Hard data drive physician buy-in for pathway development efforts
Hard data drive physician buy-in for pathway development efforts
Mere involvement isn’t enough, experts say
Physician support: Your pathway projects and other quality improvement initiatives won’t work without it. Yet at many hospitals, it remains the single toughest problem case managers face. Indeed, every year since 1991, when Hospital Case Management conducted its first reader survey, you’ve listed achieving physician buy-in among the top five challenges you deal with in your job.
Although there aren’t any easy solutions guaranteed to work at every institution, experts suggest there are things you can do to win over even the most die-hard physician holdouts. The first and most obvious step is to involve them in the quality improvement process from the very beginning, says Robert Murray, MD, director of clinical resource management at Children’s Hospital in Columbus, OH.
Case managers at Children’s learned that lesson the hard way, when physicians effectively killed the hospital’s first clinical pathway project a few years ago. "The reason it failed was that it was a nursing endeavor," he says. "Because [administrators] assigned it to the nurses, physicians did not accept it."
The second time around, the hospital took a different approach. First, it brought Murray on board a physician with a special interest in preventive medicine who recognized that cost containment isn’t necessarily at odds with high-quality patient care. Murray immediately enlisted the help of the hospital’s chief of medicine and the chief executive officer, who accompanied him on visits to every section in the hospital. "We explained why we were doing this and how important it was," Murray says. "That set the tone. We said, This is an important thing. We’re going to use the data we collect to make some positive changes. Here’s the strategic plan of the hospital, and this is how pathways fit into it.’"
Murray followed up by conducting a second round of visits, accompanied by a case manager in that section, the section’s physician champion, and the hospital’s head of data collection. "We’d spend a lot of time with people going over the data and coming to some consensus as to who should be on the committee writing the pathway, what the timetable was, and what the goals should be," Murray says.
Afterward, Murray and his team continued to meet with physicians regularly to hone the pathways and keep the physicians apprised of resulting data. "After a pathway’s done, we go back to them every quarter and see if it needs to be revised, what kind of information is coming out, and how well everything’s going."
Murray stresses the need for enlisting physician champions for individual pathways as a basic component of pathway success. For the hospital’s pneumonia pathway, for example, Murray recruited the chief of infectious diseases, a "greatly loved and widely respected physician. He took charge of that pathway, gave a presentation at grand rounds, and spoke to the residents and staff about what the thinking was of the group that formed the pathway," Murray says. "When someone like that stands up and says this is the way to do it and this is the way it’s going to be, it’s much better accepted than if an administrator or an administrative physician says it."
Donna Court, RN, MN, an interdisciplinary pathway nurse at Shepherd Center in Atlanta, has taken a similar approach. The author of two academic articles on the subject of enlisting physician champions, Court recommends first approaching physician leaders such as the chief of staff. An alternative is to first win over the harshest critic.
"Sometimes it’s best to get the worst believer and somehow switch them around on a particular project," she says. "But definitely you have to have some physician sponsorship. Physician involvement is key."
Ease burdens on physicians’ time
So you’ve consulted the physicians, secured key champions, and actively involved them in development of the pathway. Now everything’s rosy right? Sorry: According to the experts, you’ve won less than half the battle. Early physician involvement gives your pathways the opportunity to succeed, but ultimate success depends on what you do next.
The keys to maintaining physician goodwill, Court says, are providing physicians with hard data on not only costs but also on patient outcomes, while minimizing unnecessary burdens on their time. "You have to be very respectful of their time and do whatever work you can outside of the group," she says. "The physicians will want to approve and look at what you do, but they don’t necessarily need to be involved in the ground-level chart review. If something shows up and you want to ask a question, try to either tie it into times when they’re [at the hospital] making rounds anyway, or they’re here for other meetings."
It can be a careful balancing act, letting the physicians feel a part of the process while at the same time not cutting too deeply into their billable hours. "You can’t bludgeon them over the head and say, Well, you need to be here at this meeting at two o’clock,’" Court says. "That’s the middle of their work day. When we did our meetings, if we needed them to come to a work group or get their stamp of approval, we tried to do it in conjunction with other things that they’re already doing."
