The Very Best Doctors Wellstar Physicians Group Annual

The Very Best Doctors Wellstar Physicians’ Group Annual Meeting, Marietta, Georgia March 8, 2007 James L. Reinertsen, M. D. jim@reinertsengroup. com 307 353 2294

In Wellstar, who would be the very best doctor 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 “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 “best doctors” • Reliable for common conditions – “Over 50% of her diabetics have Hb. A 1 c’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” ars, e y 7 er 1 v o e on k d a e t g t chan nters tha d n u , ce an sion y s f s i e i t r n m u The o ide h proced orsening t n e e g g has b cel at tou cancers, w eatable le x tr and e ions—rare ingly un m it cond ailure, see … f heart blockages y arter

Questions 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 Regulators and payors • Public reporting and P 4 P – CMS Core Measures – Health. Grades – 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? 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? Pro • 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 – Hb. A 1 c 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: Can you do it all? (Is it realistic for you to aspire to be “Dr. E. Z. Reliable-Goodhands? ”)

Back 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 relationships and transforming information Time and Touch

Some 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 Question

Other examples of physicians creating time 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 new knowledge to get time back. 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) Chaos Processes are largely custom -crafted each time Each doctor writes individual orders, gives to RN Preventing, treating acute and chronic disease in US 10 -1 Standard specs, checklists, training, trying hard 10 -2 Standard process; redundancy, habits and patterns… 10 -3 Obsession with Failure: Prevent Mitigate Redesign 5 people External describe 1 describe 5 approval process; RN processes; necessary for managed feedback on prevention certain compliance bundle orders Typical MD Best MD ADEs per group 1000 doses working copyrightperformance in best The Reinertsen Group hard hospitals 10 -5 Loss of identity Equivalent actor Safety in anesthesia

Conclusion: Physicians have the opportunity to give ourselves back a lot of time. What we do with the time is up to us. If we use it wisely, we have the chance of becoming “Dr. E. Z. Reliable-Goodhands”

Question 3: What does any of this have to do with physician group practice?

With regard to quality, group practices should be 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? • 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

1. Discover Common Purpose: 6. Adopt an Engaging Style: 1. 1 Improve patient outcomes 1. 2 Reduce hassles and wasted time 1. 3 Understand the organization’s culture 1. 4 Understand the legal opportunities and barriers 6. 1 Involve physicians from the beginning 6. 2 Work with the real leaders 6. 3 Work with early adopters 6. 4 Make physician involvement visible 6. 5 Build trust within each quality initiative 6. 6 Communicate candidly, often 6. 7 Value physicians time with your time 5. Show Courage: 2. Reframe Values and Beliefs: Engaging Physicians in Quality and Safety 5. 1 Provide Backup all the way to the Board 4. Use “Engaging” Improvement Methods 2. 1 Make physicians partners, not customers 2. 2 Promote both system and individual responsibility for quality 3. Segment the Engagement Plan: 3. 1 Use the 20/80 Rule 3. 2 Identify and activate champions 3. 3 Educate and inform structural leaders 3. 4 Develop project management skills 3. 5 Identify and work with “laggards” 22 4. 1 Standardize what’s standardizable, and no more 4. 2 Generate light, not heat, with data 4. 3 Make the right thing easy to try copyright The Reinertsen Group © 2007 Institute for Healthcare Improvement 4. 4 Make the right thing easy to do

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?