Hello, my name is Lisa Hsieh, and I'm here to talk about engaging physicians in quality improvement using cost savings reinvestment program. So just to note that this is a re-recording of the SHM Converge event. Unfortunately, the recording there was not of high quality, so we're here giving it again. So we will not have the exact same physician, the audience engagement that we had before, but we will review the principles of the program, and I am very happy to answer any questions that people may have after watching this recording. You can see my email here. So thank you. So there are no disclosures for the speakers of this session. So to introduce myself, my name is Lisa Hsieh, and I am a hospitalist at Stanford Health Care. And so one of my roles, I do a lot of quality improvement, is I am the chair of the cost savings reinvestment program, which is what we'll be talking about today. And I want to say up front that this program has really changed my life as well as my other hospitalist colleagues. Through this program, we have been able to do quality improvement initiatives, and through the cost savings reinvestment, actually reinvest in programs that we care about. So really happy to share this with you, and again, as I mentioned before, happy to answer any questions. My colleague is Renee Boggs. She's the director of strategic initiatives. She is basically the – she's like the heart behind this program. Unfortunately, she cannot make it today, but also very happy to answer any questions. But Renee and I have worked together for several years in this program, and we were very passionate about this, so happy to speak about it. So here are the session objectives. We wanted just to basically create and describe the benefits of a cost savings program with physician leadership, and we wanted to help to create strategies to promote cost savings ideas that are not advised centrally by your organization. We'll discuss effective physician engagement strategies using quality improvement, and then we'll also talk about the benefits of sharing a portion of the cost savings from these improvements. You can see the agenda. We'll talk briefly about the incentive to innovate. We'll do some nuts and bolts about how to implement a physician engagement program, and then again, what are the strategies for identification and implementation of cost savings opportunities. Okay, cost control initiatives. So what are the benefits of engaging physicians in cost savings? First, physicians control 60 to 80 percent of healthcare expenses. They use things, right? So supply costs, utilization, and we make clinical decisions. We also have firsthand knowledge of clinical workflows. We interpret and apply relevant clinical performance and outcome measures, and physicians and many clinicians, they do lead changes in clinical practice. So these are really why it's so important to engage physicians in cost savings. Now there's a lot of challenges with this as well. As you may all know, many physicians view their responsibilities as exclusively providing best care possible for the patient right in front of them, and many of them feel like cost reduction is not part of their role, and many people are, you know, clinicians are very, very busy. So they don't have a lot of time to design or build cost savings initiatives. Also in healthcare, sometimes, and many times, how much these costs is not transparent at all. It's like many without prices. Many of us do not know how much it costs to order an MRI or a CT scan or, you know, an expensive IV medication. And then finally, directly rewarding physicians for cost control can pose ethical and legal challenges. We're going to briefly talk about physician motivation because, you know, like how do we, you know, incentivize people, you know, it's intrinsic motivation and extrinsic. So this program really focuses on intrinsic motivation. Now we want to really engage our physicians and like how can we improve the health of their patients, like what is the right thing to do, you know, doing something very well. And so, you know, like these are the things for intrinsic motivation, whereas extrinsic is more, you know, for simple, straightforward things. So, but these would include like salary, fee-for-service, capitation, target payments and bonuses, which we do use some in quality improvement. Physicians really have high intrinsic motivation, and we do believe that this program really helps promote, like, you know, this, we basically let the physicians, you know, talk about the projects, do the projects they really want. And based on that, we feel like they will do it because it's something that really bothers them. If they find like waste in the OR, how can we really encourage a surgeon to think about reducing that waste in the OR? Okay, so how do we actually set up the program? So the vision of the cost savings remittance program is really a partnership between the School of Medicine and Stanford HealthCare to increase the value of care for our patients. And the mission is to benefit both the School of Medicine and Stanford HealthCare, again, by engaging physicians to develop and implement initiatives that reduce costs while maintaining or actually enhancing the quality of care provided to our patients. And so, again, as I said, it's a partnership between the School of Medicine and Stanford HealthCare. And how we do this is that a portion of the realized cost savings from these improvements are basically shared with the School of Medicine. And the physicians that lead the programs actually help decide what to do with these funds. It may be to purchase equipment, research, QI, education, other things that are really important to them. What it cannot be used for is it cannot be used for compensation or bonuses. The way we actually do the savings is that we calculate it based on direct costs over the 12-month period. So we have, let's say, an intervention start date. We will look back 12 months before. That will be the baseline costs. And then we'll take that start date and look 12 months after the intervention. And that will be your improvement period. So if between savings of $50,000 to $500,000, we will transfer 50% of this cost savings to the department. And over $500,000, then it will be 25%. We want to see sustainment. So 80% of the savings will be transferred after the first 12-month improvement period. And then after your second 12-month period, your second year, if you have sustained improvements, we'll then transfer the rest of the 20%. And I got feedback to show this slide earlier in this presentation. So this is our journey since 2017 when we started this program. And you can see over the past eight years, we have saved $37 million. And I can tell you that is a return on investment. It does not cost that much to run this program. In fact, it's a very lean program. It's myself, and I do not get paid to do this as the chair of the program. And Renee Box, who is the program director, we support her. But otherwise, it's a very lean program. And over the years, if you can see, what's really interesting is that the program started as really physician preference items, like in the OR, like supply chain. And over time, we have grown to pharmaceuticals and then also clinical improvement. Some