RECOGNIZING AND REWARDING
MEDICAL EXCELLENCE
Kenneth W. Kizer, M.D., M.P.H.
Distinguished Professor and Director
Institute for Population Health Improvement
University of California Davis Health System
March 7, 2013
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Offer a historical perspective on the quest for
high quality health care and clinical excellence
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Attempt to describe what is known to constitute
clinical excellence
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Briefly highlight why it is especially important to
recognize and reward clinical excellence today
WHAT IS THE INSTITUTE FOR
POPULATION HEALTH IMPROVEMENT,
UC DAVIS HEALTH SYSTEM?
Institute for Population Health Improvement
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Established as an independent operating unit in the University
of California Davis Health System in mid-2011; has since
developed a diverse portfolio of funded activities >$70M
Population health – the intersection of public health and the
clinical sciences
New value-based health care payment models require that
population health management be a core competency for health
care systems
Serves as a resource for health care reform, health policy and
clinical quality improvement
Assists government health-related agencies in designing,
implementing and administering programs
Seeks to
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Improve the effectiveness and efficiency of clinical care
Build health leadership and health care management capacity
Leverage data sources to develop clinical intelligence
Promotes understanding of the multiple determinants of health
and appreciation of health being a function of the totality of
one’s circumstances
REPRESENTATIVE IPHI ACTIVITIES
 Provide technical assistance in quality improvement and other
support to the state Department of Health Care Services for
Medi-Cal (California’s $60+B/yr Medicaid program)
 Medi-Cal Quality Improvement Program
 Delivery System Reform Incentive Payments (DSRIP) Program
 Designing the CA-specific Evaluation of the California Coordinated Care
Initiative
 California’s Non-Designated Public Hospitals DSRIP-like Initiative
 Manage operations of the California Cancer Registry
 Manage the California Health Information Exchange
Development Program
 Provide technical assistance and support for multiple statewide
chronic disease prevention and surveillance programs (e,g, heart
disease, stroke, arthritis, tobacco control, cervical and breast cancer
screening, healthy eating, active living)
 Conducting a statewide assessment of surgical adverse events
 Investigating the feasibility of developing “Community
Paramedicine”
 Conducting various population health research programs
 Use of the OncotypeDx Genetic Assay in Medi-Cal Beneficiaries with Breast Cancer
THE QUEST FOR
CLINICAL EXCELLENCE
IS NOT NEW
The Quest for Clinical Excellence
“If a physician make a large incision with
the operating knife and cure it,…, he
shall receive ten shekels in money.
If a physician make a large incision with
the operating knife, and kill him,…, his
hands shall be cut off.”
Code of Hammurabi, ca 1772 BC
The Quest for Clinical Excellence
“I would give great praise
to the physician whose
mistakes are small for
perfect accuracy is
seldom to be seen”
Hippocrates, ca 430 BC
Arete - The ancient Greek
concept of excellence (also
translated as virtue) or being the
best you can be or reaching
your highest human potential.
This notion of excellence was
linked with the notion of the
fulfillment of purpose or reason
for being: the act of living up to
one's full potential.
Also taken to mean using all of
one’s faculties to achieve the
highest effectiveness.
The Quest for Clinical Excellence
“Grant me the courage
to realize my daily
mistakes so that
tomorrow I shall be
able to see and
understand in a better
light what I could not
comprehend in the dim
light of yesterday”
Maimonides (1135-1204)
The Quest for Clinical Excellence
“Students notoriously vote
with their feet, seeking out
the best and most innovative
teachers of their subject. The
most ambitious students
have been travelling long
distances for their education
since universities were first
founded in the thirteenth
century, making their own
educational pilgrimage or
peregrination.”
The Quest for Clinical Excellence
“. . . even admitting to
the full extent the great
value of the hospital
improvements in recent
years, a vast deal of the
suffering, and some at
least of the mortality, in
these establishments is
avoidable.”
Florence Nightingale,
1863
The Quest for Clinical Excellence
“To understand God’s
thoughts, we must
study statistics, for
these are the measure
of His purpose.” .
Florence Nightingale
The Quest for Clinical Excellence
In 1914, Earnest A.
Codman, MD, advanced
the concept of quality
assurance (aka quality
control) based on
identifying and weeding
out “deficient
practitioners”
The Quest for Clinical Excellence
 Avedis Donabedian, MD,
“father” of modern
healthcare quality and
medical outcomes research
 In the 1960s, advanced a
framework for viewing
healthcare quality:
 Structure
 Process
 Outcomes
Evolving Concepts of Healthcare
Quality: Learning from Manufacturing
 Industrial quality improvement in mid- and late
1900s based on the teachings of  Walter A. Shewhart – PDCA cycle, reduce variation,
statistical process control
 Philip B. Crosby – ‘zero defects’
 William E. Deming – 14 principles; popularized PDCA, “In
God we trust. All others bring data.”
 Kaoru Ishikawa – fishbone cause and effect diagrams,
quality circles
 Joseph M. Juran – ’80/20 rule’, role of culture
 Peter Drucker – decentralization, simplyfication,“You can
only manage what you measure”
 Total Quality Management (TQM)
 Continuous Quality Improvement (CQI)
U.S. Healthcare Quality Tipping Point
 IOM National Roundtable on Health Care Quality. “The
Urgent Need to Improve Health Care Quality.” JAMA
1998: 280: 1000-1005
 Quality First: Better Health Care for All Americans,
President’s Advisory Commission on Consumer
Protection and Quality in the Health Care Industry. 1998
 The Milbank Quarterly, 1998; Vol 76 : #4 – esp paper by
Schuster, McGlynn and Brook, “How Good is the Quality
of Health Care in the United States” pp 517-63
 Ensuring Quality Cancer Care. IOM. 1999
 To Err is Human: Building a Safer Health System. IOM.
