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Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three Principles to Solve the Problem

When it comes to successful quality improvement (QI) in healthcare, clinicians tend to be the missing link. Fortunately, the disconnect between QI initiatives and the day-to-day work of clinicians can be explained and resolved if health systems adopt and embrace three clinician-focused principles:

Principle #1: QI starts at the front line (initiatives should be identified and driven by clinicians).
Principle #2: QI makes it easy for clinicians to do the right thing (removes barriers to good work rather than increasing the amount of work clinicians do).
Principle #3: QI empowers clinicians to adapt care (even if it’s not QI protocol).

Although some clinicians are enthusiastic advocates of their systems’ QI efforts, most are suspicious because they’re frequently cut out of the decision-making process or forced to ignore their best clinical judgement. Health systems that work to close the gap between leaders and clinicians by embracing these three principles will add the missing link—clinicians—back into successful healthcare QI.

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Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three Principles to Solve the Problem

  1. 1. Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three Principles to Solve the Problem
  2. 2. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Solving Healthcare Quality Improvement Everyone in healthcare understands the importance of healthcare quality improve- ment (QI), which is defined by the Health Resources and Services Administration (HRSA) as “systematic and continuous actions that lead to measurable improve- ment in healthcare services and the health status of targeted patient groups.” QI is essential in healthcare because it can enhance the efficiency of processes, reduce costs, and increase the reliability and predictability of systems of care—all of which lead to improved patient outcomes.
  3. 3. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Solving Healthcare Quality Improvement Given the industry’s consensus about the importance of QI in healthcare, why is there a major disconnect between QI initiatives and the day-to-day work of clinicians? This presentation takes a close look at the important role clinicians play in health systems’ QI programs—and examines why they tend to be the missing link. It also shares three vital principles healthcare organizations should live by to make the most of their QI projects.
  4. 4. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Quality improvement done right makes it easy for clinicians to deliver high quality care to their patients. Effective QI does more than acknowledge clinicians’ expertise—it depends on it. And, rather than punish clinicians for not strictly adhering to QI-driven protocol, the most successful QI initiatives balance standardization with customization. Unfortunately, many healthcare organizations’ QI efforts are hindered by their unwillingness to harness the power of the frontline.
  5. 5. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline What the Frontline Really Thinks About Quality Improvement Work The Accreditation Council for Graduate Medical Education (ACGME) has designated six core competencies all residents from all specialties are expected to develop over their residency. In addition to Patient Care and Medical Knowledge, topics like Practice-Based Learning and Improve- ment, and Systems-Based Practice are included. Many healthcare systems require employed physicians and mid-levels to complete a QI project yearly. There’s no doubt clinicians care about quality improvement and want to improve processes.
  6. 6. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline What the Frontline Really Thinks About Quality Improvement Work Healthcare leaders asking the frontline to do their part to improve operating time efficiency can lose sight of the fact that a clinician’s primary concern is, for example, ensuring proper surgical margins for the removed tumor—not improving the system’s bottom line. Therefore, clinician perceptions vary regarding their systems’ QI efforts. From actively opposing QI on one end to enthusiastically embracing it on the other, most clinicians fall somewhere in the middle.
  7. 7. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline What the Frontline Really Thinks About Quality Improvement Work Turning this overwhelming majority of hesitant clinicians into QI champions requires a massive cultural shift—a shift that sees the frontline as the beginning of QI work, not the end. It’s a shift that sees improvement work as a way to reduce the burden on clinicians, not add to their workload. A shift that values both the scientific and artistic nature of medicine by balancing standardization with necessary and appropriate customization.
  8. 8. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Add the Missing Link Back into Quality Improvement: Three Clinician-Focused Principles Health system leaders responsible for implementing successful QI initiatives face the challenge of reengaging their frontline. The system wide culture changes required to do this may seem insurmountable, but there are three clinician-focused principles that will help healthcare leaders get on the right path.
  9. 9. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Add the Missing Link Back into Quality Improvement: Three Clinician-Focused Principles Effective QI acknowledges the important role clinicians play in improving and sustaining processes, understands that clinicians are dedicated to their patients. That makes it easy for clinicians to prioritize their clinical work and do what they do best: DELIVER CARE
