
anceIm
provement
(1yearTim
efram
e)
1 month 2-4 months 2 months 3-6 months 1 month
Using measurement and local data…to inform and drive improvement
• ProcessandOutcomedata• Crea;ngabuzz,acampaign,energy–thewishtobepartofsomething
• Ini;alQItraining,followup,regularreviewandsharingwithstakeholders
• BasictraininginQItechniques,dataandsupport
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Sample Project: Increasing Efficiency & Decreasing Length of Stay
in Vascular Surgery • Hypothesis• Projectiden;fiedbysurgeons,engagedAQendingandDivisionChief• Increasingiden;fica;onandearlymanagementofavoidabledelayswilldecreaselengthofstay–focusonpa;entswithO/Era;o>1day
• OverlappingprojectbetweenSurgicalQualityOfficersandCareRedesign• Results
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Current Process
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Proposed New Process for Workflow
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Surgical Quality Officers; Reflection -what we will do differently in the next
iteration • InvolveAnesthesiology• Compensa;onlinkedtoaQendance• Projectsmoreclearlylinkedtoorganiza;onalgoals• Moreformal;meinQItraining• Lessofa‘research”approachtodata,lessretrospec;veanalysis–moreuseofsamplingandruncharts
• GreaterinvolvementofhospitalQIdepartment• Morecelebra;onandpromo;onofsuccess50
We’ve shared our experience …. What does some of the research say….
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• Askdoctorstolead–mantrais“physician-led,data-driven,evidencebased”• Askdoctorswhattheywanttoworkon• Makeiteasyfordoctorstoleadandtopar;cipate• Recogni;onfordoctorswholead• Supportformedicalstaffleaderswithcourage• Opportuni;estolearnandgrowGosfeldAG,ReinertsenJL(2010).AchievingClinicalIntegra;onwithHighlyEngagedPhysicians.Unpublishedmanuscriptin“MedicalEngagementtooimportanttobelektochance”ClarkJ.TheKing’sFund2012
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hPp://www.kingsfund.org.uk/sites/files/kf/medical-engagement-nhs-john-clark-leadership-review2012-paper.pdfhhPps://www.kingsfund.org.uk/sites/default/files/field/field_publicaOon_file/medical-engagement-a-journey-not-
an-event-jul14_0.pdf
Lessons from McLeod Hospital’s Transformation
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Consider Behavioral Economics
AnnInternMed2016;164:114-119
• Improvingqualityispartofdoctorsprofessionaliden;ty-tappingintothiscanbeapowerfulmo;vatorforchange
• Clinicianledqualityimprovementcanleadtogreaterstandardiza;on,moreequitablecare,greaterqualitycontrol,improvedpa;entsa;sfac;onandbeQerpa;entoutcomes
• QImustbealignedwithresourcealloca;on,supportedbyprofessionaltraining,commissioningandregula;onandintegratedintoservicemanagement
• QItobesustainablemustbeintegratedwithorganiza;onaldirec;onandresources
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www.health.org.uk
How do you get clinicians involved in quality improvement?
1. Consideryourorganiza;onstrackrecord–emphasizewhythisprogramwillsucceed–howisitdifferent?
2. Givedoctors;meandresourcestoac;velyengage3. Explana;onsofthepurposeoftheprogramshouldbe
phrasedtoreflectpriori;esandconcernsofclinicians4. Evidenceofefficacy–localevidencewillhelp5. Externalexper;sewherepossibletoaddcredibility6. Localprogramchampions(credibilitywithother
clinicians)7. Managementinvolvement–inaposi;ontosupport
clinicians
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MedicalEngagementinorganisaOonwidesafetyandqualityimprovementprogrammes.
ParandetalQualSafHealthCare2010;19:e44
Seven Themes for Medical Engagement
Harness Passion • Whatistheirpassion,whatistheirclinicaldesire?• Isittobethebestgastroenterologistever–howcanyouhelpthemgetthere?• Tohavethelowestmortalityforsepsis–howcanyourQIworkgetthemthere?• AskhowcanIhelpyou..bethebestdoctor…havethebestteam..savethemostpa;ents?
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In Summary • Wehavedesignedandledanumberofprogramswhichengageanddevelopphysiciansinimprovementleadership
• Wewillmodifythenextroundoftheseprogramsbasedonourexperienceandfeedback
• Wehaveseentangibleimprovements,ROIandjoyinworkincreaseforphysiciansandtheirteams
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THEKECKEFFECT
ENGAGEDPHYSICIANSIMPROVINGTHEQUALITYOFOURCARE
THANKYOU!