Under pressure to deliver value, increase efficiency, and lower costs, health systems and hospitals are seeking ways to advance the capabilities of their physicians.
This article appears in the September/October 2018 edition of HealthLeaders magazine.
At least half of the nation's physicians are sick of their jobs at a time when demands on their skills are more critical than ever. In the past, hospital leaders could reliably throw money at the problem. Not so much anymore.
A tried-and-true way to "engage" physicians historically has been through their paychecks to prod along everything from quality incentives to EHR implementation. The kitty of cash that leadership teams had on hand to make physicians happy is almost empty these days, operating margins being what they are. Without income in hand, hospital leaders must rely on some thrifty and tested "satisfiers" that work in any good business: create a reliable team around them, involve them in the business, and add technology that—for one—makes their job easier.
Leaders may recognize an opportunity: that the underlying fundamentals of physician labor are changing. The benefits of high reliability, team-based healthcare takes the physician from being the only voice in the huddle to a leading voice in a coordinated care plan. Bringing physicians into decisions on supply chain creates the beginnings of a business partnership.
Under pressure to deliver value, increase efficiency, and lower costs, three leading health systems are advancing the capabilities of their physicians through a supportive and productive environment.
A 2017 study published by the National Academy of Medicine found that more than half of surveyed physicians were exhibiting substantial signs of burnout.
No health system can address burnout without first understanding one of the root causes: quality of care. At Cleveland Clinic, efforts to become a high-reliability organization since 2013 have achieved a trifecta: improved patient outcomes, boosted physician satisfaction, and reduced physician burnout.
"There is a big problem in healthcare with burnout, which is complex and involves lack of job enjoyment, feeling stressed, and work-life balance challenges. All of those things improve when you have a team working together smoothly to get the best outcomes for patients," says Edmund Sabanegh, MD, main campus hospital president.
The correlation between team-based care and physician satisfaction is direct, says Sabanegh.
"Things that help us successfully treat patients—team approaches, checklists, and spreading of responsibility—improve our engagement and satisfaction with our career field," he says.
1. Happiness Begins With High-Reliability
Cleveland Clinic's high-reliability initiative has revolved around basic team building, policy standardization, real-time operational management, creating a culture of safety, and sustaining redundancy in the clinical setting.
"There has been a revolution at Cleveland Clinic over the past several years to emphasize a culture of high reliability and safety, as well as to emphasize a team approach to everything we do," Sabanegh says.
But inconsistency in administrative and operational policies is a major challenge for health systems seeking to attain high-reliability, says Sabanegh.
"One of the challenges for any large healthcare system is there are many sites for delivery of care. A pitfall that you can have is failing to recognize the nooks and crannies of the system, then having different policies and standard operating procedures for different areas," he says.
Cleveland Clinic, which features 19 acute-care hospitals, has made policy standardization a priority, he says. "We have worked hard to standardize our policies to make sure that a nurse who works in one ward, then works in another location in our system has a similar expectation and similar understanding of processes," he says.
One of Cleveland Clinic's high-reliability cultural initiatives has upended decades of tradition in the health system's operating rooms. As opposed to the top surgeon dominating discussions and decision-making in the OR, the health system has adopted a team-oriented approach including operating room pauses, he says.
"If we have a surgery and anyone in the room is unsure of equipment status or a missing supply like a sponge, there can be a pause. Any member of the team can say, 'I want to look at where we are before we proceed any further with this procedure.' It could be the most junior member of the surgical team or it could be the most senior member."
To achieve real-time operational management, Cleveland Clinic adopted a reporting system based on tiered huddles this year.
"Every morning, on every nursing unit, there is a huddle of the team. They discuss what has gone right, opportunities, and concerns for the day ahead," Sabanegh says.
The discussions at the ward level are reported to the hospital leadership level, including the president, chief nursing officer, chief medical officer, and chief quality officer.
The hospital leadership's huddle is reported to the health system leadership. Information gathered through the tiered reporting allows senior leadership to take action quickly at any location in the organization,
"As the hospitals' president, I am hearing every day from every hospital in our system about their challenges and opportunities for the day ahead. What is our workload and how can we balance it? What kind of infrastructure support do we need? What kinds of repairs are needed?" Sabanegh says.
Gathering timely information from throughout the health system is invaluable from both management and labor perspectives, Sabanegh says.
"Real-time operational management gives us both an early warning system for problems and challenges for the entire enterprise, and a great venue to communicate up and down the organization. Everybody is hearing about challenges at other places and how those challenges are being solved," he says.
Culture is essential to creating a high-reliability organization, he says. "We are working very hard to create a culture of safety and high-reliability. Every time the leaders of the organization speak, they talk about
Staff members are encouraged to identify quality concerns with public recognitions such as awards. "We don't want to be in a reactive mode. Our system fails when we have a serious safety event. What we want to identify is the near miss or something that could turn into a serious safety event down the road,"
Although redundancy is often equated with waste, Cleveland Clinic sees value in redundancy in the clinical setting, he says.
