{"id":3883,"date":"2016-06-16T23:23:40","date_gmt":"2016-06-16T23:23:40","guid":{"rendered":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/?page_id=3883"},"modified":"2016-06-16T23:59:27","modified_gmt":"2016-06-16T23:59:27","slug":"physician-integration-along-the-patient-safety-spectrum-from-pre-school-to-phd","status":"publish","type":"page","link":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/physician-integration-along-the-patient-safety-spectrum-from-pre-school-to-phd\/","title":{"rendered":"Physician Integration Along the Patient Safety Spectrum: From Pre-School to PhD"},"content":{"rendered":"Physician Integration Along the Patient Safety Spectrum: From Pre-School to PhD\nIntroduction\nThe hospital risk manager exclaimed, \u201cI have good news and I have bad news. The good news is we have just employed 1,000 physicians. The bad news is we have just employed 1,000 physicians! How do we begin the process of onboarding and integrating them into our culture from a risk, safety and quality perspective?\n\u201cWhere do we start? Is it basic risk blocking and tackling: the elements of a medical malpractice action, communication and handoffs? When do we get to cyber risk, EMTALA, HIPAA, Just Culture, teambuilding\u2026 quality metrics and programs for the highest risk specialties? Help!\u201d\nTSG has been asked that question at so many conferences and trade shows we decided to take a structured approach to providing an answer. We have reached out to several very well-known veteran risk, safety and quality leaders about their experience in physician integration and onboarding and asked them to \u201ctake us to school.\u201d Rather than give you the TSG version, here is the story from four very different organizations at various stages of physician integration.\nBut before we begin, let\u2019s take a peek from 20,000 feet. Why has this become an issue in the first place? The drivers for clinical integration have been well published in white papers, journals and the press. There is general agreement as to why integration is occurring, but there is a broad spectrum regarding how and to what extent it is happening.\nWithout getting lost in the weeds, there is a new reimbursement paradigm that requires a new construct, a new organizational structure. It is time to pave the way for quality and value-based reimbursement, and that requires a fundamental transition in the structure of healthcare delivery.\n\nWhy own physician practices? In the not too distant future, it will not be possible to divvy up the fee-for- service pie. The performance-based reimbursement world will require a close integration of the medical staff. Integration will be necessary from a cost and a functional perspective. \nWithin the new paradigm, there will be winners and losers. The winners will have integrated with clinicians and maintained or increased market share through practice ownership or integration. The winners will coordinate with clinicians to maintain or grow revenue under Value-Based Purchasing, HAC, HCAHPS, readmissions reductions, and the quality-based incentive or penalty de jour. \nHospital leadership working with clinicians as a single team for patient safety, for risk reduction, for reducing variability in care and medical errors, and achieving quality metrics will live to tell the tale. Hospital organizations that are not preparing for the inevitable will see market share go elsewhere: higher costs, loss of incentives, stiff penalties and loss of already thin margins.\nSo let\u2019s hear from our well-known risk and quality leadership. What did they do? How did they accomplish it? How long did it take? What are the keys to success?\nQuestion to Hospital System:\n\u201cI am curious, as health systems employ or create closer relationships with the medical staff, sometimes taking responsibility for insuring those practitioners, what educational efforts have you made to level set or what are the most significant or current pain points, problems, risks? If you could wave your wand and get them all on board with understanding certain key issues, spanning all specialties, what would you want them to know or be aware of? \n\u201cWould it be keys to successful communication (documentation essentials, handoffs\u2026), satisfaction, cyber risk, common medication errors, risk and the EHR, more general medicolegal issues? I am just naming a few to initiate the thought across. What are the biggest pain points across the continuum for you?\u201d\n\nOrganization #1\nThis is a short story! This organization is a recent 40-hospital spin off from a very much larger organization. The new organization started life within the last 6 months. We knew that not much could have been accomplished, but were wondering about plans for the future.\n\u201cSo Mr. J, I sent you an outline of the subject of today\u2019s discussion points and wondered if you had given it any thought.