Engaging Physicians as Partners

By Jennifer Ewing RN, MS, CNSStroke Program Coordinator

Neuroscience Critical Care Nurse SpecialistCommunity Hospital, Munster IN Community Healthcare System

Financial Disclosure: Nothing to disclose Unlabeled / Unapproved Uses Disclosure:Nothing to disclose

Objectives

1. Review historical relationships of hospitals and physicians.

2. Adopt skills to assess your hospital / program for potential cultural concerns that lead to disengagement with physicians.

3. Discuss what to avoid when attempting to engage physicians in your programs.

4. Understand and develop strategies to engage physicians in your program or quality agenda.

Community Healthcare SystemCommunity Hospital -445 bed hospital in Munster, IN

St. Catherine Hospital- 180 bed hospital in East Chicago, IN

St. Mary Medical Center – 190 bed hospital in Hobart, IN

All three hospitals in the system are Primary Stroke Centers

Community Hospital

• ER volumes exceed 70,000 visits per year

•More admissions than any single hospital in Lake County, Indiana

Healthgrades®

2014 Distinguished Hospital Award for Clinical Excellence

11 Years in a row 2004-2014

Neuroscience Service Line• Top 5% in the Nation for Neurosciences 2013-2014

• Top 10% in the Nation for Neurosurgery in 2013

• Top 5% in the Nation for Stroke 2013-2014

Cardiac Service Line• Top 10% in the Nation for Overall Cardiac Services 2012-2014• Top 5% in the Nation for Cardiac Surgery 2014• Top 10% in the Nation for Cardiology Services 2012-2014

Community Hospital • Independent Physician Groups

• Many specialty groups • Highly Competitive

• ED Physician group contracted • Large, part –time • many first positions

St. Catherine Hospital • Independent Physicians• Employed physicians • “House Doctors”• Few specialty groups

• ED physician group contracted• small group • experienced

How to Engage Physicians in Quality Practices???? • History of hospitals and physicians – competition with each other• Physicians primary focus is their practice • Physician attachment to individual autonomy• Organized medical staff models in hospitals • Lack of system perspective• Time constraints

What we know…• 70 - 90% of all Medical practices in hospitals are doctor driven • Little is done without doctor orders • Expertise is expected • Centers for Medicare and Medicaid Services (CMS) and The Joint

Commission (TJC) - drive actions of hospitals • Financial accountability - Focus on Quality

• Programs / Quality Projects • Physicians are designated as the lead • Nurses facilitate projects

• Stroke Programs • Stroke Coordinators • Medical Director• Physician champions

Program

Administration

Nurse Leader Quality leader

Physician

Research Background of Hospital / System Information Research the history of the hospital’s culture in regard to physician practice• Employed physicians • Independent practices

Hospital Administration’s relationship with physicians

ID the key players

Reporting structure

Policies

Program Structure Expectations • Defined by certifying bodies• Institutions expectations• Roles / Responsibilities•Medical Director – paid

position• Program / Organizational chart

Examples - who does it well

Virginia Mason Medical CenterMayo Health System (reduced mortality rates 30 – 40 %!)Tallahassee Memorial Hospital

The Physician Engagement Difficulty Assessment Institute for Healthcare Improvement

• Uses current structure• Historical factors • Scoring in seven areas

• Leaders can use this to make case for change

• Higher scores identify needs for culture changes

•Make action plans to focus on areas when culture changes may not take place quickly

• Great for Stroke Coordinators, but even better for executive administration

1. Physician connectedness • The majority of active staff physicians are:Score = 1 – employedScore = 2 – affiliated with system (PPO)Score = 3 – independent

2. Physician loyalty Score = 1 – physicians are employedScore = 2 – admit primarily to the hospital Score = 3 – admit to multiple hospitals

3. Stability of medical staff structures Score = 1 – staff culture stable for yearsScore = 2 – staff merged from more than one facilityScore = 3 – recent merger

4. Medical staff bylaws are:Score = 1 – dynamic and up to date Score = 2 – revised within last few years Score = 3 – years since revised

5. Medical Executive Committee is: Score = 1 – balanced, resolves feuds and common belief that wise and fair decisions are made – viewed like Supreme Court Score = 2 – represents medical staff minimal involvement from administration and department chairs serve as authority for decisions Score = 3 – seen to protect individual physician rights, reactive and formal

6. Historic culture of medical staff Score = 1 – full engagement with initiatives Score = 2 – some engagement – rely on administration Score = 3 – minimal engagement – traditional structure only departmental boundaries

7. Board engagement with medical staff Score = 1 – Board engages directly with medical staffScore = 2 – Board watches quality from administration reportsScore = 3 – Board allows medical staff to receive quality reports

What to avoid when engaging physicians

Financial focus over clinical outcomesIgnore cultural issuesPromoting a blame or fault atmosphere No attention to time constraints

What to avoid when engaging physicians

Expecting all physicians to agree

Lack of communication skills and open conversation

No written physician engagement plan

Late involvement

Strategies to Engage Physicians

• Strong leadership presence from the start• Promote system and individual responsibility • Partnership visible – collaboration obvious• Physician involvement from beginning• Close loops when possible

Strategies to Engage Physicians• Use the evidence wisely to standardize • Reinforce Individualizing patient specific needs

• Set goals mutually and ask about expectations • Build and maintain trust• Prioritize follow up

• Value physician’s time• Communicate clearly

Strategies to Engage Physicians

• Provide credible and transparent data• Link quality agenda to physician quality agenda•Work with the early adopters • Positive attitudes and themes • Target the “nay sayers” right away

Strategies to Engage Physicians

• Employing physicians •Nurturing champions• Communicating physician contributions

TIPS• Standardize how, what, where, who, and when. •What is evidence driven•How is system process.•When define time parameters and timelines.

Initial Protocols tested and then changes are made defined by outcomes. The data.

Stroke Coordinators

Learn the organization – learn the ropes Establish credibility Avoid over commitment Find a mentor Focus on Clinical Outcomes Communication, Communication, Communication!!

Questions???

Thank you

References:Berenson, RA, Ginsburg, PB, May, JH. Hospital-physician relations: Competition and Cooperation. Hospital Affairs. Jan-Feb; 26(1): 31-43. 2006. Duffy, M, Dresser, S, Fulton, J. Clinical Nurse Specialist Toolkit. Springer Publishing

Company. New York, NY; NACNS 2009.Liebhaber, A, Draper, D, Cohen, G. Hospital Strategies to Engage Physicians in Quality

Agenda. Health System Change. Issue Brief; Oct. 2009. Reinertsen, JL, Gosfield, AG, Rupp, W, Whittington, JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambrige, Massachusetts: Institute for Healthcare Improvement; 2009.