7 Rules for Engaging Clinicians in Quality Improvement

Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement

If you get off on the wrong foot with a physician or any clinical provider youíre in trouble and youíre in recovery mode. The first thing that Iíve learned is that a lot of physicians in particular associate quality improvement with quality assurance and quality assurance is generally felt to be more punitive, judgmental, youíre being compared to somebody else and obviously thatís not in the spirit of quality improvement. Itís hard because so much of what we see today in fact is quality assurance. Pay for performance is a good example where physicians are in fact being profiled compared to others, compared against the standard and that can be really chilling.

The first rule is emphasize the improvement and try to stay away from the realities of quality assurance which we know continue to be an issue.

The second thing to avoid is language that implies that what we are teaching you now comes from Japan, comes from Toyota, has this mystical quality of coming from the East and somehow being profound. Really quality improvement is pretty simple and while we have learned a lot from Toyota and from lean methods and Toyota production system, we donít have to talk that way to engage clinicians and in fact it makes it seem at least to a lot of people to be an off-putting thing that doesnít relate to their work so thatís the second point.

The third is that in quality improvement we often have an agenda that may have to do with non-clinical care issues, for example waiting times in the office or what a patient has filled out on their satisfaction survey and you know Iím a clinical person and I care that patients are waiting in my office too long or that they may have had some dissatisfaction with the service, but basically what I wake up in the morning worrying about is the clinical care Iím going to provide to the patient. For the example take a surgeon who does prostate surgery. And heís going to do surgery to extricate cancer by removing the prostate gland so yeah he cares about the waiting time and the service and all that but basically he wants to know at the end of the day, have I successfully removed the cancer? Is the patient cancer free? Can the patient resume normal sexual activity or are they going to be impotent after the surgery? Are they going to be incontinent of urine or are they going to be able to hold their urine? These are the profound clinical issues and if you canít relate your quality improvement work to what matters to the clinician and what ultimately matters to the patient, then you lose them so thatís the third point.

The fourth point is that we often emphasize the methods of quality improvement in a way that can seem not so relevant to the clinician. So for example we often ask clinical staff to do a process flow diagram and thatís really important. You have to understand the process of care, the system of care to really improve it but you canít ask a surgeon to come to a meeting at 10 am then sit for 2 hours and do a process flow diagram. That just isnít going to work. What I would do would be to sketch out kind of a template for what I thought and the clinical staff I would meet with thought was the way the process works then I get up at 5:00 AM or 4:00 AM and I go to the operating room and the pre op area where heís having a cup of coffee and a cold stale bagel and I say ďhereís what we got here what do you think?Ē And that way I show a respect for his or her clinical work and they understand that Iím sensitive to their workload and their schedule so thatís the 4th point.

The 5th point is that we need to be up front about the fiscal agenda. You know thereís all this talk about value and value is important, you know itís the quality cost equation but sometimes when we talk about quality improvement, we obfuscate the fiscal thing that we are actually trying to be sensitive to cost or trying sometimes to reduce cost to save money. Just be open about it. You know say ďlook, we understand that this quality improvement work is going to take time and we are focused on improving care for the patient but also we are in fact in a real world economy here where we have to be conscious of the cost of the care we provide.Ē Thatís far better than saying what I heard many many times from quality improvement leaders ďquality improvement is free.Ē Itís not. Itís not free. In the end we may save money by doing quality improvement thatís part of the process but to the person doing the quality improvement itself it takes time and thereís real cost in terms of opportunity cost and what else they wonít be able to do that day.

The next point is that clinicians at least most of the people I know are interested in data and we donít give them in most institutions and most clinics the data they need in real time thatís relevant to the improvement theyíre trying to do. Thatís really, thatís a downer. I want to see the data and I donít want to see the data that you think is improvement oh quality important guru, I want to see the data thatís important in my work. If Iím going to improve, give me the data, donít tell me the computer system canít handle it. So being sensitive to what the clinician needs in the way of data and giving it to them without complaint and excuses is really important.

And finally a lot of physicians of course are working in academic environments and to them quality improvement work may not be valued to the same extent as it would be to do laboratory research or health services research. Well I think you have to lay out the academic case for doing quality improvement. We are fortunate we live in a time where if you do quality improvement well, you can in fact get credit for it in an academic promotional pathway. Iím a living example of that. My work is not in any, at least I donít think, that brilliant but its sound work and itís been recognized and published and Iím a professor thatís at Harvard. So I think there is a pathway forward. It takes time, you have to work in an inter-professional way and if you do that well, youíll get credit. And these days it doesnít have to be in the New England journal, it can be in a quality journal or it can be posted on the web, or it can be a clinical practice guideline that everyone uses so thereís a lot of ways to do this.