The Very Best DoctorsThe Very Best Doctors

Wellstar Physicians’ GroupAnnual Meeting, Marietta, Georgia

March 8, 2007

James L. Reinertsen, M.D.jim@reinertsengroup.com

307 353 2294

In Wellstar, who would be the In Wellstar, who would be the very very best doctorbest doctor for me if I needed… for me if I needed…

• …ongoing primary care for diabetes and hypertension?

• …a colon resection?

Why do you recommend that particular physician?

Commonly cited attributes of Commonly cited attributes of “best doctors”“best doctors”

• Superb diagnostician– “She finds the zebra in a herd of horses.”

• Great technical skills– “If someone’s hands must be in your belly, his are the

hands you want.”

• Excellent bedside manner– “I’ve never had a patient come back to me unhappy with

him”

• Impressive pedigree– “Besides, she trained at Hopkins”

Uncommonly cited attributes of Uncommonly cited attributes of “best doctors”“best doctors”

• Reliable for common conditions– “Over 50% of her diabetics have HbA1c’s less

than 7!”– “His surgical site infection rate is an order of

magnitude better than a typical surgeon’s.”

• Accessible and “easy to use”– “You can see her the same day you call”– “His office team works like a Swiss watch”

Similar story for “best hospitals”Similar story for “best hospitals”

The mission, unchanged over 17 years,

has been to identify centers that take on

and excel at tough procedures and

conditions—rare cancers, worsening

heart failure, seemingly untreatable leg-

artery blockages…

Questions for this eveningQuestions for this evening• Which of these views of “best doctor” is

prevalent – in our profession?– among regulators, health plans, and policy types?

• Is it possible for “Dr. Zebra Good-Hands” and “Dr. Easy Access-Reliable” to be one and the same person?

• What does a medical group practice have to do with any of this?

Tensions between two views of quality Tensions between two views of quality Regulators and payors

• Public reporting and P4P– CMS Core Measures– HealthGrades– NCQA Physician Diabetes

Recognition– CMS/Premier– BTE

• Focus on process, reliability of EBM

• Measure what is available

Physicians• Professional reputation

– Diagnostic acumen– Technical magic– Bedside manner– Good judgment

• Focus on outcomes, stories, legends, relationships

• Value what is unmeasurable

Are these two views compatible?Are these two views compatible?

Yes, partly:

To the extent that performance measures of process are strongly predictive of

outcomes, then the regulatory/payer perspective aligns with physicians’

perspective.

Do process measures drive outcomes?Do process measures drive outcomes?ProPro

• Accumulating evidence for predictive relationship for many measures– VAP and Ventilator Bundle

• By and large, what gets measured improves

• High return if we improve from current baseline

• We have to start somewhere

• Our customers demand some sort of accountability

Con

• Uneven relationship of individual measures to outcomes– HbA1c versus BP control

• Difficulty in attribution to individual physicians

• Diminishing returns at high reliabilities?

• Unmeasured but important?

• “Burden” of improvement conflicts with time needed to be a good doctor

Question Two:Question Two:

Can you do it all?Can you do it all?

(Is it realistic for you to aspire to be (Is it realistic for you to aspire to be

“Dr. E. Z. Reliable-Goodhands?”)“Dr. E. Z. Reliable-Goodhands?”)

Back to basics: what doctors doBack to basics: what doctors do• Address the three timeless needs of patients

– Explain the current situation• What is happening to me? Why?

– Predict the future• What is going to happen to me? When?

– Change my future• If that’s what’s going to happen to me, can you change it for

the better? How?