\u201d\n\u201cWell Dr. D., I have given it some thought. As of six months ago I took on responsibility for 400 employed physicians, and honestly I have no idea yet what the integration strategy will be. I still don\u2019t know who we insure and what docs have their own insurance. We are still addressing the basic fundamentals of starting a new organization and have a ways to go. I do see a captive insurance company in our future, and within the next 6 to 8 months we will be working out our strategy for developing the kind of culture you are asking about. As I have done with prior organizations, I hope to fund some of our risk and safety programs out of the captive, but that will take some time.\n\u201cWe will begin programming in the highest risk specialties including OB, ER and Surgery, and will look for educational opportunities in the marketplace as well as internal development. We will develop playbooks for key risk and safety and will implement them across the enterprise as I have done in other organizations.\n\u201cBut we are just at the beginning of that journey and have a long road to go.\u201d\nOrganization # 2\n\u201cDr. A, have you had an opportunity to review our questions on physician integration and onboarding. If so, perhaps you would share your vision and recount some of your successes and challenges in this changing medical marketplace.\u201d\n\u201cDr. D., yes, and we are happy to engage in the discussion. I am the Chief Medical Officer, and joining me are our VP of Risk and VP of Quality.\n\u201cWe decided upon an integration strategy approximately two years ago and have been actively employing physicians and purchasing clinic practices. We feel that is a key to maintaining market share in our communities and reducing duplication of administrative services and lowering costs. We are a Midwest organization with approximately 17 hospitals and 300 clinics in a three-state area. We now employ 900 physicians.\n\u201cWhat an organization will need in terms of physician integration depends in large part on their stage in the developmental spectrum. We have just now gotten our arms around the basic new structure, and our current focus is dealing with basic risk and quality issues across all specialties. We think of this stage of the process as \u2018onboarding,\u2019 and we are looking for liability basics. We have decided to implement a curriculum of general risk-related issues and will make that education mandatory for all employed physicians. We will probably provide a menu of 5 to 10 important risk subjects and require the physicians to choose an agreed upon number of those.\n\u201cOur current general areas of concern are as follows, in no particular order:\n\nRisk nuances related to Electronic Medical Records\nHandoffs in care \u2013 ED to Hospitalist, inpatient to nursing home, etc.\nVirtual space work \u2013 we provide 24-hour care utilizing a telehealth network\nHelping providers understand what creates risk\nDocumentation essentials\nThe decision-making process \u2013 avoiding cognitive errors\nTransition in care errors\n\n\u201cThe organization will also develop specific strategies for the highest risk service lines \u2013 specifically programs in Emergency Medicine, OB and Surgery.\n\u201cWe look forward to the process, and view this as a work in progress and expect significant evolution over the years.\u201d\nOrganization #3\n\u201cMr. S., I know from discussions we have had over the years that you began a transition process some years ago. Can you share your thoughts about the road you have been on?\u201d\n\u201cAbsolutely. We began this process approximately five years ago. The need for a new construct was apparent and we began aggressively employing physicians and buying physician practices. As a part of the new paradigm, we knew that we needed to focus on population health, and that our attention to wellness represented high-quality care, and in the long run could dramatically reduce the cost of healthcare. We also recognized that our inpatient census would inevitably decrease as our outpatient census increased, and that transition is well under way.\n\u201cIn addition, our market on the East Coast is incredibly competitive, and we felt an urgency to get out there early and bring the physician practices into our organization. Yesterday physicians were on staff at multiple hospitals. In the new paradigm, physicians will increasingly integrated into a single health system, although there will be some variation on that theme.\n\u201cFor the first two years we were just out there hiring, and now employ approximately 2,000 physicians. We needed a critical mass to achieve success. The next two years was about how to manage. From a human resources and administrative perspective, it was about contracts, retention, and getting the right team on the bus.\n\u201cWe decided that within the employment model, that there should be limited variability in contractual relationships. All practitioners are on a salary plus incentive and have a 5-year employment agreement with penalties for early termination.\n\u201cThe incentives relate to a range of risk and quality goals as well as the financial viability of the organization. That includes patient volume, RVUs, quality (although this is less well defined but will become more meaningful over time), safety, and patient satisfaction.