Physician Engagement in Cancer Care Delivery Redesign
By Nicole Hartung, MD
CMS Innovation’s Oncology Care Model began on July 1st. This alternative payment model tests whether specific changes in cancer care delivery can result in “better care, smarter spending, and healthier people.” There are numerous process, outcome, financial, and patient-reported metrics being evaluated throughout the course of the program. Practice success in the program will depend on a practice’s ability to consider, create, and implement redesign activities to enhance the delivery of cancer care. This task will take a tremendous amount of thoughtful input from numerous stakeholders; to be successful, physicians will need to take a lead role in both care changes and peer-to-peer discussions of implementation to ensure consistent, evidence-based delivery of care to every patient, every time.
Knowing how to begin the daunting process of integrating physicians in quality and performance projects can be intimidating — yet there is excellent literature available to help lead the way. The Institute for Healthcare Improvement’s (IHI) Innovation Series 2007 white paper on the subject provides an excellent starting place.1 This article provides a framework to engage physicians in hospital-based quality improvement. However, the elements of their structure can easily be adapted to oncologist engagement in cancer care redesign in the context of the OCM. Using the implementation of the OCM-required Institute of Medicine-derived treatment plan, we can review how the IHI engagement structure can support physicians.
Discover a Common Purpose
As cancer care providers, we all have a common goal — to provide the best patient care possible. The OCM requires specific treatment plans delivered to the patient: Documenting stage of disease and important biomarkers, prognosis, treatment, intent of treatment, expected outcomes of treatment and side effects, along with other components. This is an additional physician-specific administrative burden. To set up realistic yet hopeful expectations for all, we have to remind physicians that the outcome of this document is to engage and educate patients in their disease and treatment, and to create a common mental model of what treatment is trying to accomplish. This includes transparency of goals of care not only within the treatment team, but also with the patient and family.
Reframe Values and Beliefs
Oncologists work long hours in a rapidly changing and increasingly complex field that is also emotionally dense. High rates of burn out (emotional exhaustion and depersonalization) are being reported in oncologists nationwide. Adding meaningless administrative overhead to a physician’s day is not helpful when trying to enact change. However, physicians can proactively partner in the process of meaningful change rather than react to it. The administrative system needs to ask physicians and expect them to partner in projects such as designing, reviewing, or testing new forms and documents such as the treatment plan.
Segment the Engagement Plan
Numerous opportunities for physician engagement exist in the thoughtful approach to change management. Prioritizing the necessary provider changes, implementing them in a step-wise fashion, and regularly communicating the overall vision and timeline for care redesign gives all participants a better sense of control and creates a joint culture of engagement.
The treatment plan is the most significant physician-required change within the OCM. Every practice has physicians that are early adopters. Finding and empowering them to speak to their experience using the treatment plan as a communication tool to patients and their families can begin an open discussion of a physician’s experience – good and bad. Utilizing these champions of positive experience can help to manage and temper the ‘laggards’ who may not yet see or understand the benefit of this form of patient-directed communication. These individuals can also be self-sustaining champions for other new activities. Lastly, creating an overall governance plan within the physician practice that supports redesign activities is needed (i.e. what to do with outliers that might not participate in the required documentation and disbursement of the treatment plan).
Use Engaging Improvement Methods
A quote attributed to Benjamin Franklin states, “Experience is the best teacher, but a fool will learn from no other.” We all learn most memorably from the projects we have struggled over. However, there are best practices that can more easily influence physician engagement. One opportunity to observe this is in the attempt to standardize.
Some standardization is good and necessary to minimize unexplainable clinical variation, streamline care, and reduce practice administrative burden. However, rigidity is not feasible or advisable in dealing with healthcare change and healthcare providers. The practice of medicine has too many unique features to subscribe to one inflexible model. Therefore, the IHI rightly promotes standardizing care processes, but allowing customization within those processes to meet the unique patient and situational demands. Within the treatment plan, this can be seen with having one standard form within a practice with a standard expectation of physicians completing the treatment-specific components. Within those expectations, variation of wording and processes of the form can occur.
Physician engagement in quality improvement cannot champion change alone. There is an obvious need for practice leadership, boards of directors, and others to back up the care delivery changes occurring not just in closed-door meetings, but also publically at points of contention. Therefore, when expected resistance to a new requirement, such as the treatment form, occurs, the group leadership and board members need to vocally support the change.
Adopt an Engaging Style
Much like using ‘engaging’ methods, adopting an engaging style in interaction with physicians can be the key to OCM success. For example, with the treatment plan implementation, it will be important to involve physician champions from the start and then have practice-wide messaging to create visibility of the proactive, productive behavior. Regular communication with the greater group of physicians is the most important effort that can be made. Succinct, clear messaging with obvious indication of expectations of physicians is helpful. Lastly, making regular site visits and meeting with physicians to explain the treatment plan and answer questions shows you value their effort and time.
Productively engaging physicians in the OCM-required care redesign activities will take time, attention, and effort. Yet this program offers a great opportunity to learn how to create an ongoing engagement strategy for physicians and, ultimately, better patient care.
Nicole Hartung, MD is medical director of quality for Minnesota Oncology and director of OCM for The US Oncology Network.
1 Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007