Excerpted from Healthcare Executive (March/April 2014) (American College of Healthcare Executives, 2014).

Physician EngagEmEnt
Strengthening the Culture
of Quality and Safety

By Jane Calayag

Physicians want to deliver the

highest quality and the safest care,
says Tejal K. Gandhi, MD, CPPS,
president of the National Patient
Safety Foundation, Boston. That
is their primary motivatorthey
dont want to harm patients.
Many healthcare leaders share the
same objective, as evidenced by the
burgeoning improvement programs
in hospitals and systems. They
understand the fiscal, moral, regulatory and health urgency to do no
harm. Plus, they view it as a primary, collective duty of everyone in
the institution. Patients expect high
quality from usand reasonably
so, explains Richard A. Hachten II,
FACHE, president and CEO,
Alegent Creighton Health, Omaha,
Neb. We have a responsibility as a
team to deliver that quality of care.
Despite their common purpose, many
leaders struggle to involve physicians in
organizationwide quality and safety
efforts. In fact, 71 percent of respondents to ACHEs 2013 Top Issues

Confronting Hospitals survey identified

engaging physicians in improving the
culture of quality as a specific challenge.
Complicating this concern is that
many physicians are autonomous or
belong to an independent practice
association (IPA). For Beth D.
Zachary, FACHE, president and
CEO, White Memorial Medical
Center, Los Angeles, engaging nonemployed physicians is a challenge for
several reasons. First, those physicians
may only spend a limited time at any
one hospital in order to meet their
IPA-imposed productivity goals
throughout the day. Second, they may
know little of the hospitals mission
and culture and consequently may not
be as invested in its quality agenda.
With health reform mandates and the
shift from volume-based to value-based
reimbursements and incentives in progress, Gandhi believes that aligning the
interests of both leaders and physicians
in quality and safety is more critical than ever. We have done a
lot since 1999 [when landmark Institute of Medicine
report To Err Is Human
was published] in
terms of how to
report errors,
how to talk

about errors and how to fix errors, but

were not all the way there, she says.
Bertine Colombo McKenna, PhD,
FACHE, executive vice president and
COO, Bassett Medical Center,
Cooperstown, N.Y., agrees. She argues
that more can be done. Theres an
opportunity for both the clinical and
business sides of healthcare to partner to
make sure the countrys healthcare system improves to the point where we have
zero defects, she says. This allows us to
become a high-reliability organization.
One way to accomplish this is to
strengthen the organizational culture
of quality and safety with the help of
clinicians. Strategies for engaging physicians vary from one organization to
another, Gandhi notes, but several
common strategies may be employed.
Commit to quality and safety first.
Before senior leaders can gain buy-in
from physicians, they first must demonstrate their own commitment and
understanding of the work needed.
Given the current focus on population
management and cutting costs, I worry
that instead of continuing to invest in

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29

Physician EngagEmEnt

Strengthening the Culture of Quality and Safety

quality and safety, leaders might shift

their resources to other things, Gandhi
says. In fact, having a strong foundation in quality and safety will help
organizations achieve population management and reduce costs.
Embed physicians in the leadership
structure. Leaders should appoint physicians to head a specific officesuch as
director of quality and safetyor invite
them to serve on committees, advises
Gandhi. Occupying these roles enables
physicians to work in partnership with
other staff and clinicians, not as someone who tells others what to do, she
explains. Gandhi adds that a co-leadership model is ideal to minimize hierarchy and maximize collaboration.
Alegent, for example, established a
chief quality officer position as part
of its senior leadership team. We
also established campus chief quality
officer positions with each of our
hospitals, our rural network and our
physician enterprise, says Rick
Miller, DO, FAAFP, senior vice president and chief quality officer,
Alegent. Furthermore, physicians
serve on the clinical practice

committee and the patient safety and

quality committee, both of which are
overseen by the board of directors
and present reports and recommendations at each board meeting.
Use valid and reliable data.
Outcomes, performance, benchmarks
and other data all point to achievements, progress and areas that are
trending below standards. Numbers
substantiate the call for changing clinical processes and clinician behavior.
As McKenna explains, Data is particularly critical to physicians.
Evidence speaks volumes in terms of
engaging physicians in the fix. If you
dont have evidence and have no
robust system in place to make
change happen and support that
change, then the frustration that
results gives way to nonengagement.
Alegent uses data to demonstrate
transparency and to continually support physicians. Weve developed an
evidence-based process that provides
physicians with the data and evidence
behind identified best practices, which
has helped physicians buy in to the

Theres an opportunity for both the clinical and business

sides of healthcare to partner to make sure the countrys
healthcare system improves to the point where we have zero
defects. This allows us to become a high-reliability
organization.
Bertine Colombo McKenna, PhD, FACHE
Bassett Medical Center

