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Nudging Physicians Toward Team-Based Care

 |  By Philip Betbeze  
   December 08, 2011

This article appears in the November 2011 issue of HealthLeaders magazine.

Preparing for a shortage of medical talent to treat the expected influx of patients in coming years is difficult work. It’s made even more difficult by the traditional doctor-first attitude that imbues the healthcare workflow. That often means the physician is the bottleneck—all treatment decisions need to filter through him or her. Many systems are trying a myriad of ways to take some of the workaday functions off the physician’s plate, with the difficult task of providing a method of physician oversight of such functions.

Those tackling this set of problems often find physicians are apprehensive about loss of autonomy, income, and career stability. Meanwhile, other members of the care team continue to feel marginalized, as ingrained attitudes about hierarchies are hard
to change.

But there are successes; they tend to come from institutions that are not afraid to try new ideas to take on the challenge of creating better patient access, tracking, and delivery of care.

Many of the changes necessary to prepare for a different future focus first on the changing medical staff model, and the responsibilities of everyone—not just the doctors—who are expected to deliver on the organization’s strategic direction.

Reframing the conversations

Thomas Noren, MD, led a 2009 medical staff reorganization at Marquette (MI) General Health System’s main component, 225-staffed-bed, Level II trauma center Marquette General Hospital. This initiative created 20 team-based groups that bring together medical staff members of similar experience and expertise so that issues, visions, and problems can be deliberated by colleagues who share common interests.

Noren, who serves as chief medical officer, says Marquette General’s traditional department structure—which consisted of medical, surgical, and others—needed to change.

“There was not much accomplished in those meetings in the past,” he says. “We concluded that had to do with the disparity of interests. The department of surgery has lots of different worlds, for example, so having a constructive conversation about looking at data and performance improvement had inherent limitations.”

 Marquette calls the medical staff evolution that ensued from this reengineering “service lines,” but the aim is far from maximizing the revenue potential surrounding profitable disease-based systems—the thought that is traditionally connoted by the term.

“I realize you’re usually talking about product lines when you mention service lines as a concept,” says Noren. “We thought service to the customer rang well so we stuck with it. But this is specifically a medical staff reorganization designed to foster hospital-physician alignment.”

Marquette General’s 21 different service lines convene meetings eight times a year, and traditional departments meet only quarterly. Service line meetings are led by elected medical staff leaders who, Noren says, possess the skills to generate enthusiasm for accomplishment. Each service line contains medical staff members, program directors, quality managers, the CMO, COO, and representatives from decision support, care management, nursing, and marketing. Additionally, ad hoc committees have people from all service lines working together on specific overlapping programs, such as the breast health committee, which includes cancer, pathology, imaging, and women’s health service line representatives.

The meetings have standing agendas, which include regular review of Press Ganey patient satisfaction scores, Premier Quality Advisor data, actions from the value analysis team, and suggestions for developing regional physician work team interactions. They follow “Rimmerman’s rules,” according to Noren, which means “everyone has an equal voice. The philosophy is all ideas are good until the best one arises.”

One example of success came from the brain and spine service lines group. In reviewing performance and cost data, the group found huge variation in the cost of spinal implants. Under various reimbursement schemes, as much as 75% of the payment for the procedure was consumed in the cost of the implant while others were as low as 25%. As a result, the hospital started negotiating with vendors and has reduced that number overall to about 41%. The hospital realized a huge savings with that alone, Noren says.

As for the cost of the service lines program, “we pay for a few more meals, but other than that, the realignment didn’t cost anything,” he says.

Noren claims this organizational structure doesn’t create 21 new silos, but instead breaks down the barriers between employed and independent physicians as well as between physicians and the rest of the care team in an effort to focus on quality, transparency, and value. About 65% of the physicians practicing at Marquette General are employed. But Noren says little to none of the conversations in the meetings have anything to do with whether the physicians are employed.

“We do not equate employment with engagement in the concept of these service lines. There’s no distinction in voice or prerogative,” Noren says. 

