Breaking Down Surgical Care Improvement Project Physician Barriers

1
Breaking Down Surgical Care Improvement Project
Physician Barriers

• Mark Michelman, M.D., M.B.A.
• Clinical Director
• FMQAI

2
Objectives

• Barriers with non-compliant physicians (SCIP)
• Successful interventions (SCIP)

3
Keys To Physician Acceptance

• Credible evidence based literature
• Evidence should be compelling
• Presented by a credible, respected physician
  (preferably their specialty)
• Explain that their peers endorse

4
Hospital Process In Place To Educate Physicians

• EBM education to medical staff
• Process to help physicians with indicators
• Concurrent review to catch missed indicators
  (early, late)
• Retrospective review (educational)
• Physician profiles

5
SCIP 1 Barriers(Antibiotic Within One Hour)

• Never gets done in one hour
• Doesnt make any difference
• No infections
• Never use antibiotics anyway

6
SCIP 1 Responses (Antibiotic Within One Hour)

• Literature clear (EBM)
• Does make a difference
• Infections are related to timing of 1st dose
• Antibiotics are effective
• Hospital process (delegate individual/ team)
• Tourniquet issue
• Vancomycin issue

7
SCIP 2 Barriers(Evidence Based Antibiotic)

• Who are these experts telling me (30 years
  experience) what to do?
• Are they clinically involved, on the
  battlefield like me?
• My patients dont get infections.
• Dont tell me how to practice medicine/surgery.
• Why cant I use Vancomycin on all my patients?
• Why cant I use antibiotic x
• FDA approved
• Endorsed by manufacturer

8
SCIP 2 Responses (Evidence Based Antibiotic)

• Experts are knowledgeable, credible, and in
  active practice.
• You have been lucky so far (wont be able to
  defend SSI with unapproved antibiotic).
• Vancomycin over utilized
• Increased infection rates
• Increased resistance
• Many antibiotics approved by FDA, and
  manufacturer endorsed, not agreed by experts as
  good prophylaxis at this time (inadequate trials,
  time)

9
SCIP 3 Barriers(Why Physicians Dont Stop ABX
at 24 Hours)

• Most difficult
• Just because.
• Fever.
• Infection.
• Tubes, drains, still in place.
• No literature to support.
• My patients are sicker.
• Training program taught me this way.
• I know what is best for my patient.

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SCIP 3 Responses(Why Physicians Dont Stop ABX
at 24 Hours)

• Ample literature to support (many years).
• (one drug, one dose, one time, many
  procedures)
• Fever usually secondary to atelectasis.
• If infection on prophylactic ABX, no sense to
  continue (?resistance).
• Contact surgical training program.
• You may not know what is best for your patients
  (only your assumption).
• Meet with ACS state chapters.
• Meet with medical school surgical programs.
• Society of Thoracic Surgery 48 Hours

11
Shaving Barriers

• Shave for years. No infection.
• Shaving doesnt cause infection.
• Must shave (hair is dirty).
• Cant see wound.
• Cant apply bandage/tape.

12
Shaving Excuse Response

• Literature supports risk of infection.
• If patient becomes infected, after shaving,
  difficult to defend.
• Options
• Clip
• Depilatory
• Nothing

13
Hypothermia

• Issues
• Hypothermia contributes to
• SSI
• Cardiac irritability, cardiac arrhythmia
• Bleeding
• Barriers
• Surgeon wants cold OR
• What is more important - comfort of surgeon vs
  risk to patient
• Solutions
• Cooling vests for surgeon.
• Warming blanket patient.
• Warming solutions.

14
Hyperglycemic Issues

• Correlation increased BS and SSI.
• Longer exposure - more frequent SSI.
• Increased BS paralyzes function of WBC.
• Response to high BS phone call just repeat.
• No process to address high post-op BS.
• My patients dont have diabetes.

15
Hyperglycemic Responses

• Data supports infection with increased BS.
• Not just CABG.
• Could apply to all procedures with hyperglycemia.
• 1/3 of med-surg patients may have DM.
• Implement hyperglycemic protocol with a trigger
  BS.

16
DVT/PE Prophylaxis Barriers

• My patients dont get DVT/PE.
• I ambulate patients quickly.
• No literature to support.
• ASA is good enough.
• Dont believe any risk.
• Elastic stockings are just fine.
• My patient had a bleeding ulcer 10 years ago
  too risky to use anticoagulants.

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DVT/PE Solution

• Ample evidence based medicine in literature.
• BRP daily inadequate ambulation.
• Patients end up in hospital with DVT/PE.
• ASA not effective.
• ES not effective.
• NB issue regarding counter pulsation pressure
  devices.
• NB chemoprophylaxis vs pressure devices.
• Age gt40, general anesthesia gt 30 minutes
• Bleeding too remote
• Geerts with Chest.2004, 1263385-4005

18
Beta Blocker Barriers

• Dont believe literature.
• Patient has asthma, COPD.
• Patient has bradycardia.

19
Beta Blocker Responses

• Evidence based literature (recent controversy.
• Only relative contraindications.

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Fistula Barriers

• Why should I?
• Takes longer to do.
• Takes longer to mature.
• Pays me no more.
• Delay in dialysis (for maturation).

21
Fistula Responses

• Right thing to do.
• Shouldnt take longer.
• Better outcomes for patient
• Quality of life
• Decreased mortality
• Less procedures.
• Reimbursement issues need to be addressed.

22
VAP Barriers

• I elevate bed.
• Nurses lower bed.
• I see no difference.
• Patient more comfortable.
• I dont believe peptic ulcer prophylaxis
  necessary.
• Dont believe weaning protocol necessary.

23
VAP Responses

• Data supports
• (recent controversy)
• No difference regarding patient comfort.
• Weaning protocols effects.
• Show physician profile.

24
Reasons to Support Physician Compliance

• Right thing to do
• Quality issue
• Financial issue (P4P)
• Liability issue
• Public reporting issue
• Need to hold physician accountable (only if
  hospital has process in place).

25
Dealing with Non-Compliant Physicians

• Carrot vs stick
• Education
• Physician profile (bubble graph)
• Counseling
• Chief of service, Chief of Staff
• Physician advisor
• VPMA/CMO
• Letter to support action (evidence based)
• Meet with MEC
• Peer Review
• Credentialing
• Track and trend

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MEC Action

• Additional counseling.
• Letter of reprimand.
• Mandate CME.
• Mandate second opinion.
• Possible corrective action (possible suspension).

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Risk for Hospital (Allowing Physicians to be
Non-Compliant with Quality Indicators)

• Poor outcome data.
• Public reporting implications (state, CMS,
  national ? impact referral pattern).
• Financial implications (P4P).
• Legal implications
• Physician was non-compliant.
• Hospital no oversight.

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Improvement Never Ends
Questions ?
Thank You
This material was prepared by Florida Medical
Quality Assurance, Inc., under contract with the
Centers for Medicare Medicaid Services (CMS).
The contents presented do not necessarily
reflect CMS policy. FL20051c151027440A.
29
Mark S. Michelman, MD, MBAClinical
DirectorFMQAIPhone [phone], extension
3540E-mail address mmichelman_at_flqio.sdps.org
This material was prepared by FMQAI under
contract with the Centers for Medicare Medicaid
Services (CMS The contents presented do not
necessarily reflect CMS policy.
FL20061cFT1C011510189