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MAR/APR 2014
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effort over time, Miller says. It also

allows us to analyze and determine the
validity of the measurements we use to
monitor quality performance.
White Memorial regards data as a
tool for monitoring and averting the
unintended consequences of clinical
decisions. We are very vigilant about
changes in processes and fluctuations
of target goals and keep our eyes
open in all avenues of care, says
Mara Bryant, senior vice president of
organizational excellence.
Provide training. Organizational
quality principles are typically not
taught in medical schools. Yet, as
Gandhi notes, many physicians get
involved in running improvement
projects. She argues that educating
physicians on the core hospitals quality and safety improvement processes
would enable them to participate
more actively and constructively.
As a learning organization, Bassett
offers its clinicians various opportunities for education and training. We
have an orientation process for new
doctors that discusses our quality and
safety programs, to give them a sense
of how they may want to be involved,
McKenna says. We have the Bassett
Institute for Learning, an internal,
self-directed university that includes
leadership studies and quality and
safety modules. We will launch a Lean
module soonbut as a way of working, not as a new program.

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Physician EngagEmEnt

Strengthening the Culture of Quality and Safety

Furthermore, Bassett presents learning in more creative ways such as

through case reviews, rounds, observations and hands-on experiences.
Offer financial incentives. Time
spent on quality work is time spent
away from patient care or revenuegenerating duties. That is the reality
for many physicians.
For physicians who have their own
practice, this type of work ends
up being a financial hit, Gandhi
says. There has to be a way to
reimburse physiciansbased on the
improved quality achievedthat
could help offset some of the time
they carve out.
At Alegent, employed physicians are
compensated for meeting annual
quality metrics, but nonemployed clinicians are unpaid for their quality
participation.
Physicians at Bassett do not yet
receive financial incentives for quality
efforts, but the organization will be
considering such an arrangement in
the future.

Make the workplace psychologically

safe. No one is going to speak up
about unsafe practices, medical errors,
near misses or potential sources of
adverse events if that person expects to
be yelled at, belittled or berated in the
process, cautions Gandhi.

This caught the attention of our

community, physicians, staff and leadership, says Hachten. Equally important was that it united Alegents
internal stakeholders and facilities in
pursuing a common goal: provide only
the best and safest care to patients.

Bassetts just culture is the embodiment of a psychologically safe environment, in which people feel safe to
report issues, says McKenna. We hold
people accountable when there has been
a pattern or trend worthy of action.

Initially guided by an external consultant, Alegent developed and deployed a

best practice-based quality program.
For example, we deployed care bundles
to reduce infection rates, Hachten
explains. Overall, it was not only the
best practices that drove our success; it
also involved continuous measurement,
transparency, and uniformity of practice
across all categories and sites of care.

The following cases detail how three

healthcare organizations established
their quality and safety culture and
how they engage their physicians.

Alegent Creighton Health

In 2005, Alegent made a bold decision: publish the less-than-perfect,
widely varied quality scores of all its
metropolitan-area hospitals in the
local newspaper Omaha WorldHerald. The move was not only a resolute step toward organizational
transparency but also a public declaration of Alegents cultural commitment to high quality and safety.

Overall, it was not only the best practices that drove

our success; it also involved continuous measurement,
transparency, and uniformity of practice across all
categories and sites of care.
Richard A. Hachten II, FACHE
Alegent Creighton Health

32

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MAR/APR 2014
ache.org

Since then, members of the medical

staff have been active participants in
sustaining and advancing Alegents
quality-focused culture. Not only do
they implement, guide and monitor
quality initiatives as chief quality officers, but they also influence clinical
performance and safe practice as representatives on quality committees.
This involvement in committee work
has, according to Miller, evolved to a
point where our physicians see it as
their job to promote and ensure that
patient care is of a high quality in all
sites of care and all specialty areas.
He adds that although physicians are
not currently paid for the time and
effort it takes to adequately coordinate
care for patients, educate them about

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Physician EngagEmEnt

Strengthening the Culture of Quality and Safety

their care and follow up, physicians

acknowledge that the data, resources
and other support they receive in return
enhances the value of their practice and
the quality of care for their patients.
In that way, Miller says, many
times physicians who initially
pushed back become champions for
our initiatives.
Automating manual processes, adopting a prospective rather than a retrospective approach to care and
developing tools to support that
approach are some other ways that
Alegent continues to engage its physicians in its quality-focused culture.

framework for establishing and maintaining a quality-focused culture.

The criteria turned our normal level of
clinical quality and patient safety into a
bigger model that is integrated into our
strategic planning process, explains
Bryant. We evolved across all metrics,
and we continue to use that model.
Zachary adds, While we have been
systematic about building a patient
safety program and getting better over
the years, however, what really helped
us achieve the progress we have made
recently was a sentinel event.

White Memorial
Medical Center

In 2006, an outbreak of Pseudomonas

infection occurred in the neonatal
intensive care unit. It was a horrible
event, and we all took it personally.
We lost a baby. We closed the NICU
while we conducted an investigation
with the California Department of
Health Services and with Childrens
Hospital Los Angeles, recalls
Zachary. It turned out we had not
properly cleaned a laryngoscope.

