Wednesday, March 28, 2007

Wednesday is Student Day

In my post below, I invited students of all persuasions to write in with questions and comments and promised a weekly response. (Also, I answered some immediately.) Let's decide that Wednesday is Student Day and, I will try to have a more extensive response to one or two questions on this day each week.

Andrew Calvin asks:

I know residencies are increasingly incorporating systems improvement curricula, and it seems some academic medical centers are starting to recognize systems improvement work as a valid career path (in addition to the clinician-researcher and clinician-educator). In terms of university faculty promotion the clinician-educators have struggled to quantify and prove their worth to their departments (vs. the more easily quantifiable publication record for the clinician-scientist), and I'm wondering how the "clinician-systems improvers" (not even sure if that's the right term) can get fully recognized for their contribution and justify their academic promotion to their university department. Perhaps that's outside your area of expertise but I'm curious to your take given your unique vantage point. How do these people get recognized/promoted/etc by the hospital, whether it's an academic hospital or not?

Are you noticing an increased activity level in SI work from your clinical staff, in particular from MDs? From your perspective, do you think there is a large or growing demand in both the academic and private sector for those SI-focused clinicians? Do you see an increasingly diverse group of clinicians getting involved in this type of hospital administration (MDs, PharmDs, RNs, RTs, etc)?

How does an SI project work between a hospital administration and a university department that staffs it - who typically is in charge? What sorts of backgrounds/training/experience have you seen that seems to help these individuals?

It is my impression that the academic promotion system is lagging behind the needs of the profession on this front. As you have seen from several posts on this blog, there is a real and extensive need for people to be engaged in system improvement study, planning, and implementation. The techniques of service and industrial process improvement that have been used for years in other service and production industries have not yet been fully incorporated or appropriately modified in a great number of hospitals.

I believe there are serious structural and/or sociological reasons for that in medical communities. First among those is that medical students, residents, and junior faculty generally do not get professional recognition for having strong interpersonal skills or engaging in teamwork. In academic medicine in particular, you are trained to be decisive and act as an individual in the clinical setting, and you receive professional recognition in the research arena for the work you do as an individual. Systems improvement activities, in contrast, require an ability to interact well with others at a personal level and to create teams to accomplish mutually agreed upon goals.

Second, in many hospitals, there is a divide between the administrative people and the medical staff. They come from different backgrounds, have different training, and find personal satisfaction in different ways. In some sad places, the relationship between the two groups is downright toxic, with MD considering administrators as intelligence-deficient and administrators considering MDs as stuck-up egotists. Even when the relationship is exceptionally good, the difference in perspectives and approach to problem solving can get in the way. (A friend of mine once said that doctors use inductive reasoning and administrators use deductive reasoning -- dunno, maybe she was right.)

But what does that have to do with academic promotion? Well, if your department or division chief does not see the value of your time spent in system improvement research, planning, or implementation, you are rowing upstream with regard to academic promotion if you have made that a cornerstone of your time on the faculty. If he or she does see the value, then you will have mentoring and support to use that aspect of your time towards either the research or teaching professional advancement path.

What's the strategy then? In choosing a hospital, find a place where these activities are strongly encouraged by the academic leaders. Then, design a career path that enables you to design and publish academically sound research studies in the field. Our Triggers group, for example, designed their program from the get-go as an academically sound experiment, and they fully intend to produce peer-reviewed journal papers on the subject. So did our Team Training group.


I cannot speak for how quickly academic medicine more broadly will endorse system improvement as a field. Perhaps you would more wise to term your activities the "science of care," but even then I see somewhat slow acceptance in some quarters. But rest assured, these activities are crucial to the future of the health care field. This is being driven by cost pressures on the industry and by a public that is ever more knowledgeable of the outcomes delivered in a hospital, as contrasted with its reputation. You will not go wrong by studying, experimenting, and implementing programs in this arena.

On your final question, who is in charge of a given system improvement activity in a hospital? The best administrators know that a program will not work unless there is a medical champion. The smartest doctors know they need a strong administrator to help. So, the most effective programs occur when a medical champion teams up with an administrative leader to garner the best of their respective learning and teaching styles and to tap the experience and skills of both disciplines. (Usually, the MD is deemed to be in charge, but it is actually a co-chairmanship.)

In saying this, I do not mean to leave out others. The Lean program described below is based on a multi-disciplinary team -- MDs, administrators, front-desk staff, medical and technical techs, respiratory and physical therapists -- as inclusive a group as possible to study, design, and implement change. Whether as part of a Lean process or more generally, everyone has something to contribute, and your job as MD leader is to be extremely respectful to people who, frankly, you often wouldn't talk with (and -- admit this now -- sadly, not even notice!) in the course of your daily activities. My best ideas often come from the clerical staff, housekeepers, transporters, food service people, surg techs, and lab techs -- those hard-working and extremely devoted people "on the ground", closest to patients, who are excellent observers of the human condition, and who are watching what is really happening.

So, by all means, pursue this arena. Look for a hospital where you will get strong support from your academic chief of service. Then, look for allies on the administrative side. Show respect to all those who work with and around you. Trust me, you will get noticed, and you will find yourself busier and more engaged than you would have ever thought possible!

6 comments:

William from The Doctor Job said...

I'm glad to see this become a regular feature. Your input as someone both in charge, but also non-physician, gives you a great perspective.

Anonymous said...

Paul;
I have no experience in the academic medicine arena, beyond my medical training 30 yrs ago, but all your comments also pertain to the community hospital environment. I must say, this is the best post on your blog that I have ever read, and it shows that you really are in touch with what's going on in your hospital, as well as knowledgeable about the essential future of this important aspect of our profession. Please continue to use your blog to try to bridge that gap between M.D.'s and administrators - it's so very important for a hospital's success in caring for its patients. I have already sent your link to the CEO of the hospital system from which I retired.