"We still believe some redundancy is necessary. We are leveraging technology to assist in catching things; but, in this generation, technology will not replace the need to have multiple sets of eyes looking at a challenge," he says.
Education and communication have been key elements of engaging physicians in high-reliability efforts at Cleveland Clinic, Sabanegh says.
Educational programs that support the health system's high-reliability efforts include Solutions for Value Enhancement (SolVE).
"Physician leaders learn about high-reliability, performance improvement, and tackling processes with risk and opportunity while avoiding risk. We have trained thousands of people in our organization in these areas,"
Cleveland Clinic also communicates with clinicians about the benefits associated with high-reliability organizations, he says.
Engaged clinicians have helped Cleveland Clinic achieve significant high-reliability gains.
The average 30-day readmission rate has fallen from 14% to 12.65%, which represents 2,100 patients per year who did not require a readmission.
Outpatient hypertension control has increased from 66% to 76%, with 15,000 more patients at prescribed goals. Cleveland Clinic estimates improved hypertension care has saved about 100 lives.
"We have seen a steady improvement in our quality outcomes, a reduction in serious safety events, and improvements in our readmissions—all things that are important to our patients and improve when our care team makes sure we are highly reliable," Sabanegh says.
2. Save Physicians and Patients With Predictive Modeling
Predictive modeling is not brand-new technology, but its utility has advanced into care scenarios that have the potential to improve patient care and give physicians a critical tool.
NorthShore University HealthSystem is using prediction models to give physicians important information about their patients. The health system has about 20 prediction models to target high-risk patients for factors such as cardiac arrest and readmission.
Prediction models help physicians decide whether their patients need interventions, says Nirav S. Shah, MD, an infectious disease specialist at NorthShore.
"The prediction modeling is refining the patient population, so that when you perform an intervention you can find the highest-risk patients. Instead of performing interventions on an entire population, we can limit the intervention to a small subset of the patients," he says.
In NorthShore's cardiac arrest prediction model, a patient's risk level for cardiac arrest helps determine whether an intensive care consultation is held. The model has resulted in fewer patients having cardiac arrest and a trend toward decreased mortality, Shah says.
NorthShore is preparing to take a leap forward in its prediction modeling efforts with a cutting-edge technology.
"The most exciting thing we are doing is embarking on a journey to integrate all of our prediction models into a single engine," he says.
Combining prediction models will expand the utility of the data for physicians and population health initiatives.
"Most institutions are getting more and more into these prediction models, but they are each in their own silo. Each prediction model has its own lexicon of risk. What we are doing is trying to combine every prediction model into a large engine, so we can subdivide patients," Shah says.
Subdividing a patient population will help NorthShore manage high-risk patients with multiple morbidities, he says. "We may have an intervention for high-risk readmission patients that could be an intervention for patients who are also high-risk heart failure."
One of the top goals of NorthShore's Clinical Analytics Prediction Engine (CAPE) is establishing a powerful data-driven learning capability, Shah says.
"We are finding a way to sub-segment our entire patient population using analytics and prediction models, so we can target specific patient populations. Then we will use this engine to quickly learn whether interventions on patients or subgroups of patients make sense."
Running randomized trials can take months to a year to complete, but CAPE will run randomized trials much faster, he says.
"On the academic side, you use randomized controlled trials, where you take populations, get consent from them to be part of the study, use resources such as the people who design these studies, then it takes six months to a year to enroll patients and analyze the data. … We will be able to speed up deciding whether an intervention makes sense from six months to a year, to a couple of weeks," Shah says.
CAPE's capabilities will deepen NorthShore's understanding of its patients.
"We are essentially using this new engine to create a learning health system, which will allow us to continuously learn from the patient population. Instead of creating randomized controlled trials that are separate from patient care, we are building the ability to conduct these trials into our system of care," he says.
Physician engagement and winning over skeptics is a crucial element of launching prediction modeling initiatives, Shah says.
"We have a track record of implementing predictive models. Initially, it can grate some physicians when they feel their autonomy is being taken over by algorithms. You have to show you are improving patient care. In the end, all providers want to improve patient care," he says.
Demonstrating positive outcomes for patients is powerfully persuasive for even the most doubtful physicians, he says. "Even if it's an algorithm that physicians feel is supplanting some of their autonomy, if they see that a prediction model is resulting in better outcomes, that will click a lightbulb immediately and they will buy into it."
Rather than diminishing physician autonomy, prediction modeling is already helping many physicians make wiser decisions, Shah says.
"Physicians use a lot of algorithms already. The Model for End-Stage Liver Disease (MELD) score shows whether someone is at high risk for death if they have liver cirrhosis. There are all kinds of tools that already exist that providers do not complain about," he says.