More than 20 years ago, White

Memorial adopted the Baldrige Criteria
for Performance Excellence as a

Although the event compromised

White Memorials credibility in the

It is this same culture that has propelled Alegent to achieve much success. In 2013, it was named one of the
top five mid-size health systems and
one of the top 15 health systems in the
U.S. by Truven Health Analytics.

I love it when our organizational accomplishments or

quality scores are recognized. We share those with our
staff and doctors so that they can be proud of the work
we do together.
Beth D. Zachary, FACHE
White Memorial Medical Center

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MAR/APR 2014
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community and cost a significant

amount of money to correct, it also
served as a catalyst for change. Our
board said, Were going to recommit
our organization to patient safety,
Zachary recalls. We turned ourselves inside out and accelerated the
work we had been doing.
To engage the medical staff in this
renewal effort, leaders retained or
installed four major mechanisms.
First, physicians serve on hospital
quality councils and lead medical staff
committees, which help us monitor
the progress of our clinical and safety
targets and set the direction of our
clinical quality objectives, says
Bryant. Members of the medical staff
attend a bi-monthly meeting with
senior leaders to address concerns and
share in the decision making.
Second, physicians steer any initiative
that has major implications on patient
care, or they co-lead it with a hospital
champion, Zachary explains. These
initiatives stem from the departmentby-department culture of safety surveys. Departments that are in the
danger zone are assigned a hospital
executive and a physician who work
directly with the department staff, she
says. Together, they identify and fix
the issuewhether its team communication, technology or medical practice.
Third, physicians attend and guide
the interdisciplinary care rounds on

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Physician EngagEmEnt

Strengthening the Culture of Quality and Safety

all patient floors. We asked the

medical staff how we could make
these rounds work. A number of
them said they would like to lead
them, Zachary says. Physicians were
on teams that designed and implemented these rounds. Theyre on the
units every day with hospital staff to
make sure we are doing things right;
they intervene as needed.
Fourth, physicians are in the midst of
developing clinical knowledge base
alerts in our EMR system, Bryant says.
Were getting to the point that they
are comfortable with the EMR and are
now analyzing what processes are so
important that they need to have alerts.
But were also cautious of alert fatigue,
so we want alerts triggered only for the
most critical processes.
California prohibits nonphysicians
from employing physicians, which is
a barrier to physician engagement.
White Memorial, however, strives to
overcome that by orienting or reorienting the medical staff to its quality
and safety culture, programs, goals
and achievements. It also appeals to
physicians natural instinct to provide
the best care.
I love it when our organizational
accomplishments or quality scores are
recognized by U.S. News & World
Report, Healthgrades and Leapfrog,
Zachary says. We share those with
our staff and doctors so that they can
be proud of the work we do together.

36

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MAR/APR 2014
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Bassett Medical Center

Ten years ago, Bassett instituted a
reach for excellence program with
comprehensive components. Over the
years, those components have been
expanded and refined to award-winning, best-practice levels.
We have received numerous national
awards from various entities,
McKenna says. But its not the award
itself that is important to us; its the
process of getting the care right.
That process, she notes, is an ongoing, multidisciplinary effort of planning, doing, checking, and acting to
enhance performance and outcomes
across the spectrum of care.
We believe we can improve constantly; that the journey is never over,
she says. We believe ensuring a highquality and safe culture is our obligation to patients, so we are always testing
and learning from our process.
Bassett, for example, administers the
Agency for Healthcare Research &
Qualitys safety culture survey, which
allows people to anonymously report
their perception of safety. Survey findings help leaders identify areas for
improvement and develop action plans.
In this culture, physicians encounter
multiple opportunities to contribute
and to team up with leaders, managers and front-line staff. For example,
We have a robust safety action council of physicians, nurses and staff,

says McKenna. They dont just

review reports; they take action on
how we can be a safer organization
for patients and employees.
Bassett also deploys a physician
administrator dyad to resolve quality
or safety issues. For example, if a
quality or safety indicator for an area
is below target, the work is handed to
the physician leader and the administrator or nurse leader of that area,
says McKenna. That team does a
deep dive to understand and remove
the barriers to meeting the target. We
then learn from the experience and
spread the best practices.
Physicians are involved in safety
rounding, designing parameters for
the EHR system, monitoring and analyzing data and conducting root-cause
analyses. Those who dont feel
involved are immediately introduced
to the many opportunities available.
Clinicians are, by nature, high performers; therefore, engaging them in
excellence is not hard as long as you
do it in the right way, says
McKenna. The only pushback we
find is when we dont explain well the
why and how of what were doing.
Jane Calayag is a freelance writer based
in Chicago.
Editors note: Richard Hachten retired
from his post as CEO of Alegent
Creighton Health in March 2014.

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