Whether prompted by government mandate, regional competition, or patient demands, healthcare organizations are adopting new care models designed to foster value-based care. Patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and a host of other options offer organizations a structured approach to improving patient outcomes while lowering the cost of care.
Obtaining recognition for implementing these models is certainly a complex process, but the underlying objective is fairly straightforward – meet the required criteria and prove to the appropriate agency that your organization can change the way it delivers care. But achieving true care model transformation – and sustaining it – is another matter. Transformation initiatives that begin with the best of intentions often stall upon implementation, and organizational units either fall back into old habits or never make any improvement in the first place.
There’s no guaranteed formula for success when it comes to care model transformation, but one way to ensure failure is to not get physicians involved. Without physician engagement, from the planning stages through implementation and beyond, even the most promising initiatives will struggle to gain momentum and likely flounder.
What Physician Engagement Means
Physician engagement is a common topic in healthcare today. According to Tom Atchison in his book Leading Healthcare Cultures: How Human Capital Drives Financial Performance, physician engagement is an intangible process that depends on the degree to which doctors are proud, loyal, and committed to a hospital’s mission, vision, and values.1 In practical terms, physician engagement means having physicians involved in, and committed to, strategic, financial, and operational initiatives in a healthcare organization.
Why it Matters
While the decision to pursue care model transformation may rest with an organization’s administrative and executive leadership, it is the physicians who are tasked with delivering care in the proposed manner. If physicians are unwilling to adopt new processes or alter behaviors, the organization may be unable to meet required criteria. Further, physicians are the leaders in the clinical setting and wield tremendous influence over other members of the care team. If the physicians won’t commit to change, then neither will the clinicians and staff who support them.
In this multi-part blog series, we’ll look at two case studies that illustrate the importance of physician engagement to care model transformation. Ultimately, we’ll see what happens when physicians are truly engaged and willing to collaborate to achieve success. But first, let’s find out what happens when they’re not.
Case Study #1: Implementing Team-Based Care Without Physician Engagement2
Several years ago, a midsize integrated health system embarked on the journey to implement a PCMH model across its primary care service line. The organization devoted substantial time and effort to the cause and was able to achieve NCQA Level III PCMH recognition.
Initially, the pilot initiatives worked as planned. Physicians, APCs, nurses, and other medical and administrative staff collaborated in a care team responsible for the health of a panel of patients. Providers saw one another’s patients, nurses assisted with care coordination and patient education, and the administrative staff ensured appropriate scheduling and follow-up. And the results were promising – the pilot groups saw increased patient satisfaction scores and received highly positive anecdotal feedback, and the system began to realize the benefits associated with PCMH recognition.
Over time, however, the system was unable to sustain team-based care in some of its practices. Many providers and staff fell back into a siloed model of delivery whereby each physician was responsible for his or her own patients, had a single nurse assigned, and did not collaborate with other staff and provider colleagues. Having not achieved true transformation, the organization eventually found itself facing a more complicated and in-depth renewal process.
Why did this happen? It was not due to lack of effort on administration’s part. Leadership communicated the need to implement team-based care and provided education and training opportunities. However, several factors contributed to a loss of momentum among physicians and APCs:
- Limited physician involvement in process development. Much of the PCMH planning process was conducted by administrative and nursing leadership, with input from only a select few physicians. Because the wider group of physicians had little say in the creation of new work flows, there was no standardization across the service line, and providers operated with highly variable processes.
- Lack of dedicated leadership. In some practices, physician and administrative leadership was limited. An administrative leader was placed in charge of the largest practice on an interim basis, and thus was unable to devote complete focus to the effort. The practice’s physician leader, meanwhile, was committed to team-based care but involved in many other initiatives, leaving little time to drive significant change.
- Lack of cross-network communication. Physicians and administrative leaders in other clinics throughout the system were focused on similar efforts, and some were experiencing success. However, there was limited communication and almost no sharing of best practices.
- Entrenched organizational culture. Historically, the organization had operated with a “top-down” decision-making process. Although the new CEO was trying to change this dynamic, physicians were reluctant to submit ideas for change based on the perception that they would not be “heard,” would not be empowered to act on an idea, or that management would simply tell them what to do to fix the problem.
- Lack of financial incentives. Providers continued to be compensated on a productivity basis. The organization did not develop any goals, performance metrics, or financial incentives for the adoption of team-based care, so physicians had no monetary motivation to engage.
What this health system discovered is similar to what many organizations find when they embark on a care model transformation initiative – it’s a full-scale effort that requires not only planning at the administrative level but also buy-in at the provider level. And success in a small pilot does not guarantee organization-wide scalability and sustainability.
Furthermore, transforming a model of care often means changing an organization’s culture as well, and that doesn’t happen quickly or easily. Nor does it happen without the regular involvement of the individuals who will be most affected by change on a day-to-day basis.
In this instance, the broader population of physicians weren’t engaged during the planning process, nor was their involvement nurtured after implementation. The organization has taken steps to address these challenges, but to date, it remains to be seen whether it will be able to continue operating as a PCMH III.
In our next post, we’ll look at a different approach to care model transformation – and a very different outcome.
As described by Kenneth Cohn in “The What and Why of Physician Engagement,” The Connected Clinician, February 2015.
Given the sensitive nature of the situation and our commitment to confidentiality, we have elected not to identify the organization referenced in this post.