2000
 Crossing the Quality Chasm: A New Health System for
the 21st Century. IOM. 2001
The Quest for Clinical Excellence
“Medicine used to be
simple, ineffective and
relatively safe. Now it
is complex, effective
and potentially
dangerous”
Sir Cyril Chantler, Lancet 1999
THE SEARCH FOR CLINICAL
EXCELLENCE HAS BEEN GOING ON
FOR AT LEAST 4,000 YEARS….BUT
THE SCIENCE AND TECHNOLOGY
OF CLINICAL QUALITY
IMPROVEMENT HAS ONLY BEGUN
TO MATURE VERY RECENTLY.
What Do We Know About Achieving
Individual Clinical Excellence?
 Not as much as we should
 While we tend to recognize it when we see it,
the science of clinical excellence is poorly
developed and primarily qualitative
 There is no single defining characteristic of
clinical excellence; it is multi-factorial
ACHIEVING CLINICAL EXCELLENCE
REQUIRES CERTAIN CORE
ATTRIBUTES AND DOING MANY
THINGS EXCEPTIONALLY WELL
What is Clinical Excellence?
THE 10 DEFINING
CHARACTERISTICS OF INDIVIDUAL
CLINICAL EXCELLENCE
Defining Characteristics of Medical Excellence #1
BROAD AND DEEP KNOWLEDGE
 Outstanding knowledge of the subject and
matters in general are foundational
 Demonstrates a high degree of curiosity and a
large appetite for learning
Defining Characteristics of Medical Excellence #2
DIAGNOSTIC AND TECHNICAL ACUMEN
 Thorough, careful, deliberative
 Analytic
 Keen ability to distinguish what is important from
the background noise and to piece disparate parts
into a coherent whole
 Outstanding judgment and intuition in the face of
uncertainty
 Demonstrates wisdom
Defining Characteristics of Medical Excellence #3
INTERPERSONAL SKILLS
 Outstanding communicator, good listener
 Adept at “tailoring” the presentation of complex
concepts and data to create understanding
 Ability to quickly “connect” and forge a meaningful
relationship with patients and colleagues
 Inspires confidence and trust
 Responsive to and considerate of others
 Good teammate
 Flexible, adaptable
 Has a calming effect, relieves stress and anxiety in
patients
 Able to help patients regain control
Defining Characteristics of Medical Excellence #4
PROFESSIONALISM
 Patient’s interests take precedence over selfinterest
 Commitment to vulnerable or “less fortunate”
populations
 Civic engagement and service for the “common
good”
 Ability to balance one’s multiple commitments
(including patients, peers, organizational, society)
Defining Characteristics of Medical Excellence #5
HUMANISM
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Compassionate, genuinely caring, altruistic
Thoughtful, reflective
Nonjudgmental, understanding, forgiving
Honest, trustworthy, high integrity
Available and accessible to patients and
colleagues, giving of his/her time
 Dedicated, committed
 Treats every patient equally
 Advocates for his/her patient
Defining Characteristics of Medical Excellence #6
WISE USE OF RESOURCES
 Practices evidence-based medicine
 Orders diagnostic tests judiciously and for clear
and appropriate reasons
 “Knows how to get things done”
Defining Characteristics of Medical Excellence #7
SCHOLARLY APPROACH TO PRACTICE
 Thoughtful application of scientific knowledge and
evidence to “real world” human circumstances and
situations
 Logical, reasoned clinical decision making
 Reflective, deliberative
 Seeks to disseminate clinical knowledge and new
findings
Defining Characteristics of Medical Excellence #8
PASSION FOR CLINICAL MEDICINE
 Enjoys doing it
 Dedication and commitment
 Infectious enthusiasm that is charismatic
Defining Characteristics of Medical Excellence #9
DESIRE FOR IMPROVEMENT
 Not satisfied with the status quo
 Forward looking
 Continually trying to improve both personal skills
and systems of care delivery
 Willingness to lead change
Defining Characteristics of Medical Excellence #10
REPUTATION
 Respected and renowned by colleagues for past
and continued accomplishments
 Sought out for especially complex problems or to
treat VIPs
 Sought out by peers
AMERICAN HEALTH CARE IS IN A TIME OF
PROFOUND CHANGE…. AND WITH GREAT
CHANGE COMES GREAT UNCERTAINTY
ABOUT WHAT IS IMPORTANT
HEALTH CARE IN TRANSITION
Affordable Care Act and
Other Health Care Reform
New Science
and
Technology
New
Payment
Models
Increased
Demand for
Services
Deteriorating
Population
Health
Culture Change; Changing
Clinician-Patient Relationships
Stein’s Law
“Things that can’t
go on forever,
don’t.”
Herbert Stein
Chairman, Council of Economic Advisors
for Presidents Nixon and Ford
WE MUST ESPECIALLY
RECOGNIZE AND
REWARD CLINICAL
EXCELLENCE IN
THESE TIMES OF
CHANGE AND ITS
MANY POTENTIALLY
CONFUSING SIGNALS
Recognizing and Rewarding Clinical
Excellence is Essential to the Future of
Academic Medicine
 Retention and recruitment of faculty
 Teaching and providing role models for
trainees
 Ensuring a future health care culture that
values clinical excellence
QUESTIONS