  10. 10. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #1: Quality Improvement Starts at the Frontline The frontline (nurses, physicians, etc.) knows better than anyone what’s going on in their hospitals. Among the most educated in any industry, the healthcare frontline takes pride in their work. QI initiatives tend to feel like top-down administrative mandates, but they should start with the frontline.
  11. 11. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #1: Quality Improvement Starts at the Frontline Leaders can start to move clinicians from the oppositional end of the spectrum of QI perception to the enthusiastic end. This is done by more than just inviting them to be a part of the QI team—but by giving them owner- ship of the QI work. By seeking their input and asking where they have seen barriers, what problems they would like to address, and what their solutions are, they are given more ownership of the QI work.
  12. 12. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #1: Quality Improvement Starts at the Frontline Healthcare leaders need to abandon the Tayloristic view of process improvement mentality that believes management knows best and should tell frontline workers what to do and how to do it. Dr. William Edwards Deming flipped this archaic approach on its head by proposing that frontline workers actually drive improvements because, unlike leaders and administrators, they are the process experts.
  13. 13. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #1: Quality Improvement Starts at the Frontline The core message of the first principle is that QI initiatives should be identified and driven by the frontline. A health system’s vitality depends on the frontline—recognizing their importance and expertise due to being on the front line, and conducting projects that address their barriers and priorities to help maintain a happy, engaged group.
  14. 14. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #2: Quality Improvement Makes It Easy for Clinicians to do the Right Thing The most successful QI projects do more than improve outcomes—they make it easy for clinicians to provide good care to their patients. Leaders need to tell clinicians: Here’s how this project will not only improve outcomes for your patients, but also make your job easier.” QI initiatives that reduce the burden on clinicians are more likely to be adopted and sustained.
  15. 15. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #2: Quality Improvement Makes It Easy for Clinicians to do the Right Thing The goal with this QI principle isn’t to oversimplify QI implementation, it’s to make it easier for clinicians to treat patients. It’s to maximize clinicians’ time with patients so they can deliver high quality care. The last thing health systems want to do is add another filter or check box that makes it harder for clinicians to do their jobs.
  16. 16. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #2: Quality Improvement Makes It Easy for Clinicians to do the Right Thing According to one study, it would take a physician 7.4 hours per workday to just fulfill preventative screening requirements let alone address the problems or respond to patient’s questions. It is an unreasonable, if not impossible, protocol that doesn’t take the demands of a clinician’s work demands into account.
  17. 17. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #2: Quality Improvement Makes It Easy for Clinicians to do the Right Thing The core message of the second principle is that QI initiatives should remove barriers to good work rather than increasing the amount of work clinicians must do. For example, one health system’s QI project involved providing physicians with a nurse and a scribe. The nurse roomed patients while the scribe followed the physician typing the conversation.
  18. 18. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #2: Quality Improvement Makes It Easy for Clinicians to do the Right Thing Eliminating the burden of typing not only made physicians’ jobs easier, but also maximized facetime with patients, improved the quality of the note in the EMR, and allowed the physician to see more patients. Instead of saying, “Here’s what we decided to do, now do it” the system said, “We’re adding staff to your team to make it easier for you to do your job and interact with your patients.”
  19. 19. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol) The most effective healthcare QI culture protects a clinician’s autonomy and craftsmanship, and understands how medicine is an art. After all, biological systems are more variable than mechanical ones. No single improvement process can treat everything and no one approach is right for every patient. Clinicians worry about patients who are exceptions to the QI rule. Leaders need to review outcomes and ask the frontline if protocols need to be revised.
  20. 20. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Non-sepsis patients exposed to potentially bad care and outcomes. Team members could be punished for not following sepsis protocol. Clinicians were not allowed to opt out based on their clinical judgement. • Draw lactate • Get blood cultures • Start antibiotics • Administer fluids Successful Healthcare Quality Improvement Focuses on the Frontline Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol) Not empowering clinicians to exercise clinical judgement and adapt care is extremely dangerous, with severe potential impacts on patient outcomes. Consider this real-world example: In one hospital, a best practice alert would fire to indicate a patient might have sepsis triggering the sepsis improvement protocol. System Problem