At Shepherd, Court has spent time streamlining the time it takes work groups to complete their business. For the center’s spinal cord pathway, Court and her colleagues have managed to cut team conference time in half. "It happened almost overnight when we implemented the pathway," she says. "Teams that were spending an hour and a half are now spending only 45 minutes. Teams that were spending an hour are down to 30 minutes." She’s also made strides in either reducing paperwork or shifting the responsibility for filling out certain forms from physicians to other clinicians or staff members. "Being respectful of their time really helps with buy-in in, because the physicians are able to see that we’re making an effort to accommodate them," she says.
Proper presentation of data is key
Another crucial component of securing physician buy-in is collecting relevant data on quality and patient outcomes, and then presenting that data to physicians in a clear, concise, valid, and reliable way, says Judy Homa-Lowry, RN, MS, CPHQ, a health care quality consultant based in Canton, MI, and the consulting editor of Hospital Case Management. "Because of how they’re trained and the way they look at things, they’re very interested in data being presented in that way," she says. "They want to know that there’s a mechanism in place for auditing of data to make sure it’s valid and reliable. To me, that’s a lot of the buy-in the physicians having confidence in what is being measured and what is being done."
That’s been particularly important at the University of Texas M.D. Anderson Cancer Center in Houston, an academic center where most physicians also conduct clinical research. "Getting the data was real important, because it’s part of our culture here," says Mitchell Morris, MD, vice president of information services and health care systems at Anderson. "Without providing the data, our pathway effort would not have gone as far as it did."
For Anderson’s 70 critical pathways, Morris and his team collect information on not only length of stay and costs, but also unexpected returns to the operating room, transfers to the surgical intensive care unit, and incidence of particular complications. "In every situation, as we’ve had an impact on length of stay, there has been no measurable impact on quality. And that’s reassured people."
Court agrees that physicians tend to be swayed by hard data rather than by anecdotal information. She says that by providing consistent, quantitative feedback to physicians, case managers at Shepherd have created an opportunity to point out where the center stands in terms of national and internal benchmarks. "And we’re saying to them, Can you help us with this? What do you think is going on?’ And they’re interested," Court says. "It’s a very exciting thing, because they want more. It’s like they’re almost starved for information."
Homa-Lowry cautions, however, that effective presentation is just as important as having good information. "If you get a slide up there and it’s not clear, or your audience really doesn’t understand the point you’re trying to make, it’s really going to shut them down and turn them off as to what they need to be doing," she says.
Court adds that you must also make sure the appropriate people are present when data are discussed. "Don’t just hand it to them," she advises. "There should be some open discussion, some interaction between all the clinicians, i.e., nursing, therapy, and others. That way, if any real change must be made, you’ve got the appropriate group there to start making those recommendations."
Another important element of presenting data is making sure physicians understand why you’re collecting it, Murray says. "They need to feel that the information that is being brought to them is not accusatory, but is something that alerts them to a problem," he says. That can be a difficult sell, given that many physicians already feel the scrutiny of managed care organizations who often use cost and length of stay data to justify excluding physicians from panels.
"The second thing is that you must give them a real clear understanding of what you’re going to do with the information," Murray says. At Children’s Hospital, changes made to the appendicitis pathway cut length of stay by one day and costs per case by $1,000. "We used that [data] to approach insurance companies to show them how the physicians were working to tackle these problems. That set up a rapport with the insurance companies, and hopefully allows us and the physicians to gain more business."
Gain docs’ trust by proving good outcomes
It also helped increase physicians’ trust in the pathway initiative, because Murray and his colleagues were able to demonstrate that quality improvement didn’t come at the expense of patient care. "We looked for things like bounce-back, infections, and kids who had to be readmitted to the emergency department because they were sent home too soon," Murray says. "And we found, at least in the initial go-round, that there wasn’t any change in those outcomes. As a result, the surgeons became a little more bold at actually revising the pathway further and shortening it down. They were doing it on their own without the pathway even telling them to."
For more information about physician buy-in, contact the following:
Donna Court, RN, MN, interdisciplinary pathway nurse at Shepherd Center, 2020 Peachtree Road NW, Atlanta, GA 30309. Telephone: (404) 350-7799.
Judy Homa-Lowry, RN, MS, CPHQ, health care quality consultant, 7245 Provincial Ct., Suite 100, Canton, MI 48187. Telephone: (313) 459-9333.
Mitchell Morris, MD, vice president, information services and health care systems, University of Texas M.D. Anderson Cancer Center, 1515 Holcomb Blvd., Houston, TX 77030. Telephone: (713) 792-2121.
Robert Murray, MD, director of clinical resource management, Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205-2696. Telephone: (614) 722-3485.
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