Engaging Physicians in Continuous Quality Improvement

Engaging Physicians in Continuous Quality Improvement Stan Lindenfeld and Douglas Vlchek The current ESRD environment poses significant challenges for the medical director and the admitting nephrologist of a dialysis facility. The expectations and requirements of their role have broadened and are under much greater scrutiny today than ever before. A positive response to this challenge lies in the appropriate incorporation of continuous quality improvement (Cal) methods into the provision of dialysis care. By embracing cal the physician will find these new requirements considerably less taxing and indeed hopefully positive in their impact on the quality of care delivered to his patients. Essential components of the cal methodology include the use of a multidisciplinary team; participative management; a consistent process, well understood by all team members; a content expert (team leader); and a trained facilitator. A familiarity with cal tools and techniques and a willingness to play whatever is the most appropriate role irfthe cal team-leader, facilitator, or contributing memberwill be positive not only to those under the nephrologist's care, but also to his own professional growth and satisfaction as well. @ 2001 by the National Kidney Foundation, Inc. Index Words: •••.

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t the beginning of this new century and millennium, the payor-principally the Health Care Financing Administration (HCFA)-has taken a strong position as far as directing the role of not only the Medical Director, but even the practicing nephrologisU-3 While we do not necessarily condone this position, we must all now accept that things just are not going to "go back to the way they were." A reduction in the physician's historical level of autonomy, with more bureaucratic oversight and accountability, is here to stay. Once we have accepted this reality, the question at hand is: How is the nephrologist, or the Medical Director of a dialysis facility, to comply with these new requirements while still balancing the demands of optimum patient care and a busy practice? We believe that one answer may well be application of continuous quality improvement (CQI)-a methodology which has been instrumental in literally saving other disciplines (eg, the auto industry, computer and electronic manufacturers, public utilities, and others) internationally.3,4 To go into more depth in explaining this state-

From DaVita Inc, Torrance, CA. Address correspondence to Douglas Vlchek, Vice President, Medical Affairs, DaVita Inc, 21250, Hawthorne Blvd, Suite 800, Torrance, CA 90503. © 2001 by the National Kidney Foundation, Inc. 1073-4449/01/0802-0006$35.00/0 doi:10.1053/jarr.2001.23985

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ment, me must examine exactly what the new environment is demanding of the physician. For the Medical Director, the year 2000 brought with it a scrutiny by HCFA not seen previously. The rate of Medicare surveys is occurring this year at a frequency 4 to 10 times that of the previous decade, and the stringency of these surveys has also increased incredibly-with deficiencies being reported as much as ten-fold that of just 1 or 2 years ago. Many of those deficiencies are related to the "Condition of Participation" for the Medical Director .1,3 This decade has also brought with it a more rigorous Office of the Inspector General (OIG) and a concentration on Medical Director contracts related to their service to ESRD facilities. The OIG focus indicates that, to adhere to anti-kickback regulations, Medical Directors of ESRD facilities must show that services rendered commensurate with compensation received. 2,3 CQI can be an extremely effective tool, both clinically and administratively, in the hands of the Medical Director who understands how to use it. For decades we (and HCFA!) have talked about using a "multidisciplinary team" to deliver care to the ESRD patient. However, any serious and honest assessment of the success of that approach cannot, at this time, give it a very high grade. Rather than try to explain why the multidisciplinary team approach has

Advances in Renal Replacement Therapy, Vol 8, No 2 (April), 2001: pp 120-124

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only been marginally successful, we ask you to take the test in Figure l. If we are honest, we probably didn't score tremendously well. This should not really be terribly surprising. Physicians generally view themselves as autonomous decision-makers. Their training does not really prepare them to be active members of a team. They generally make patient care decisions and choose treat-

ment options based on their sole evaluation and assessment. Though this is entirely appropriate in many clinical situations, it does not prepare them to be comfortable in a true team environment. If and when they operate with a team, they generally view themselves and act only as the leader whose decisions should not be questioned but carried out. This approach needs to be revised to effectively function in

1. Members recognize their interdependence and understand both personal and team goals are best accomplished with mutual support. 2. Members feel a sense of ownership for their jobs and unit because they are committed to goals they helped establish. 3. Members contribute to the organization's success by applying their unique talent and knowledge to team's objectives. 4. Members work in a climate of trust and are encouraged to openly express ideas, opinions, disagreements, and feelings. Questions are welcomed. 5. Members practice open and honest communication. They make an effort to understand each other's point of view. 6. Members are encouraged to develop skills and apply what they learn on the job. They receive the support of the team. 7. Members participate in decisions affecting the team but understand their leader must make a final ruling (but only when the team cannot decide, or when an emergency exists) Positive results, not conformity are the goal. 8. Members recognize conflict is a normal aspect of human interaction but they view such situations as an opportunity for new ideas and creativity. They work to resolve conflict quickly and constructively. 9. We have agreed upon a purpose and written purpose statement.

