Engaging Physicians as Partners
By
Jennifer Ewing RN, MS, CNS
Stroke Program Coordinator
Neuroscience Critical Care Nurse Specialist
Community 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 System
Community 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
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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
Program
• Physicians are designated as the lead
• Nurses facilitate projects
• Stroke Programs
• Stroke Coordinators
• Medical Director
• Physician champions
Administration
Nurse Leader
Physician
Quality leader
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 Center
Mayo 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 – employed
Score = 2 – affiliated with system (PPO)
Score = 3 – independent
2. Physician loyalty
Score = 1 – physicians are employed
Score = 2 – admit primarily to the hospital
Score = 3 – admit to multiple hospitals
3. Stability of medical staff structures
Score = 1 – staff culture stable for years
Score = 2 – staff merged from more than one facility
Score = 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 staff
Score = 2 – Board watches quality from administration reports
Score = 3 – Board allows medical staff to receive quality reports
What to avoid when engaging physicians
Financial focus over clinical outcomes
Ignore cultural issues
Promoting 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
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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.