Medical Staff Leadership as an Agent of Safety & Quality in Healthcare

Organizations:Relationships & Teamwork

Keith Doram, MD, MBA, FACPSr. VP and Chief Medical OfficerChristiana Care Health SystemAssociate Professor of MedicinePenn State College of Medicine

Harry Truman once said…

“You know what makes leadership? It is the ability to get men to do what they don’t want to and like it.”

Learning Objectives

Better understand how medical staff leadership can influence the ability of a healthcare organization to improve patient safety & quality

Discuss barriers for medical staff and healthcare administrators related to leadership and good relationships

Provide an overview of the Christiana Care Heath System and the role of the Chief Medical Officer

Useful Definitions

Leaders are people who do the right thing; managers are people who do things right. Both roles are crucial, but they differ profoundly. I often observe people in top positions doing the wrong thing well.

- Warren Bennis

Safety is first & foremost “doing no harm”.

Quality (in hospitals & healthcare) is doing the right thing right—not just for one patient, but for all patients.

Twelve Leadership Competencies(The M.I.C.P.S. – Management Incentive Comp Plans)

Managing Relationships Cultivating Relationships Conflict Prevention and

Negotiation Influencing Building Coalitions AdvocacyCommunication Responsiveness Information Brokerage

Performance & Quality Set Goals & Standards Accountability Manage ChangeSetting Direction Vision & Purpose Org. Perspective Initiative

Source: Advisory Board Interviews and Analysis, 2004

Effective Executive Leadership, according to Peter Drucker:

There appears to be little correlation between a person’s effectiveness and his/her intelligence, imagination, or knowledge. Brilliant men/women are often strikingly ineffectual; they fell to realize that brilliant insight is not by itself an achievement.

The good news is that, “Effectiveness can be learned”.

Effective leader executives can be fat or lean, extrovert or shy, drink a lot or not at all—but they all share five habits or practices…(Drucker)

Know where there time goes and manage it Gear efforts to results than to work Build on strengths not weaknesses Concentrate on a few things that will

produce outstanding results They make effective decisions

– Judgment based on “dissenting opinions” rather than on a “consensus of the facts”

Most Hospitals are in need of a New Leadership Model

“ I thought about becoming a leader in my speciality, but it didn’t seem that compelling. I’m really interested in bringing in new technologies and growing our service…but leadership in this hospital is all about going to meetings and making sure new doctors fill out their paperwork.”– Anesthesiologist, Large East Coast AMC

Organizational Barriers for Physician Leadership in Hospitals(Source: Physician Leadership Academy, 2004)

Administrators’ View

1. Undervalued Prtnrshp

2. Insuff. Follow-thru

3. Insuff. Analysis

4. Lack of knowledge

5. Inadequate Structure

6. Poor negotiations

7. Insuff. role definition

Physicians’ View

1. Lack of knowledge

2. Poor peer relations

3. Insuff. Analysis

4. Undervalued Prtnrshp

5. Insuff. Follow-thru

6. Inadequate Structure

7. Lack of commitment

Comments from physicians:

“Talking to administration is like talking to the boogeyman.” – Southeast physician leader

“Physicians aren’t very collaborative people. And they resist change probably more than the average person. And while they agree on conceptual issues, they have great difficulty in actually working together to achieve their goal.” – Physician leader, Advisory Board Focus Group

Key Factors That Determine Physician Leadership Involvement in Hospitals(Source: Advisory Board 2002 Survey of 531 physicians in 10 specialties)

1. Compensation for time spent working on hospital issues

2. Provision of support staff by hospital3. Personal interest4. Opportunity for research and publishing5. Opportunity for prestige and recognition

CCHS has a mentorship program, a formalized year-round faculty development curriculum with the ACP Executive training program and the Advisory Board

Key Factors That Motivate and Determine Physician Behavior

Good Rationale Peer-Pressure Real Threats Money

JCAHO safety/quality measures are a great yardstick for EBM – Do you think the doctors share that view?

JCAHO Pt Safety Goals are EBM– Improve accuracy of patient ID– Improve effectiveness of communication among

caregivers (e.g., readback, abbreviations)– Improve safety of using medications– Eliminate wrong-site, wrong patient…surgery– Improve safety of using infusion pumps– Improve effectiveness of clinical alarm systems– Reduce the risk of healthcare-acquired infections

JCAHO and Quality – has 18 standing advisory groups and a number of coalitions (AMA, ACC, AHA, AHRQ, CMS, NCQ, Pharmacopoeia…)

Benefits of Beta-Blockers for Acute MI– Clinical Trials: STEMI, MIAMI, ISIS-1, TIMI-II

15% Lower mortality over 7 days (p = 0.05)– Circulation 2004;110(5):588-636– Lancet 1986;2(8498):57-66– N Engl J Med 1989;320(10):618-27– Am J Cardiol 1985;56(14):10G-40G

These Standards are Just Good EBM!!

Learnings from CCHS…

Key Metrics

7,000 Births (Level IV Neonatal Care Unit) 60,000 Admissions 51,000 Surgical Procedures 1,000 Open Heart Surgeries 1,200,000 Outpatient & Home Health Visits 135,000 Emergency Department Visits

Level 1 Trauma Center

1,200 Medical/Dental Staff $1.2 Billion Annual Health System Revenues

Education

220 residents & fellowsDiagnostic RadiologyEmergency MedicineEmergency Medicine/

Internal MedicineFamily Practice

(Osteopathic and Allopathic)General Practice DentistryGeneral SurgeryInternal MedicineMedicine/Pediatrics

Obstetrics and GynecologyOral and Maxillofacial SurgeryOsteopathic Traditional

Rotating InternshipPreliminary Medicine YearPharmacy PracticePodiatric Medicine and Podiatric SurgeryTransitional Year

Neonatology Fellowship

Education

420 medical students Delaware Institute for Medical Education and Research,

(DIMER) Delaware Institute for Dental Education and Research,

(DIDER) Affiliation

– Jefferson Medical College– University of Delaware– Delaware Technical and Community College

Research

– 3 Bone Marrow Transplant – 55 Cardiology – 26 Critical

Care/Trauma/Surgery – 3 Adolescent Medicine – 18 Diabetes – 40 Emergency Medicine – 7 Family Medicine – 2 Genetics – 84 GYN Oncology – 2 HIV – 9 Infectious Disease – 10 Internal Medicine– 41 Maternal Fetal Medicine – 19 Neonatology – 2 Neurology/Neurosurgery

4 Nursing 11 Obstetrics/Gynecology

2 Occupational Health 205 Oncology/Hematology

2 Orthopedics 21 Other Research 15 Pathology and Laboratory

2 Pediatric Neurology 96 Pediatric Oncology

3 Pediatrics 1 Perinatology 7 Pharmacy/Pharmacology 5 Preventive Medicine 5 Pulmonary/Respiratory

32 Radiology/Radiation Oncology

732 Total Clinical Trials