What's in it for me? Gaining physician buy-in to improvement

John Toussaint

Deep within every doctor, a scientist lurks, says Dr. John Toussaint, Managing Director of healthcare organization Thedacare, and tapping into that inner scientist is one of the keys to getting physicians actively engaged in improvement. In this article, Dr. Toussaint looks at what it takes to get physicians on board.

The healthcare system needs to change. The rate of cost increases are unsustainable and are threatening the financial viability of every nation in the world. But we can’t get the system to change unless we can get the doctors to change. Having been on a ten year journey to radically improve care and reduce cost there are a few simple lessons that I’ve learned about working with physicians:

Words Matter We have found that anything related to Toyota and especially any Japanese words related to the Toyota production system are major turn offs for doctors. It’s not completely clear why doctors are so skeptical of methods that have come from manufacturing. Our current hypothesis is that they may be threatened by anything that is perceived to erode their autonomy but it may also be that they look at this as just another failed management attempt to bring change.

"What’s in it for me??" Doctors will support activities that can actually make their lives easier. It’s important that improvement events take waste out and not just move the waste to the doctor’s corner. Eliminating the registration questions that patients answer in the hospital only to shift that work to the doctor’s office is simply throwing the waste over the wall to the doctor. This will give the lean implementation process a bad name and doctors will rightfully push back and become cynical.

On the other hand if on time surgical starts occur only 20% of the time and the doctors are clamoring because this reduces their efficiency then the lean tools should be applied to fix the problem. This begins to build trust within the doctor community that lean improvement tools actually work. The focus therefore, should be on fixing the doctors’ problems.

Data Drives the Scientist. Deep within every doctor, a scientist lurks. Trained in data collection and usage, taught to rely on the scientific method, doctors are most comfortable with arguments that include numbers. Unfortunately, the fear of malpractice and damaged reputations has resulted in a reluctance to make public doctors’ and hospitals’ scores on critical quality markers. That fear must be conquered. A lean healthcare initiative always begins with data collection and dissemination. What data is collected, and how it is presented, will change over time as an organization’s needs and focus changes, but getting and broadcasting the facts is always necessary because data can cause people to change behavior.

For instance, shortly after a weeklong improvement event or kaizen in Labor & Delivery – when a young mother helped redesign the birthing process – a group was taking a closer look at the neonatal value stream and noticed that a surprising percentage of babies were delivered earlier than the normal gestation time of 39 or 40 weeks. Pre-term birth is defined as occurring at or before 37 weeks and 12.7 percent of U.S. babies are born pre- term, exposing them to medical complications and developmental delays. However, a number of recent studies have shown that babies born even a bit too early -- at 37 or 38 weeks -- have a greater chance of chronic respiratory disease and learning disorders than children born at 39 weeks or later. At ThedaCare, 35 percent of babies were born during this "early term" period.

An improvement team dug deeper into the data, made additional inquiries and found many of these babies were delivered on purpose – by inducing labor at a prearranged date agreed upon by mother and doctor. It may have been convenient for physicians and families, but it put those babies at a higher risk of complications at birth and often resulted in weeks spent in the neonatal ICU. (ThedaCare tracks babies’ time spent in the neonatal ICU as one measure of the relative health of premature babies.) The team worked with staff and doctors to create new protocols, including setting a 39-week lower limit for inducing labor.

Adherence to the new protocols was spotty at first. Then, physician performance data was posted on the walls in the obstetrics departments, with every physician's name over his or her track record. There was 100 percent compliance on the new protocols within a month. As a result, premature babies requiring intensive care now spend an average of 16 days in the ICU instead of the previous 30.

Doctors are competitive by nature. It is a necessary attribute to getting through medical school and then earning desirable residencies and fellowships. Making data public – if the data is honest and relevant – taps into every doctor’s competitive nature. Presenting unblinded physician performance like management did in labor and delivery caused some grumbling, but it also ignited a drive to be the best.

Summary Our experience shows if we use the appropriate language to build an improvement system, understand what the doctor’s real problems are and fix them, and if we bring actionable and accurate data to the table in an un-blinded format, significant and sustainable change in patient care is possible.

Author’s note: For a more in depth discussion of each point mentioned above, see our recently published book On the Mend.