  21. 21. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol) In medicine, it’s common sense that no single patient can be treated entirely by protocols, and no single protocol can treat all patients. Systems need clinicians’ expertise as much as they need standardization. The sepsis exampled showed a feedback loop must be in place to allow physicians treatment options for the good of the patient. Set-in-stone protocols ignore clinical judge- ment, eliminate clinician autonomy, and may result in significant harm to patients.
  22. 22. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Successful Healthcare Quality Improvement Focuses on the Frontline Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol) The core message of the third principle is that healthcare organizations need to empower clinicians to adapt care according to their clinical expertise, even if it’s outside the QI protocol. Using a feedback loop to evaluate decisions, systems can continue to enhance protocols and clinical knowledge.
  23. 23. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Three Principles in Action: The Ideal Healthcare Quality Improvement Experience One of my experiences as a surgery intern demonstrates these three QI principles in action. My rotation took me through a different surgical service every four weeks. Each service had their own processes, including how patients were discharged. Every time I switched services I had to relearn a new discharge process. What should have been streamlined, consistent, and straightforward, was complicated and made it harder for me to do my job.
  24. 24. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Three Principles in Action: The Ideal Healthcare Quality Improvement Experience Two interns proposed standardizing discharge summaries to the department. They developed a template that standardized what needed to be standardized but allowed individual services to adapt the summary based on their unique needs with an easy-to-use electronic check box. The result was a smoother, more effective discharge for patients. It showed how the three clinician-focused QI principles could work together effectively.
  25. 25. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Three Principles in Action: The Ideal Healthcare Quality Improvement Experience The major takeaway from the surgical discharge summary improvement QI is: The improvement idea came from the frontline. The improvement idea made it simple and easy for the frontline to do the right thing. The improvement idea encouraged clinicians to adapt the protocol. > > >
  26. 26. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Unifying Leaders and Clinicians to Improve Healthcare Quality Healthcare administrators and clinicians are in different (often oppositional) tribes—one focused on patient outcomes and one focused on bottom- line financials. Healthcare leaders on both sides should be striving to bridge the gap and unify. With contrasting cultures and goals within these two tribes, leaders can start developing a common language by incorporating the three clinician- focused principles into their QI work. Engage the frontline Ease the burden of providing care Empower clinicians to adapt patient care > > >
  27. 27. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Unifying Leaders and Clinicians to Improve Healthcare Quality At the heart of each of these principles is communication— communication about cost, time commitment, and outcomes. Remember, the frontline’s firmly rooted commitment to patients by outlining how, specifically, the QI project will improve the quality of care patients receive.
  28. 28. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Unifying Leaders and Clinicians to Improve Healthcare Quality Healthcare quality improvement culture changes are hard to make when health systems are stuck in the inertia of having done QI projects the same way for so long. But changing the direction of the QI ship can happen by believing in the value of the frontline, the importance of making it easy for people to do the right thing, and the art-science balancing act that is healthcare.
  29. 29. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. For more information: “This book is a fantastic piece of work” – Robert Lindeman MD, FAAP, Chief Physician Quality Officer
  30. 30. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. More about this topic Link to original article for a more in-depth discussion. Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three Principles to Solve the Problem Five Deming Principles That Help Healthcare Process Improvement Dr. John Haughom, Senior Advisor 6 Steps for Implementing Successful Performance Improvement Initiatives in Healthcare Bobbi Brown, VP of Financial Engagement; Leslie Falk, Customer Engagement, VP Healthcare Performance Improvement Readiness Assessment: The Key to Achieving the IHI Triple Aim Ann Tinker, Engagement Executive, VP; Susan Easton, Engagement Executive, VP 6 Proven Strategies for Engaging Physicians—and 4 Ways to Fail Dr. Bryan Oshiro, Chief Medical Officer, Senior VP
  31. 31. © 2016 Health Catalyst Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. Dr. Daniel Barlow joined Health Catalyst in October of 2016. Prior to Health Catalyst, he was a resident in General Surgery at Dartmouth. Dan has an MD from the Geisel School of Medicine at Dartmouth and an MS in clinical research from The Dartmouth Institute of Health Policy and Clinical Research. Other Clinical Quality Improvement Resources Click to read additional information at www.healthcatalyst.com

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