Dr. BK said...

Dear Student,

I never saw this blog until late tonight, so I decided that since you got such an informative answer from this blog, and you seem so earnestly passionate about SI, I would respond.

I am a psychologist in a very large and well-know research academic medicine department. We have another name for SI, it is QA/QI and outcomes. I direct this for many parts of our department. I can report ONLY to MDs who take my reports to the proper committees. However, the MDs who work in this field ACT like administrators in function. They improve systems of care within the whole hospital and within departments. In my department, as said in the posting, the importance of this activity is different to different people. To the medical director of the hospital and the administrators,for all my SI work, all the many peer-reviewed journal articles and grant pilot studies that I do, it doesn't really help me for promotion. Or anyone else for that matter. Even though this is a critical area of research, it is considered administrative duties and only counts as such.

The MDs who are successful in my department who are interested in SI, have re-conceptualized patient care models into RCTs and K awards that bring in funding and buy your time to do OTHER research. My opinion, for the little it is worth, is that, the MDs who have pursued SI have not had a good time of it. They are subtly pressured to let others do it, and pick a more fundable area for your career path.

I hope this helps. I LOVE SI, that is why I would second the advice from this blog. Go with your passions, but be aware of the politics of this activity in relationship to your promotion. Have it spelled out to you by a mentor or your chair.

Thanks for listening, and this was a great posting!

Paul Levy said...

A note from our chief of medicine, Mark Zeidel,

Dear Paul:

It happens that I wrote an editorial with Brent James a few years back on the need for promotions, publications and grants to focus on quality improvement, so that faculty members could be promoted based on their quality improvement activities."

It is entitled "Improving the quality of health care in America: What medical schools, leading medical journals, and federal funding agencies can do." It is in the February 1, 2002, edition (Volume 112, pp 165-167) of the American Journal of Medicine. For those of you with access to Pubmed, the article can be accessed through Pubmed by searching under "Zeidel ml and james b". Sorry, but it does not seem to be online to general readers.

divakar mandapati, md said...

This is a great post. We really need to bring industrial process improvement techniques into the practice of medicine. Our own experiment with a "ground up " multidisciplinary approach has resulted in decreased costs, and increased patient satisfaction in cardiac surgical care.

Andrew Calvin said...

Whoa, this just keeps getting better and better! Mr. Levy, for your next trick can you get a comment by the Dean of HMS maybe?

To my disappointment Dr. Zeidel is correct in that the article is not freely available. But I believe that I can post snippets, for academic purposes and edited down based on the likely background of your readers, which I've done below.

Thanks again!
Andrew Calvin

Improving the quality of health care in America: what medical schools, leading medical journals, and federal funding agencies can do

Mark L. Zeidel MD and Brent C. James MD



The quality movement applies to health care a set of process improvement methods that were pioneered for manufacturing industries. These approaches focus on measuring quantifiable outcomes to define episodes of variance from an accepted range of values. Efforts are then made to reduce variance and continuously improve the process of care. As a result of this continuous process, patients with similar conditions receive similar treatments, and the processes of caring for these patients improve in consistency, quality, and cost. The algorithm for continuous process improvement involves repeated cycles of “plan, do, study, act.” … Despite these successes and to the detriment of patient care, the medical community as a whole has been slow to adopt these approaches.

Surprisingly, academic health centers (AHCs), which have traditionally led the development, implementation, and dissemination of improvements in health care, have not taken a leadership role in the quality movement…Clearly, even AHCs have much work to do to provide optimal care.

In many respects, AHCs are remarkably well suited to applying the methods of process improvement to the care of their patients. Nearly all large AHCs have on staff faculty members with strong statistical and outcomes research backgrounds. These faculty members have already participated in clinical trials and have mastered the rigors of conducting research on patients. In addition, AHCs tend to have large, centralized faculty practice plans. These practice plans feature large cohorts of patients who have similar diseases and who are undergoing similar treatments. These groups of patients are cared for by faculty members who already practice as a group, sharing among themselves the coverage of their patients. A large patient cohort cared for by a limited number of physicians represents an ideal substrate for measuring quantifiable outcomes. Under these conditions, it becomes relatively easy to determine over a short time the advantages or disadvantages of changes made in the processes of care. Finally, the standardization of care and the careful collection of outcome data inherent in continuous process improvement efforts make it easier to generate data for publication from routine clinical care activities.

Given the important potential role of AHCs in the quality movement and their ability to participate and lead effectively, why are they not leading the charge? The major barriers relate to the needs of their faculty members, whose advancement in the academic ranks depends on extramural (usually federal) funding and publication of their work in prominent journals. As a result, academics tend to focus on an academic cycle of “plan, do, study, and publish,” rather than on the continuous process improvement cycle of plan, do, study, act.

We suggest that these faculty members be encouraged vigorously to lead process improvement efforts in their areas of clinical expertise. They should be given protected time and funding to participate in training in continuous process improvement techniques. Moreover, academic leaders should work closely with hospital and clinic administrators to ensure that clinical faculty members have the resources to develop and complete continuous process improvement projects…. Medical school promotions committees should consider most favorably clinician-educators who lead and participate in successful continuous process improvement efforts.

Of course, many of the faculty members in AMC’s are clinical investigators. To get these faculty members to participate in and lead quality improvement efforts, we must persuade them to plan, do, study, act, and then publish. The currency of academic medicine comes in the form of publications in leading journals and in federal funding. Leading medical journals can encourage clinical investigators to undertake continuous quality improvement efforts by setting aside space for studies of such efforts…

Another critical ingredient in efforts to recruit AHCs and their faculty to the quality movement is the availability of federal funding for such projects…