of our biggest cost savings have been in clinical improvement redesign. And so, you know, appropriate accommodations, you know, making sure we…and we had a recent redesign of an EP procedure that saved millions of dollars. So, I apologize, I'm going to close this. So you can see those are big cost savings here of $13 million for the EP service, early discharge. And also, just making the EP procedure more inexpensive. And then just appropriate accommodations and level of care. As part of this physician engagement program, we obviously have to be clear what is physician engagement. So, one of the things is that the physicians, you know, help think of the idea, or at least part of the design, implementation, sustainment. The original proposal can…or idea can reach a physician leader or, you know, an operational partner who comes to them with an idea, but it definitely needs significant physician engagement to move forward. They have to have clinical subject matter expertise of the physician that exceeds the standard of care beyond, like, their medical direction responsibilities. And they need to be responsible for the implementation and sustainability. They, you know, one of the strengths is really the communication within the community. And you know, really getting their peers involved, ongoing monitoring interventions, and also really driving those best practices. So, it's, you know, so much more effective to have a peer leading this rather than, like, an administrator. So, these are really some of the strengths of the program. And what really makes it unique is, again, I mentioned that intrinsic motivation. Physicians choose projects that really matter to them. And we help support them, you know, through coaching. We provide them cost data. We help them with stakeholder involvement. And we also have a centralized incentive program that drives very large projects within our departments. But the beauty of this program is that it really crowdsources all our physicians. So, any physician who has a good idea can come forward and put a proposal into the CSRP program. Whereas some of our bigger clinical departments and programs, they can only choose a couple of projects to do. And so, they can't capture all projects. And we have examples of some of our GI physicians have come forward with some of the state projects that we did not do through our central program. We have many lab utilization projects that also did not go through our central program. So, this program, I think, works very well with a centralized program in capturing all physician ideas. There's a shared risk. So, if the project does not save any money, there is no cost sharing. So, you know, there's very little risk to the Stanford healthcare. It's a quick way methodology. And then also, it helps medical directors partner with their peers in getting them more involved in projects that they could not move by themselves. For example, like I mentioned, we recently did a daily lab utilization project. And the lab director was involved, but we needed the involvement of our hospitalist group and other physician leaders in other departments. And then, at the end, the cost sharing is done for reinvestment. And we mentioned, you know, it can be used for anything beyond that's not compensation or bonuses. So, an example that we did with my colleague and I, we created a mini C-GRIB program to run sustainability programs to reduce waste in our healthcare system. We felt very strongly about this. So, we used our money to help, you know, jumpstart other C-GRIB projects. And this is a push and pull. So, I would say the pull is, like, our physicians coming up with ideas they see on the ground that really they identify. Whereas the push might be we, as an institution, know that we use a lot of ibutylenol, and we may come to our physician leaders and say, you know, how can we think of ways to improve on that? So, like, there are ways that... We had a project where we looked at echocardiograms and we used benchmarking, and we saw we ordered more ECHOs than almost all other AMCs, and so we designed a project using limited ECHOs to see if that would help with, you know, ordering of our full ECHOs, or decrease the ordering of our full ECHOs. Okay. We have a governance charter. Our CMO and COO are our sponsors, and we also have, you know, voting members. What we did learn over the years of how important it was to include our service line VPs, as well as sustainability, pharmacy, nursing, but you can see that we have key stakeholders in this group. We also have requirements. We have a detailed checklist that we go through. You know, it needs to be aligned with the operational plan, needs to show physician and leader engagement. We need to have our department chair sign off, the senior VP, et cetera. This is really just to make sure, to ensure success of the project, of having our leaders be involved and aware of the project and can provide resources when needed. It's also really important to make sure these cost-efficient products do not impact the quality or outcomes of our care. We want these projects to, you know, we always ask for balancing measures, and we will ask the physician leaders to provide those before the project starts and throughout, you know, and after the project ends to make sure that there is, the care has not been, the care has not been affected. So the balancing measures are really important to look at. Okay. So you can see, we also look at financial impact and measurement. Our finance team actually works really closely with us to help with the cost savings calculations, and we do provide feedback to our teams, you know, once a quarter on how they're doing from a cost-saving standpoint. You know, the team should be using their own process measures to, of course, look at improvements in their project, but we will provide some cost savings calculations throughout the year. So given, like I said, the thing we mentioned that we learned over the years, how important it is to have our major stakeholders. So if a project involves supply chain, we have our supply and chair VP review the project. If it involves a pharmaceutical, we have our pharmaceutical, you know, chair review it, and then sustainability, which has been a big emphasis at our institution. We have our sustainability team look at this, and this is really to help ensure success of the project and as well as alignment. We also have a core team that reviews projects. You can see the different roles in there, but it's, again, very important for us to have like nursing, digital IT. So, you know, a lot of our projects involve Epic and creating a best practice alert or order sets, et cetera. So if we see that as a requirement for the project to move forward, we will ask our IT team to review the project and give approval. So thank you again. These are, I would say, highlights of our program. You can see my email address here. I welcome any emails from you about questions of the program. In the slide deck that will be shared, we have examples of many of the projects that we've done. So if you're just curious to see, please review the slide deck. And again, like I said, I'm happy to answer any questions.

physician engagement

cost savings

quality improvement

healthcare expenses

patient care