The farmer vs. the architect

Matthew Hanley, MD, is vice president of medical affairs at Centra Health, which realigned its medical staff in a similar way over the past couple of years. The Lynchburg, VA–based nonprofit health system includes 358-bed Lynchburg General and 206-bed Virginia Baptist Hospitals; 93-bed Southside Community Hospital in Farmville is an affiliate.

Hanley implemented a shared governance structure for the emergency department. “We had open collaboration, were very data driven and transparency based, and we had a high level of accountability for results,” he says.

The ED group tackled wait times in the ED, for example, and variation among ED physicians on testing, service scores, and length of stay.

Now he’s trying his collaborative philosophy on a grand scale.

Hanley likes to look at the work he’s doing to cut costs and improve quality in terms of an analogy: the farmer vs. the architect.

“An architect represents a top-down philosophy,” he says, while the farmer nurtures and isn’t really sure what’s going to come from that nurturing.

“My job is to move the rocks out, pick the weeds, and make the ground fertile so when these experts come in, I have given them enough tools and enthusiasm to allow them to grow their own ideas.”

The experts of whom he speaks aren’t consultants or high-powered physicians; they’re people on the front lines of care. 

“People who work on the front line are the experts. If you want fundamental knowledge of the process, you need to talk to them,” he says. “I’m not an expert in cardiology or pediatrics, but I can help get them to figure out where they have opportunities for change because they’re already hooked in.”

Historically, Centra has featured high quality, high patient satisfaction, and low costs, says Hanley, so it’s a challenge to see where improvement can be made. The reason Centra has accomplished its lower costs is aggressively managing the supply chain, revenue cycle, length-of-stay case management, and productivity and, to continue Hanley’s analogy, it feels like it has harvested much of the low-hanging fruit in cutting healthcare costs.

But with a patient mix that skews 55% Medicare, Hanley says Centra “is living closer to the edge than some of the other systems, and that’s forced us to look at a lot of stuff that others are only looking at now. The benchmark going forward is surviving under Medicare.”

Centra has some variables in its favor. It has a well-developed EMR that has used computerized physician order entry for five years, has standardized order sets, and culturally, “we are a single-specialty town, so we don’t have another big hospital to compete with,” he says.

Still, future success will center on innovations in clinical care delivery, Hanley says, and that’s something where process engineers have an important contribution to make.

“If I wanted a breakdown on a financial report I could get that in a couple of hours,” he says. “But if I want some detailed report on a clinical process, that could take days.”

That’s not unusual, but Hanley wants to make it so that possible changes in clinical care delivery can be modeled. His reliance on process engineers started after his emergency medicine physician group was absorbed into Centra in 2006.

“When we became employees, we wanted a process engineer for our department who didn’t have history in healthcare so they could be objective. We made a commitment to the science of quality improvement. That was a huge decision for us.”

Many of the gains made by the ED group were data driven and facilitated by the process engineer.

“So when I moved into this role, that idea has always been there,” he says. “Sometimes it’s better to be lucky than good.”

Lucky or not, he knew a good thing when he saw it. Now, process engineering is a vital part of the performance improvement regime and has become its own department. The pharmacy and therapeutics committee tackled the medication delivery process, and in doing so saved about $1 million in drug purchasing costs. The performance improvement department also concentrated resources on DRG profitability studies and implemented the clinical council, which, Hanley admits, is “part infrastructure and part culture.”

The clinical council—which includes professionals from physicians to nurses to administrators—is a broad forum to discuss and implement quality and process improvement ideas along service lines.

“It extends beyond the borders of the organization’s quality. It’s really about community quality and, going forward, will take a greater level of collaboration to create the solutions we need,” says Hanley.

“The clinical council is a budding plant right now,” he says. “We’re trying to build a platform of constant process improvement, where it becomes an intrinsic part of the work we do. We have a system in place with tools and resources and space to continually improve. We have a very good start, but we may need a couple more growing seasons.”


This article appears in the November 2011 issue of HealthLeaders magazine.

Philip Betbeze is the senior leadership editor at HealthLeaders.

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