\n\u201cWe decentralized the organizational structure and created a medical group to represent the employed physicians. Through a variety of mechanisms, the medical group is very connected with organizational leadership.\n\u201cAs we approached our fifth year, we decided that it was time to address clinical excellence, quality, reducing variability in practice, meeting the standard of care, following the evidence. For example the Ortho group standardized the approach to joint surgery across all providers, including technique, hardware, and antibiotic use based on the best evidence.\n\u201cThe medical group then assembled into clinical practice groups. So for example, Cardiovascular, Ortho, Neuro and ED are organized into practice groups, each with clinical practice leaders.\n\u201cIt may make sense early on to educate practitioners across the spectrum with enterprise-wide-type issues such as the basics of medical malpractice, insurance coverage, transitions and handoffs, EMTALA, HIPAA, and other such issues. However, in order to achieve compliance with quality metrics and more importantly reduce variability, reduce the failure to diagnose, and to standardize based upon medical evidence, it was important to create a working group for each specialty. Standardization of clinical practice and reducing variability has to come from the clinicians in close association with leadership.\n\u201cInterestingly, clinical leaders have begun asking for hard information on adverse outcomes, incidents and issues in particular specialties. They are using this information to focus on specific issues and individuals. They are truly buying into this culture.\n\u201cIn the future we will continue to work on our culture &#8211; who we are, what we represent as a system. We are working very hard to create a culture where administration and clinicians work together on the same team. There are quarterly meetings between medical and administrative leadership. We make an effort at creating transparency between all leadership groups.\u201d\nOrganization #4: Last But Not Least\nOur final discussion was with a national organization that has utilized an employment model from its inception. They have well over 10,000 employed physicians.\n\u201cMr. M., you probably have the most mature employed physician model in the country. Can you share with us your approach to integrating new practitioners and how to keep the existing clinicians on board?\u201d\nInterestingly the initial response started with the organizational safety culture (see their diagram below.) This organization has invested heavily in safety culture. They first presented the organizational construct which currently includes 5 pillars of safety.\n&nbsp;\n\n\u201cLeadership\nPatient safety is part of our culture and it starts from the top down. Safety is part of every presentation by leadership in every instance. This must be a top down priority. Leadership is at the tip of an inverted pyramid. Culture development starts with leadership and percolates into every aspect of the organization. We believe that is why they get such strong buy from front-line physicians. Safety includes work place safety, patient safety \u2013 the entire continuum.\n\u201cPatient and Family Centered Care\nAt the center of our construct is Patient and Family Centered Care, which has four key components:\n\nDignity and Respect\nInformation Sharing\nParticipation in Care to the extent desired, and\nCollaboration with a subset of patients\n\n\u201cTechnical and Cognitive Competence\nBasic medical training, continuing medical education, and ongoing evaluation of competence.\n\u201cTeamwork and Communication \nThis generally has to be learned post-professional training. We address this through some online education and simulation.\n\u201cStandard Work Reliably Implemented\nImprovement and implementation methodology. Any standardization within acceptable science is better than random variation in clinical practice because it allows us to measure deviations and outcomes and to improve. A good example is working with the best medical evidence, implementing protocols, and reducing variability in practice.\n\u201cWe teach a culture of improvement. One of the keys to our Patient Safety Program is the use of our national adverse outcomes database. We have worked diligently to facilitate and expedite the process of reporting incidents and adverse outcomes to our national database. We study the database for trends and use them to develop patient safety programs.\n\u201cGenerally we have the same pain points as other organizations. The failure to diagnose is probably our biggest pain point and \u00be of funded safety projects have a \u2018failure to diagnose\u2019 focus.\n\u201cAnother key for our organization is a robust peer review process that is reproduced at every hospital with minimal variation.\n\u201cOne of the key elements in our education is a focus on the cognitive space. That is the process by which clinical decisions are made, understanding cognitive pitfalls and human bias \u2013 heuristics. We also believe that it is important to support the decision-making thought process through decision support in the electronic medical record.