Shah predicts CAPE—which is being built in the health system's Epic electronic medical record, will be appealing to physicians who view EMR data entry as a waste of time.
"You are essentially putting in a lot of data, and it's not giving you valuable information in return. You can show physicians that prediction models are providing them with key insight for outcomes that are important to them and that the data they are entering has a return on investment," Shah says.
In addition to using prediction models to supplement physician decision-making, NorthShore has been improving Epic's user experience for years, Shah says.
"We were the first to adopt Epic on the inpatient and outpatient sides. So, there are many things that we have done from an optimization standpoint—providing physicians with dashboards and other capabilities to help them make the best decisions for their patients," he says.
An Epic improvement adopted this summer helps inpatient clinicians pick the right antibiotic for patients before culture data is available, he says.
"When someone comes in for treatment, we often do not know which antibiotics are going to work for the patient. We want to find the perfect antibiotic for any given patient, so we can reduce the risk of the patient getting worse and reduce the risk of resistance," Shah says.
The new antibiotics capability in Epic includes data from What's Going Around—a graphical representation of five illnesses in Chicago's northern suburbs such as strep throat and flu-like illness.
The key was creating a program that draws several patient variables directly from Epic, Shah says.
"It uses infectious disease guidelines, it uses prediction modeling, and it uses the What's Going Around epidemiological tool. All of that information is integrated into a single decision-making tool that allows a provider to determine the best antibiotic for their patients before there is culture data to guide therapy," he says.
3. Physicians Empowered to Help With Supply Chain
Kettering Health Network is tapping the clinical expertise of physicians to improve clinically integrated supply chains, which support value-based care with physician engagement, data analytics, point-of-use management, and strategic contracting.
Trisha Gillum, director of supply chain management at Kettering, says physicians can play diverse roles in a clinically integrated supply chain.
"It can be as small as a physician champion on a single project, to being a physician champion for a service line, to being on the payroll for supply chain," she says.
Gillum says the best physician champions for medical supply changes are personally engaged in the effort. "They are willing to understand both the financial and the clinical nuances to a project. They are also willing to speak with their peers—to be a cheerleader or champion for a project."
When Kettering identifies engaged and respected physicians who are interested in serving in the champion role, the doctors receive training from The Advisory Board Company. Physician champion programs at this Washington, D.C.–based consultancy range from individual sessions to a physician leadership track that has sessions held over several months.
Two primary elements of the education programs are business instruction and learning about the nuances of the changing healthcare industry.
"Many physicians are not in tune with everything that is going on in the hospital environment," Gillum says. "They don't understand when we say we need to save money. So, there is education about financial pressures and clinical pressures."
Another educational goal is giving physicians leadership skills, she says.
"We are asking them to step out of their traditional roles and communicate with their peers at an advocacy level. To do that, we not only need to provide the data to support product conversations, but also give them the tools necessary to have those conversations."
In a clinically integrated supply chain, physician champions play a potentially decisive role in proposed supply changes, Gillum says.
"If you really want a physician to get engaged, they will bring their own mindset about what the answers should be. You cannot expect a physician to come onboard and rubberstamp the process," she says.
Supply chain managers and other leaders should be open to opposing views from physician champions, she says. "They are going to want to engage in the process. They are going to want to modify it. So, you may end up in an entirely different place than you expected."
When physician champions object to proposed supply changes, open communication is essential, Gillum says.
"You have to be transparent. You can't ask a physician to own something like a cost-savings initiative unless you are willing to say how much we are going to make on a procedure. You have to be willing to share all of the data and to give physician champions all the facts to make intelligent decisions," she says.
Supply chain managers should treat physician champions as valued teammates, Gillum says. "You have to realize that you have asked physicians to play a supply chain role and to provide information. If you disregard what they are saying, you are going to lose partners."
The best-case scenario for physician champions is when they take ownership of a supply change project, she says.
"I had a physician who went out and talked with every one of his peers who performed a particular procedure. He convinced every one of them that we needed to make a change. He was able to accomplish more in those conversations than I could have accomplished in months of conversations with the same group of physicians," she says.
Gillum says the two primary benefits for clinicians who assume physician champion roles are gaining experience that helps them compete for hospital administration jobs and helping to decide supply changes that could impact their patients.
"I had one physician say [that] he was passionate about the supplies he used on his patients. The best way physicians can control the supplies that they get is to be part of the conversation and part of the decision," she says.
Photo credit: Nirav S. Shah, MD, infectious disease specialist, NorthShore University HealthSystem (Jean-Marc Giboux/Getty Images)
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Clinicians can play a pivotal role in supply chain as physician champions.
Fostering a high-reliability organization creates a supportive environment for physicians.
Predictive modeling can enhance clinician decision-making.