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

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Yes No 10. We have agreed upon the process we are examining as well as the internal and Yes external customers and suppliers. No 11. We have identified the limits and expectations of the team's work. Yes -No 12. We have agreed upon the team roles (or who will have which responsibilities) Yes and we have agreed on ground rules. No 13. We have well-defined meeting times and agendas. Yes No 14. We have create work plans; we have productive meetings. Yes No 15. We always make decisions based on observable data. Yes No 16. We evaluate potential decisions as a team; I do not make the decisions Yes independently. No 17. We consistently reassess the results of solutions we put in place. Yes No 18. We document all of our work. Yes No

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Figure 1. Attributes of the successful team. Data from Maddux,12 Scholtes,13,14 and Goal QPC/Joiner Associates. 15

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the CQI environment. The gains achieved by allowing for a more appropriate team-member approach will significantly outweigh giving up of the traditional approach. CQI yields a "multiplier effect" on the Medical Director's efforts. As a "management tool," history has clearly proven that the CQI team approach, incorporating participative management, yields results-even to extremely complex problems and situationsfar superior, most often with greatly reduced expenditure of human effort or monetary expense, than alternatives used in the past. 4 -8 Moreover, the fact is, very few Medical Directors have any kind of formal training in management or administration. Despite this, HCFA expects the Medical Director to be responsible, or at least partially responsible, for many, if not all, aspects of managing and administering the dialysis facility. This disparity puts most Medical Directors in a difficult predicament, but one that might easily be remedied by CQI. CQI provides an easy-tolearn and easy-to-implement management system which is consistent with the scientific process physicians have known and used since undergraduate school. For the nephrologists, in return for the MCP paid, HCFA is now beginning to indicate that its expectation is for the physician to deliver demonstrable quality of care to the patient for whom he/she is responsible. 3 The last 10 years have shown us that the nephrologist can demonstrate (and document!) this by engaging in a process that delivers higher quality outcomes than his base effort, alone, is able to do. 9 That process is CQI. Additionally, as noted previously, CQI brings the nephrologist into that "multidisciplinary team," which HCFA also requires.

What Does It Take for a Nephrologist to Do CQI? Recent studies of organizations worldwide have focused on what is being called the "Knowing-Doing Gap." It is clearly being shown that success in business and in healthcare is less reliant on knowledge, or even knowledge-sharing, than it is on harnessing that knowledge and putting the knowledge into action.1°,ll So, in the remainder of this

report, we will focus on a few simple parts of the formula as to how the nephrologist or Medical Director can practically use CQI to achieve some of the advantages noted earlier. For the nephrologist or the Medical Director of an ESRD facility to implement a CQI process and continue to use this approach as an effective tool both for improving clinical results as well as managing and administering the facility, 3 components are needed: 1. A team 2. A physician who is a facilitator (if CQI is not already present in the facility) or, at least, a team leader 3. A consistent, well understood CQI process

Attributes of an Effective Team: First, let's define a "team" (in the CQI sense) as a combination of the following attributes: • Realistic, achievable goals can be established for the team and individual members because those responsible for doing the work contribute to their construction. • Staff and physicians commit to support each other to make the team successful. • Team members understand one another's priorities and help or support when difficulties arise. • Communication is open. The expression of new ideas, improved work methods, and articulation of problems and concerns is encouraged. • Problem solving is more effective because the expertise of the entire team is available. • Performance feedback is more meaningful because team members understand what is expected and can monitor their performance against expectations. • Conflict is understood as normal and viewed as an opportunity to solve problems. Through open discussion it can be resolved before it becomes destructive. • Balance is maintained between group productivity and the satisfaction of personal team members' needs. • The team is recognized for outstanding results, as are individuals for their personal contributions. • Members are encouraged to test their abilities and tryout ideas. This becomes infec-

Engaging Physicians in CQI

tious and stimulates individuals to become stronger performers. • Team members recognize the importance of disciplined work habits and conform their behavior to meet team standards. • Learning to work effectively as a team in one unit is good preparation for working as a team with other units. It is also good preparation for advancement. 12- 14

