How physicians drive innovation in medical product selection

Learn how new medical products and services that physicians use meet quality, safety, and value standards in the latest PermanenteDocs Chat featuring Sande Irwin, MD, chair of the Kaiser Permanente National Product Council.

Dr. Irwin talks to host Alex McDonald, MD, of the Southern California Permanente Medical Group, about how the Council evaluates medical products — everything from otoscopes and exam chairs to surgical tools and MRI scanners — through a uniquely integrated team made of more than 700 members who are physicians and also medical professionals from nursing, environmental services staff and more.

Guest

• Sande Irwin, MD, Chair, Kaiser Permanente National Product Council

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello everyone. Welcome to today’s Permanente Docs Chat. I am your host as always, Alex McDonald. I practice family and sports medicine here in Fontana, California as part of the Southern California Permanente Medical Group. For today’s chat, we have a returning guest. Dr. Sande Irwin is the physician lead of the National Product Council, and we’re going to be talking about all things National Product Council. I bet most of you don’t even know what that is. So Dr. Irwin, welcome back to the podcast. I appreciate you returning.

Sande Irwin, MD: Thank you. It’s really good to be here, Alex. I appreciate it. And please call me Sande.

AM: Alright, will do. So if you guys are joining us live, please put your questions in the Q & A box. We’ll get to these as many as we can, but these chats are short and high yield, so make sure you get those questions in early. So Sande, start by telling us who you are and what you do.

SI: So I’m a head and neck surgeon by trade and I’m based with Northwest Permanente. I still, despite the fact that I am the chair and lead of the National Product Council, I am still an active clinician. I still have a portion of my FTE that’s in active clinical care. So I’m still operating, I’m still seeing patients, still taking call. I got involved with the National Product Council quite some time ago.

AM: Okay, great. And you forgot to mention that you went into the best medical school ever, so shout out to University of Vermont. So not that we’re biased or anything like that. Well, so let’s take a step back here. Before I did my prep for this podcast and my prior discussion a couple years ago, I didn’t even know what the National Product Council was. So tell us, what is the National Product Council and why should physicians care about it?

Overview of the physician-led National Product Council

SI: The National Product Council is an entity that is sponsored by The Permanente Federation and it is a collaboration, a structured collaboration between clinicians and our supply chain service partners to ensure clinical oversight and quality and value of the products that we use in patient care. The National Product Council within Kaiser Permanente is pretty unique across the United States and the structure that we have because it is such a robust and well-supported structure because it is physician led.

Due to that clinical partnership between the clinicians and our supply chain partners, we have the ability to establish and maintain standards and provide clinically-driven decision support for the choice of products that we use in patient care. And when I say physician led, I think it’s really important to understand the gravity of that because we have a structure that includes over 500 physicians and non-physician health care clinicians who are accepted and empowered to be the voice of their constituents, who are our colleagues. That gives us the ability to really provide backing and support for the value-based use of the products that we provide.

AM: That’s such a great example of something that happens sort of seamlessly in the background that many of us don’t even know what happens and how this even works. I mean, I’ll give my own example. Right now I perform vasectomies here in my clinic along with a couple other clinicians and we are working on improving our practice and by doing so we need different instruments or a few new tools for this procedure. And I’ve actually reached out to materials management and they’ve worked very closely to try to make sure we get the right tools to do this procedure in a safe, evidence-based way to make sure we take better care of our patients. Is that a great example of why this matters?

SI: Yeah. You can think of it in broad terms of anything that touches our patients or anything that touches you and is something you encounter in your daily delivery of patient care, whether it is those instruments in your vasectomy tray, whether it is the handheld otoscope that you use in your primary care clinic, whether it’s the exam chair in your primary clinic, if you walk into that room and you look around, everything in there had some sort of oversight by a team on the National Product Council to make sure that it was appropriate. Now, clinic chairs, exam chairs, they’re not sexy, right? Surgical tools? I’m a surgeon, so I think surgical tools are quite sexy. But it’s important if you have an exam chair that doesn’t accommodate the size of your patient or can’t accommodate a person who needs a transfer from a wheelchair, that becomes a big problem. So even the pedestrian things that we use in patient care are important.

AM: And that’s makes such a big difference on when things are working properly. No one notices, but when there’s a problem it’s like, oh yeah, this wheelchair, excuse me, this exam chair doesn’t work for X, Y, and Z. It becomes a huge issue for not only physicians but also for patients. So I think that’s a really good example. Tell me more about how you became interested or aware of the National Product Council and how you developed this leadership role.

SI: Yeah, so my journey with the National Product Council started back in 2006. I had been with Permanente [Medical Groups] for a few years and the head and neck surgery sourcing team under the National Product Council was looking for a rhinologist from the Northwest who would come down to Southern California and meet with some vendors and look at some stuff. And they were just looking for somebody who was interested and I’m a sinus surgeon, I really care a lot about image guidance, which was the product they were looking at. And I said, heck yes, I would love to have some say in this. So I went and I gave my input and they picked the right system, in my humble opinion. But through that process I actually ended up becoming a permanent member of that head and neck team. And over the next almost two decades, I’ve had the privilege of moving up through some of the different layers of the National Product Council to where I’m now as the chair.

