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System achieves dramatic improvements
Key domains measured
Quality professionals will tell you that one of the greatest barriers to success is lack of physician buy-in; but that buy-in is often difficult to achieve. Imagine the challenge faced five years ago at the Rochester General Health System (RGHS) in Rochester, NY, when physician satisfaction surveys showed results as low as the 11th percentile. Today, those results are approaching the 90th percentile.
How did RGHS achieve such a dramatic turnaround? In short, it measured one key area at a time i.e., administrative response time, communication, tools and equipment, ease of practicing medicine and worked with physicians to address each one.
But this success was really part of a much bigger undertaking, says Mark Clement, president and CEO, who assumed his position five years ago. "We went to work on improving not only physician confidence in quality care delivery all over the system, but overall satisfaction with practice and the working environment," he says. "It was the result of a strategic planning process I took leadership through."
'Immersion' is first step
Clement says that after his arrival, he immersed himself in the system for 90 days, learning all he could about an enterprise that includes two hospitals, three long-term care facilities and several hundred private and employee physicians. He got out to the front lines of the different business units, spoke with affiliates, and met with physicians and other team members.
"Several themes emerged," he recalls. "Historically, the system had gone through a difficult financial turnaround, and that almost always leaves some challenges as relates to culture. I heard loud and clear from the doctors that they felt we were not as responsive as they wanted us to be; they did not have the kind of voice they wanted to have in terms of making improvement and identifying things they wanted to change. I also heard they did not find the practice environment as convenient and efficient from the hours they worked to how they processed orders and shared information."
It also became clear to Clement that "Our long-term success really turned on our ability to improve clinical care, outcomes, patient safety, and working in greater alignment and partnership with the doctors. We believed the current finance and payment system was outmoded and the fee-for-service model had to give way to rewarding providers less for volume and more for value. We wanted to provide the best care in the most appropriate setting."
Quantifying the problem
The first step in any improvement, Clement asserts, is organizational awareness around the importance and the imperative of the improvement. "A lot of what I had heard was anecdotal; I wanted to quantify physician satisfaction," he shares. What he found was that satisfaction "was not that great. Our community hospital was around the 10th percentile, and our larger tertiary facility, Rochester General, was in the 30th."
Between 60% and 70% of the doctors participated, "So the results were representative of what they were thinking and feeling," he says.
Improving physician satisfaction, he continues, "really requires the entire organization to get behind the initiative. We shared the information pretty openly and widely, and did not sugarcoat it; we basically said 'It is what it is.'"
This, he says, created some discomfort within the organization, but that was intentional. "We worked to create an open, honest, transparent culture; a lot of organizations don't do that," he says. "We used the information to create discomfort around how we performed on a number of fronts team-member satisfaction, patient satisfaction. Then, everyone considered it important to develop a patient-centered, team-based model."
Organizing improvement teams
Once Clement created larger organizational awareness and the imperative that things needed to improve, he began to organize teams. "If we had done this within a vacuum, without those elements, I think it would have been less effective," he says.
Areas requiring improvement were addressed by both system initiatives and "local" initiatives, Clement says. "We created a systemwide steering group to address physician satisfaction key physician leaders, department chiefs, two very strong executive champions senior executives from each of the two hospitals and me," he says. "We helped set priorities, and cascaded both them and improvement expectations to the local level."
So, for example, community-based physicians had expressed displeasure with how the ED communicated with them when they treated their patients; there was also general dissatisfaction with the level of quality care and timeliness in the ED.
"We sought to improve not only quality of care but wait times, the number of patients who left without being seen, overall patient satisfaction, and the way they communicated back to the primary care providers," Clement says. We held the ED leadership, the chief of emergency medicine, nursing leadership, and the administrator accountable; they were challenged to go to work on and fix those issues." Over a 12-24 month period, he reports, "We saw dramatic improvement."
Another issue was raised by the hospitalists, who handle 70%-80% of the hospital's admissions. "We heard complaints about handoffs communication at critical decision-making times during the patient stay and at discharge, as well as communication and collaboration with primary care providers," Clement says. "We pulled a PI team together to develop clarity around communication standards. For example, at the point of admission, what are the expectations of the hospitalists? When critical clinical decisions have to be made, such as whether surgery is needed, which of them require collaboration with the community-based primary care provider?"
Clement specifically asked the chiefs of services and administration leaders to assume responsibility for physician satisfaction scores. He adds that he believes in "an alignment, accountability and performance management system that cascades system goals and imperatives; all clinical and administrative leaders need their own goals." So, for example, the chief medicine at Rochester General has an annual goal related to improving physician satisfaction.
"Satisfaction has gone to well above the 80th percentile in the last three or four years, with dramatic improvement in virtually every area," Clement reports. "And physician confidence in quality of care is in the 90th percentile."
Physicians are essential
During the past several years a number of successful quality initiatives have been undertaken by RGHS, but Clement says success would not have been possible without involvement of the physicians. "It can't be done without the active participation and collaboration of physicians and physician leaders," he says. "As a result of my initial immersion, it was clear that in order to improve clinical outcomes, patient safety, and all the areas we needed to improve, we needed to engage our physicians." The system has invested a great deal in physician leadership, he adds, including Leadership Development Institutes held three or four times a year.
"We have saved lives as a result," he notes. "For example, our infection rates have dropped rapidly; we've gone 600 days without a central-line infection."
All of this fits within the overall vision Clement has brought to the system. "Over the last three years, through a strategic planning process we developed a vision that is part of what the whole organization is trying to do," says Christine D'Amico, vice president of organizational development. The plan is expressed around key "pillars," that include service, quality, people, financial performance, and growth.
"If you are a physician leader and have a position of authority, you have goals tied to the pillars," explains Richard Gangemi, MD, senior vice president for academic and medical affairs. "So, for example, it has been a system goal to decrease mortality, and physicians will have quality goals whether they are related to central-line infections, urinary-tract infections, or surgical-site infections and as they work on those goals to improve their scores they are aligned to drive adverse events and mortality rates down."
This type of data, he adds, has in turn helped raise physician satisfaction. "If you look at the goals, there is clarity as to where we want to go, how we will measure success, and how we will measure outcomes," says Gangemi. "Clarity is the pleasing part to the doctors."
This success required the participation of numerous physicians, he continues. "We have 600 managers, and most of them have quality goals," he shares. "Many of them are around issues like decreasing infections, decubitous ulcers, proper use of antibiotics, reducing MRSA or c. difficile, and so on. As those leaders reach their goals there's a cumulative effect; it all adds up and affects the mortality rate."
Board is critical
Gangemi adds that it's impossible to overstate the importance of the board's role in this success. "Most systems spend the lion's share of their time around finance and strategy and growth; our board spends the first half hour to 45 minutes of their meetings solely on quality," he says.
In fact, he continues, "The dashboards we have around quality and safety actually had a large contribution from them what they wanted to see, how visually they felt more comfortable looking at certain display methods, and what was more meaningful to them," says Gangemi. "So, while we could show them graphs, they wanted us to punctuate the mortality rate report with the number of lives saved. They wanted us to say, 'We saved 15 lives this month.' That was more meaningful to them."
[For more information, contact:
Mark Clement, President and CEO; Christine D'Amico, Vice President of Organizational Development; Richard Gangemi, MD, Senior Vice President for Academic and Medical Affairs Rochester General Health System, 1425 Portland Avenue, Rochester, NY 14621. Phone: (877) 922-5465]