• Perform two core processes: – Transforming and translating information – Building relationships capable of supporting healing

Critical requirements for building healing Critical requirements for building healing relationships and transforming informationrelationships and transforming information

Time and Touch

Some common time-stealersSome common time-stealers

• Documenting so that you can get paid

• Finding information needed for care

• Making things work when the system doesn’t

• Asking permission to deliver care

• Redoing work someone has already done

• Managing your backlog of patients

• Custom-crafting work you could do as a team

Jody’s QuestionJody’s Question

Other examples of physicians creating Other examples of physicians creating time to be better doctorstime to be better doctors

• Park Nicollet Clinic: 239 standing order sets + computerized patient record = 1-2 hours saved per doctor per day. (David Abelson)

• Methodist (Mpls) GI Lab: 30 patients per day to 64 patients per day in same space, same number of physicians, increased time in critical aspects of colonoscopy, and 1 hour total time less per day for each doctor. (David Wessner)

• Austin (TX) physicians: “Open access made my life better, and improved chronic disease process measures without even trying.” (Mark Murray)

The good news: We don’t have to invent The good news: We don’t have to invent new knowledge to get time back. new knowledge to get time back.

Just use the knowledge we already have.Just use the knowledge we already have.

• Systems theory

• Flow management

• Reliability science

• Lean production systems

• Rapid cycle improvement

• …

Levels of Reliability in Health Care (Amalberti, Nolan)Levels of Reliability in Health Care (Amalberti, Nolan)

Chaos 10-1 10-2 10-3 10-5

Processes are largely custom-crafted each time

Standard specs, checklists, training, trying hard

Standard process; redundancy, habits and patterns…

Obsession with Failure: Prevent Mitigate

Redesign

Loss of identity

Each doctor writes individual orders, gives to RN

5 people describe 5 processes; feedback on compliance

5 people describe 1 process; RN managed prevention bundle

External approval necessary for certain orders

Equivalent

actor

Preventing, treating acute and chronic disease in US

Typical MD group working hard

Best MD group performance

ADEs per 1000 doses in best hospitals

Safety in anesthesia

Conclusion: Physicians have the Conclusion: Physicians have the opportunity to give ourselves back opportunity to give ourselves back a lot of time. What we do with the a lot of time. What we do with the

time is up to us. If we use it wisely, time is up to us. If we use it wisely, we have the we have the chancechance of becoming of becoming “Dr. E. Z. Reliable-Goodhands”“Dr. E. Z. Reliable-Goodhands”

Question 3: Question 3:

What does any of this have to do What does any of this have to do with physician group practice?with physician group practice?

With regard to quality, group practices With regard to quality, group practices should beshould be in a position to… in a position to…

• Choose to work on something important, rather than simply react to external requests

• Practice the science of medicine as a group, and the art of medicine as individuals

• Create a “system” in which each individual doctor has the opportunity to be “Dr. E.Z. Reliable-Goodhands”

Why?Why?

• Public Practice: the common medical record• Opportunity to select physicians with shared

values• Opportunity to remake the physician “compact”• Opportunity to build other common systems:

core work processes, staff training, disease registries, advanced access…

• Opportunity to influence the external environment

Engaging Physicians in Quality and Safety

1. Discover Common Purpose:

2. Reframe Values and Beliefs:

1.1 Improve patient outcomes1.2 Reduce hassles and wasted time1.3 Understand the organization’s culture1.4 Understand the legal opportunities and barriers

2.1 Make physicians partners, not customers2.2 Promote both system and individual responsibility for quality

3. Segment the Engagement Plan:

3.1 Use the 20/80 Rule3.2 Identify and activate champions3.3 Educate and inform structural leaders3.4 Develop project management skills

4. Use “Engaging” Improvement Methods

4.1 Standardize what’s standardizable, and no more4.2 Generate light, not heat, with data4.3 Make the right thing easy to try4.4 Make the right thing easy to do

5. Show Courage:

5.1 Provide Backup all the way to the Board

© 2007 Institute for Healthcare Improvement

3.5 Identify and work with “laggards”

6. Adopt an Engaging Style:

6.3 Work with early adopters6.4 Make physician involvement visible6.5 Build trust within each quality initiative6.6 Communicate candidly, often

6.1 Involve physicians from the beginning

6.7 Value physicians time with your time

6.2 Work with the real leaders

Questions for discussion:Questions for discussion:

• Is the primary driver of your quality work external requirements, or internal aspirations?

• How much of your wasted time every day is a self-inflicted wound?

• If you could save time by practicing science as a team, why aren’t you? Or are you?

• Is computerization going to solve these problems for you, or make them worse?