The Clinical Practice Program: A How-to-Guide for Physician Leaders On Starting Up a Successful Program

CHAPTER 1

SEVEN PILLARS

There is a distinct difference between the science of healthcare and the science of healthcare delivery. The science of healthcare is what we commonly think of when someone speaks of medical literature. This can be everything from a case report to a large multi-institutional prospective, randomized, placebo controlled study. In theory, the culmination of this literature becomes the basis of our clinical practice. What we see in practice is not always hot off the presses from the latest medical journals. There is, what is referred to as the bench-to-bedside gap. It’s estimated that this time lag between what is demonstrated in research (bench) takes, on average, 17 years to find its way into the regular daily practice of medicine (bedside)¹. Transferring the knowledge developed at the bench to the bedside is referred to as knowledge translation². It is one of the things that distinguishes the science of healthcare from the science of healthcare delivery.

The model we have used for centuries is one where research is performed to test a hypothesis regarding a clinical question. The results are reported in the literature, and the assumption is that physicians read the literature, and change their practice based on the best available science. While this sounds good in theory, it does not always happen this way in practice. There are many reasons for this, not the least of which is the results reported in the literature are not always correct. When I was in medical school we were told that 50% of what we were going to be taught would prove to not be true. As you can imagine, our teachers did not know what part of our education represented the untrue part. It was going to be up to us to figure that out, and improve upon that body of literature over the course of our careers. There is no doubt that the literature has improved and grown in volume. It is the translation part that we are still struggling to perfect.

The basic question is, how do we take what we know works and operationalize that knowledge into our everyday practice within our healthcare systems? This book describes one of the ways to do this successfully, and my personal journey of what I learned in the process. You will encounter other ways to implement clinical practice change across hospitals and healthcare systems, but probably no other one that achieves it as quickly, and with such proven success as the method you are about to learn.

Each year our healthcare system put together a list of strategic initiatives for our balanced scorecard. Like many in the healthcare industry we had a balanced scorecard with four main categories. They were financial, customer, operations and learning. Under operations we typically would include strategic initiatives supporting the implementation of one or more clinical practices. I was asked to be a member of a committee that was looking at surgical practices. There were initiatives looking at changing clinical practices for orthopedics, blood transfusion and bowel surgery. My vote was for orthopedics, as I did not believe we would be able to get any major clinical practice changes accepted across our system for bowel surgery and blood transfusion. Needless to say I was deeply skeptical about getting any significant clinical practice changes implemented across a large healthcare system spread out over seven states. I later heard the strategic initiatives committee approved an initiative for bowel surgery. My first thought was, this is a big mistake. My second thought was, I pity the fool who gets stuck leading that initiative. You guessed it, a week later I was asked to lead the initiative.

Shortly after accepting the invitation to lead the initiative, I began buffing up my curriculum vitae. I thought for sure this initiative was doomed, had no chance for success and my career was in its final days. I kept those thoughts to myself. I also promised myself that I would give it my best. I figured, if it was going to fail, then I didn’t want it to fail for lack of effort on my part. It ended up being far more successful than I could have imagined. It also opened my eyes to the idea that clinical practice changes can occur over a large healthcare system by intention. The success of this initiative provided to me greater access to other quality and operational projects. There were many successes and failures along the way, and the one thing they all had in common was I learned what it takes to distinguish successful programs from the less than successful programs. I’ve written about two specific programs in my previous books, The Robotics Program: A How-to-Guide for Physician Leaders on Starting Up a Successful Program and The Value Analysis Program: A How-to-Guide for Physician Leaders on Starting Up a Successful Program.

So for whom is this book written? As you can see from the titles, these books are written for physician leaders. The target audience is specifically physician leaders who are responsible for starting up programs for their group, department, hospital or healthcare system. There are parts of each book that are redundant. This is by design. My recommendation is to start with the topic of most interest to you. Since you are reading a book on starting up a clinical practice program, then we can safely assume this is the area of most interest to you. Successfully implementing a Clinical Practice Program using the model proposed in this book should enable you to do two things. The first is to use this new skill to implement other clinical practices in your healthcare system. The second is to provide a model for how to start up other types of programs in general. With that in mind, reading the other books should only be done if you are really having difficulty getting a particular program up and running. They can provide some hints and suggestions that should be able to help you. For now, start with a Clinical Practice Program and build on that experience. So what is a Clinical Practice Program?

A Clinical Practice Program is a facility or system based program, which will develop and implement clinical practices for your healthcare organization. The fundamental purpose of any Clinical Practice Program is to effect clinical practice change that improves outcomes for patients and the healthcare system. A Clinical Practice Program is the overarching structure, whereas, a Clinical Practice Council is the formal executive arm which provides oversight in determining how that structure is integrated into the system and how it performs. Clinical Practice Teams are the sub-groups that may be used by a program to obtain insight and support from subject matter experts on the development and implementation of clinical practices. In the remainder of this book we will discuss the specific features of a successful Clinical Practice Program and especially successful Clinical Practice Teams.

In the remainder of this chapter, we will focus on what I refer to as the Seven Pillars of successful programs. If you read my previous books, then this will be very familiar. It is my belief that all successful programs will feature the seven pillars in some manner. These are higher level elements that successful programs build into their structure. To remember the Seven Pillars, think of the mnemonic SPECIAL PI. This stands for, Seven pillars, Purpose, Engagement, Communication, Infrastructure, Accountability, Leadership and Performance Improvement. Chapters two through eight will provide a description of each element in detail. The final two sections are checklists. The first is Appendix A which includes a checklist for how to start-up a successful program and specifically a successful Clinical Practice Committee or Team. The second is Appendix B which describes The Ten Step Plan for developing and successfully implementing a clinical practice in your hospital or across your healthcare system. The following is a summary of the seven pillars.

The Seven Pillars

1) PURPOSE: There are key elements to any successful program. It begins with having a purpose. Everyone on your team must understand the why. In chapter 2, we discuss the why in detail. In summary, it is because a formal organized approach to clinical practice implementation produces better outcomes with greater buy-in compared to not having a program.

2) ENGAGEMENT: Engagement has become a buzz word in the healthcare industry. More specifically hospital administrators and physician leaders want physician engagement. For many it has become a quest for the Holy Grail. The unstated belief is, If we only had physician engagement, then we could solve all of our problems in healthcare. There is no doubt that physician engagement is important for change management in healthcare. Before we get to this place though, we need to set up our program to become engaging. Chapter 3 will discuss this in greater detail. In summary, the first step in this process is to stop doing those things that disengage people, and move on to those things that create an engaging program.

3) COMMUNICATION: A Program must communicate with its stakeholders. It is impossible to educate and inform people without a consistent process for communicating to them. Communication must be a two-way process. A program must not only communicate to its stakeholders, but its stakeholders must