Issue link: https://beckershealthcare.uberflip.com/i/501108
52 manner and whose office best accommodates their location, which is one of the main reasons we've been expanding access to Stanford Children's Health across Northern California and the U.S. western region. The three A's of a successful medical practice are affability, avail- ability and ability, and it's in that order. The ability piece, which would be most closely linked to quality, is nearly impossible to measure. JL: Hypothetically, you probably could tell the difference. If you observe a clinician working in an environment where care is team- based, and other members of the team are performing roles like care coordination, leading patient navigation and working with specialists such as clinical pharmacists to achieve the highest level of outcomes possible, you would be seeing high quality care. The physician would be more engaged in patient-centered ac- tivities and would be more patient-focused, rather than struggling with administrative burdens or electronic devices. Evidence- based goals and guidelines should be used when appropriate, and those protocols can be adjusted based on independent pa- tient factors. Variation would be allowed where variation makes sense for the patient. Social and economic factors would be con- sidered in the treatment plans. SM: High-quality care today is more clinically led than it has been in the past. Successful high-quality care is now delivered in a team-based environment. Rather than just the physician, the whole care team is responsible for managing the needs of the whole patient, which may even include managing a patient's psychosocial and economic needs associated with their care. Patients experience high-quality care through a combination of factors in this team-based model. However, if we do want to put a lens on physicians, and compare two physicians in a room op- erating on a patient, high-quality care looks extremely similar, if not exactly alike throughout the entire process from preoperative care to discharge. In our procedural volume, we have a standard process that allows team-based care to work and allows those standard practices to be delivered consistently to our population. SW: High-quality health care is safe and efficient. The interaction between clinical care team members and patients should be one of a stable partnership rather than a hurried visit. High-quality care is reflected in environments that include patients in the decision- making process while forming care plans and that factor in their personal goals. Patient engagement or 'activation' is a marker of this type of high-quality practice. Increasingly, high-quality care is team-based, coordinated and focused on prevention and manag- ing chronic conditions. Q: How do you actively motivate physicians and other staff to efficiently deliver high-quality care? SA: I believe most physicians and other staff are highly motivated to do the right thing. Leadership needs to help physicians and staff prioritize and create mechanisms that ensure quality. Data trans- parency and public reporting can be very strong motivators. Incen- tives, both financial and other forms of recognition, also have a role. Although it has not been conclusively demonstrated, payment reform also has the potential to have a significant influence. DL: I think you constantly talk about it and you measure it to the best of your ability. Given how complicated it is to truly define quality, it's been shown over and over again in medical communi- ties, if you start to measure something, the outcomes improve. I'm a surgeon, so I go back to the history of surgical quality. If you go back to the very first data set in the Department of Veterans Af- fairs that looks at heart surgery outcomes, it was mandated in the 1990s because of a report that was done on 60 Minutes by Lesley Stahl describing how bad cardiac care was in the VA system. As a result, the federal government told the VA system to report qual- ity outcomes and to report them against national norms. So the VA system started this program that ultimately turned into NSQIP. Just in the process of measuring these things, the complication rate went down, the mortality rate went down and the overall out- comes in the VA system for cardiac surgery across the country improved. Just coming up with a way to measure these things that could be potentially related to quality helps motivate physicians to do better. There are a lot of places beginning to put incentives in the physi- cian pay scale based on quality, outcomes and safety measures. I actually think the more important thing, because physicians are an inherently competitive group, is if you tell a physician, 'We're going to measure this,' they will try to make it better. JL: Physicians and other healthcare providers choose to work in our industry because they care about their patients and want to provide high-quality care. Health systems and payers should be incented to provide the tools (e.g. EMRs) that support the behav- ioral choices that lead to high-quality care. For example, evidence- based best practice guidelines should be incorporated into order sets. Providers should be given feedback regarding the choices they make, such as adoption of the guidelines, and whether those choices are aligned with or deviate from best practices and in- stitutional goals. Care choices should also be informed by cost effectiveness data and financial impact on the patient based on their benefit structures — information that needs to be available at the point of care. There are data available to support the concept of properly constructed incentives at the provider level, but we must not forget that incentives aimed at supporting high-quality care need to influence system-level decisions. SM: It's a couple of things. One is really encouraging, developing and delivering these team-based models, with clinical leadership dyads, physician leaders and other staff leaders. It's continually motivating staff on the front line and continually reorienting them to enhance the care they are giving. Another is aligning the fi- nancial incentives — bonuses, shared savings or value-based contract opportunities — to the behaviors of high-quality care. Enhanced clinical leadership, financial incentives and focusing the key incentives on the key behaviors will motivate clinicians to deliver high-quality care. SW: My strategy to engage our DMC physicians involves "mini- campaigns" nested within our overall vision to become a high- reliability organization. One example is our "Safety for Life" campaign. I issue "call to actions" that spell out the need for im- provement, what our goal/target is, what tools we've created to help them accomplish this goal and what specific steps we need them to take to get there. DMC works consistently towards ex- ceptional quality, safety and patient experience scores, compli- mented by the integration of LEAN Daily Management. The LEAN model structures daily goal setting for all levels of staff to continu- ally improve care. n