\n\u201cHere is an example of a regional orientation, or onboarding or as we call it, risk 101 education for new docs. Some of this is online, some is live. All front-line staff and leadership will also attend this live every 2 to 4 years.\n\u201cThe organization has multiple regions, each with a certain degree of autonomy, but we are working at creating a consistent national approach to onboarding with oversight from the national risk management team.\n\u201cHere is an example from one of the regions, but it is similar to others.\n\nMedical malpractice overview. Duty, breach\u2026\nOn-call requirements, obligations, potential for exposure to liability and EMTALA issues\nMed mal coverage and tail.\nCurbside consults and related issues medical legal issues\nDocumentation \u2013 pearls and pitfalls. Copy and paste issues with EMRs\nInformed consent and non-delegable duty\nDisclosure and apology\nMajor FTD categories; e.g., surgical mishaps\nMedical errors\nImprovement methodology\nStandardization and variability. Drift causing deviation. Explanation for deviation\nJust Culture\n\n\u201cWe utilize outsourced education and other safety tools such as our Patient Satisfaction Program, teamwork and communication.\n\u201cEvidence-based medicine development is a joint partnership between the medical group and leadership. The development process is sponsored by and driven by the medical group. We view this as a major opportunity to standardize this nationally and close some of the variation gaps.\n\u201cThat said, the organization is currently working with the recent \u201cFree From Harm\u201d publication from the National Patient Safety Foundation (NPSF) and considering the \u2018eight pillars\u2019 or recommendations suggested in that document (which is available online through the NPSF).\u201d\n\nAlthough a complete treatment of the NPSF \u201cFree From Harm\u201d publication is beyond the scope of the article, this vision statement does provide organizations with an important developmental framework.\u00a0But fundamentally the NPSF vision tells us that \u201cfuture progress depends on a total systems approach to safety.\u201d Early in the transformation process (pre-school), it may be necessary to identify specific problems and pain points and identify mechanisms to prevent them. This approach may lead to meaningful change, but in isolation, does not lead to widespread holistic change (PhD).\nConclusion\nThis has been a fascinating and educational journey. Clearly there are stages in the transformation process, and the immediate focus will vary depending upon where on the spectrum your \norganization lies. This article describes the journey of 4 organizations that span the spectrum from a fledgling spin off to a huge mature national organization that was conceived with integration as part of its vision.\nThose organizations undergoing transformation may need to start with purchasing practices, contracting and human resources types of issues. But this early approach must be coordinated with a vision to the future that takes into account culture, teamwork, and patient focus as key fundamental considerations. The organization must commit to a systems approach, addressing systems design, human failures, human factors engineering, safety culture, error reporting and analysis.\nOnce that construct or vision is in place, the educational and other requirements for physician integration and onboarding should, in large part, define themselves. There will always be a place for circumscribed safety initiatives in response to specific problem identification. But teaching the fundamentals of a holistic culture of safety across the spectrum will lead to the fundamental transformation required in today\u2019s medical world.\n","protected":false},"excerpt":{"rendered":"<p>Physician Integration Along the Patient Safety Spectrum: From Pre-School to PhD Introduction The hospital risk manager exclaimed, \u201cI have good news and I have bad news. The good news is we have just employed 1,000 physicians. The bad news is we have just employed 1,000 physicians! How do we begin the process of onboarding and&#8230;<a class='learnmore' href='https:\/\/www.thesullivangroup.com\/RSQSolutions\/physician-integration-along-the-patient-safety-spectrum-from-pre-school-to-phd\/'>Read More<\/a><\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"om_disable_all_campaigns":false,"footnotes":""},"acf":[],"_links":{"self":[{"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/pages\/3883"}],"collection":[{"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/comments?post=3883"}],"version-history":[{"count":14,"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/pages\/3883\/revisions"}],"predecessor-version":[{"id":3907,"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/pages\/3883\/revisions\/3907"}],"wp:attachment":[{"href":"https:\/\/www.thesullivangroup.com\/RSQSolutions\/wp-json\/wp\/v2\/media?parent=3883"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}