How Does the Nephrologist Become a Leader? The CQI team leader, traditionally, is that person who understands the process or issue being studied the best. The team leader brings vital content knowledge to the other team members and supplies the motivation. The best leaders also possess the following competencies: 1. The ability to think in terms of systems and

knowing how to lead systems. 2. The ability to understand the variability of working, planning and problem solving. 3. Understanding how we learn, develop, and improve, and leading true learning and improvement. 4. Understanding people and why they behave as they do. 5. Understanding the interdependence and interaction between systems, variation, learning, and human behavior. Knowing how each affects the others. 6. Giving vision, meaning, direction, and focus to the organization,13

Nephrologist/Medical Director as Facilitator Different from the role of the leader, the facilitator must have knowledge and experience in CQI. He/she does not necessarily need to have expert knowledge regarding the process or item being examined. And, perhaps, the most important requirement for the successful facilitator is a easy-to-use and easy-to-teach CQI team process. Figure 2 outlines a process developed as a combination of those previously presented by Deming4 and Walton,5 Berwick,7 Vlchek,9 and others. The advantage of this process is that it is simple, yet detailed steps make it possible for any staff member, regardless of educational background, to actively participate. Functions performed by the facilitator include: 15,16 • Opening the meeting. • Reviewing the agenda with the group; making changes as appropriate. • Making sure someone is taking notes and someone keeps track of time. • Moving through the CQI team process 1 item at a time. • Facilitating discussions; making sure no one dominates and that everyone participates. • Helping the team choose appropriate discussion and decision methods. • Having the group evaluate each meeting. • Gathering ideas for next meetings. (1) Fann a Team

Figure 2. The process.

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• Assuring that intermeeting action items are distributed fairly and appropriately. • Assuring that intermeeting action items are completed. • Closing the meeting.

leader, facilitator, or contributing memberwill be positive not only to those under his care but to his professional growth and satisfaction as well.

It is important to point out that although it is often positive for the nephrologist to serve as either the team leader or facilitator, there are situations where others can function in this role more effectively than the physician. Previous training and experience is possessed by a significant number of individuals on the dialysis care team in many environments. In these situations, it will be most appropriate for the nephrologist or Medical Director to serve only as an equal member of the team and contribute in that manner even though he/she is not in the "lead" position. This may be difficult for some but will be rewarded by a much more successful outcome.

References

Summary The current ESRD environment poses significant challenges for the Medical Director and the admitting nephrologist of a dialysis facility. The expectations and requirements of their role have broadened and are under much greater scrutiny today than ever before. We believe that a positive response to this challenge lies in the appropriate incorporation of CQI methods into the provision of dialysis care. By embracing CQI, the physician will find these new requirements considerably less taxing and indeed hopefully positive in their impact on the quality of care delivered to his patients. A familiarity with CQI tools and techniques and a willingness to play whatever is the most appropriate role in the CQI team-

1. Code of Federal Regulations: 4 2 CFR Part 405(u). Conditions of Participation for Providers of ESRD Services 2. Owen W: The Dialysis Facility Medical Director: Scope of Work and Documentation of Services. Taronto, Canada, American Society of Nephrology, 2000 3. Yessian M: Government Oversight: The OIG's Focus on ESRD in the Coming Years. Toronto, Canada, American Society of Nephrology, 2000 4. Deming WE: Out of the Crisis. Cambridge, MA, Massachusetts Institute of Technology, Center for Advanced Engineering Studies, 1989 5. Walton M: The Deming Management Method. New York, NY, Putnam Publishing Group, 1986 6. Vlchek 0, Day L: Aquality improvement model for renal care. Nephrol News & Issues 1991 (suppl 1) 7. Berwick 0: Curing Healthcare. San Francisco, CA, Jossey-Bass, 1990 8. Vlchek 0: The Santayana review: Leaming from our mistakes in clinical practice. Semin Dial 6:223-226, 1993 9. Gross S, Burton B, Vlchek 0 : A CQI approach to improved vascular access outcomes. Nephrol News & Issues 9:72-74, 1995 10. Pfeffer J , Sutton R: The Knowing-Doing Gap. Boston, MA, Harvard Business School Press, 1999 11. Kouzes J, Posner B: Credibility. San Francisco, CA, Jossey-Bass, 1993 12. Maddux RB: Teambuilding. Menlo Park, CA, Crisp Publications, 1992 13. Scholtes PR: The Leader's Handbook. New York, NY, McGraw Hill, 1999 14. Scholtes PR: The Team Handbook. New York, NY, McGraw Hill, 1988 15. Brassard M (ed): The Team Memory Jogger. Methuen, MA, GoaI/QPc, 1991 16. Vlchek 0, Burrows-Hudson S, Kammerer J: A Reference Manual on Continuous Quality Improvement in Dialysis. Newport Beach, CA, Forsythe, Marcelli & Johnson, 1993