ORLANDO, Fla.—It’s still in its early stages, but a program at Keck Medicine of the University of Southern California to engage physicians in quality improvement efforts has already shown signs of success.
The organization has seen a 7% reduction in length of stay across the hospital since the initiative began a year ago. And while it may be only a single-digit number, that improvement means the hospital can take in 25 more patients, Carol Peden, M.D., executive director, Center for Health System Innovation, University of Southern California, told attendees at the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Health Care.
Keck Medicine of USC is the University of Southern California’s medical enterprise, one of only two university-based medical systems in the Los Angeles area. The enterprise was formed in 2009 and includes three hospitals and 60 clinics. It also has tripled in size in the last six years, earned $1.6 billion in net revenue this year and has seen 30% growth in the last two fiscal years.
But there are growing pains when you try to drive improvement and grow at such a fast pace, said Felipe Osorno, executive administrator, value improvement office at Keck Medicine USC. “It’s like trying to change the tires in a car while doing 70 miles an hour,” he said.
Success, hospital leaders believed, was getting physicians engaged in the process as they are the main drivers of decision-making, they have the expertise and most importantly, they have a passion for making things better. And that meant designing a program where physicians were respected for their competency and skills, their opinions were valued, they had good relationships with their medical colleagues, they had a broader sense of meaning in their work and they had a voice in clinical operations and processes.
Program combined lean thinking, collaborative learning
Osorno worked with Peden and Kaveh Houshmand Azad, director of Keck’s operating system, on the engagement initiative merging their experience with lean management and the IHI’s model for improvement and collaborative learning. Their goal was to create an environment where physicians that come to work at Keck have two jobs. “One is to do their jobs and the second is to improve their jobs,” he said.
To create a culture of improvement within the organization, the team worked with IT colleagues to create a data warehouse for all information to make data available and transparent. They also needed to build a physician training program that went beyond the classroom to teach doctors a new way to think and approach problem-solving for systemwide initiatives and specialty-level improvement efforts.
But they didn’t want to just education physicians, they wanted them to have fun to try to get back some of the joy in work, said Peden. To help foster that environment, they created a forum where the 700 physicians on staff could meet with one another and developed cohorts so they could collaborate with their colleagues.
Azad said the Keck School of Medicine of USC provided resources and gave time for doctors to participate in the project. The program was structured to include four days of training over the course of 10 days where physicians learned about building a case for quality and lean-thinking specific tools to help them identify a problem statement and then have the tools to support that statement. They worked on practicing change management on the third and fourth days.
The training included simulations and physicians worked together on different methods like fishbone diagrams, root cause analysis and value-stream mapping to improve processes and gain confidence that the tools work and were applicable to real-life and clinical scenarios, he said. They also provided training and coaching over 10 months to help them remeasure results, make adjustments and share the approach with others.
Reframing discussions to motivate physicians
Osorno said he also learned that while hospital administrators may be motivated to reduce costs, physicians aren’t engaged by projects that focus on costs and waste. It turns them off, he said. When the discussion is reframed so the project focused on providing exceptional care to patients and working on inefficiencies within the system that annoyed physicians, the conversation changed. “We spent a lot of time aligning a burning platform and getting feedback before we even started. That time was valuable because we were all starting at the same point,” he said.
They identified the biggest opportunities for reducing length of stay in the hospital and then who were the right physicians to engage from the start. “You need to start with the early adopters,” Osorno said. “You can’t start with folks who will fight you tooth and nail. You want to start with early successes and then evolve from there.”
So they chose the chairs of departments who raised their hands first. These were doctors who were influential and also open to trying new ideas. And then, Orsorno said, they looked at patient charts to get a true sense of their patient populations and how care was delivered. For many physicians, it was the first time they really looked at length of stay and how the hospital compared to national benchmarks.
The team credits much of the success of the program to the fact that physicians had transparent data to rely upon. As part of the project, the team created patient trackers so physicians could see how patients were doing in real time. Whenever clinicians opened a patient chart, they could see how long the patient was in the hospital and how it compared to length of stay for patients in a similar diagnosis group around the country.
As the initiative enters its second year, Peden said that the team is making slight changes. As an incentive, they will link compensation to attendance so physicians won’t get paid for their participation until the end of the year when they complete the program. Instead of having physicians pick their own projects, the team will also focus on projects that more align with the organization’s goals.