AM: That’s awesome. I think it’s so interesting, just an example of how we as physicians, we’re trained to do this one thing, but then within Permanente [Medical Groups] there’s so many other ways you can get involved and do unique and different aspects of leadership and health care delivery, which you didn’t even know possible all while staying within the Kaiser Permanente family, so to speak, which I think is kind of unique. So that’s a great example. You touched on this a little bit also, but how is again, physician-led National Product Council unique to [Kaiser] Permanente compared to the way it’s done in other systems?

Value-based use in medical product selection

SI: Probably the most unique part of it is that it is an intentional and structured process that proactively engages clinicians in decision-making. And it’s the largest structure of its kind in the United States. Like I said, we have, if you count everyone on the teams, including our sourcing experts as well as our clinical experts, we have about 80 subspecialty teams. So we have a broad coverage of the different areas of expertise. And so you don’t have – no offense, Alex – but you don’t have a primary care doctor who is making decisions about my head and neck surgical instruments. You don’t have a urologist making decisions about my radiologist input on MRI scanners. So we have a broad breadth of subject matter expertise. We have over 700 team members and that structure is formalized, it is supported by the enterprise, it’s supported both by our Permanente Medical Group leadership across the enterprise and by our health plan partners. I don’t think that that exists anywhere else. And it’s important because not only are we involved in clinical quality, we’re also involved in value-based sourcing, value-based use. We want good quality, the right good quality stuff to provide patient care, but we also want to be good stewards of our patients’ resources and we want to provide value. So we don’t want to pay a lot of money for stuff that is not high quality.

AM: Or that your physicians don’t want.

SI: Or that our physicians don’t want.

AM: I think that’s really unique and I have some colleagues who work outside in the fee-for-service world and a lot of times they’re told what instruments they can and can use by usually someone who’s not even a physician, let alone understanding how that product impacts patient care.

SI: And that’s the key, someone who’s not even a physician. So let’s be honest with each other. Within Kaiser Permanente we also provide a suite of materials for our physicians to use and we do have some control over what’s available and what’s not available. But those decisions are not made by a clerk or a purchasing person who really doesn’t understand what we’re doing to provide patient care. It’s made by our colleagues, by the subject matter experts in our area. And I really feel like because of that we have a lot of trust in the decisions that are made that we wouldn’t otherwise have. I don’t want to be using an instrument that was chosen by one of my favorite people, my clinic supply chain guy, who I love and is amazing, but he doesn’t know anything about what I do.

AM: Exactly. So we have a question here in the chat, which I think is great. As a physician-led organization, if there’s a change in product for whatever reason, how are you winning hearts and minds of physicians to get on board with that switch, which might change their practice sometimes? Do you ever have pushback and how do you help them understand the bigger picture to really improve care and quality and service to our patients?

Managing physician feedback and gaining buy-in of product changes

SI: So we do that in a couple of ways. Number one, we recognize that it’s not always the case. A single product is going to meet all of the needs for a specific scenario. So we don’t always have a single standard. We sometimes have a dual standard or sometimes as many as three products that all are available for use for a specific thing. So we really work very hard to make sure that we are meeting the full spectrum of clinical needs around a specific product type. We also recognize that sometimes we’re wrong and we don’t make the best choice. And we don’t want to commit the hubris of thinking that once we’ve decided, that there’s never going to be any new information; that would mean that we don’t need to change something. So we have developed a formal process to support feedback. We have an exception process. So if a clinician feels as though the current contracted product is not adequate to the task, they have a path to say, I need something different, here’s why. And that goes to our sourcing team, our clinician sourcing team, and they consider that. They look at the evidence basis and sometimes not infrequently, we say, okay, yeah, actually you need an exception for this device or this product. Sometimes they say, look, we actually have looked at all of that and we understand where you’re coming from, but you can do that job with what we have.

But there is a pathway, there’s not just a wall. Sometimes we have doctors who are pretty darn adamant. And when you talk about resistance, my approach to that is they’re frontline physicians, we are frontline physicians, and we can talk to each other. And we embrace those clinicians and we invite them to participate. That’s the main way I think that you engage people who are skeptical or really questioning the process: invite them in. There are a lot of members of our teams now that started off as dissatisfied end users and some of them made their case and got their product, got their exception approved and some of them didn’t. But still [they] were willing and engaged and interested enough to say, okay, I want to be part of this process and they’re on the teams now. And so it’s not perfect, but it really has been working well for us.

AM: Having it be a peer-to-peer conversation, an otolaryngologist to an otolaryngologist as opposed to a family medicine doctor to an otolaryngologist, I think having that area of expertise, which you shared, and also the peer-to-peer really makes a huge difference. And having everyone work together and collaborate creates a better end product. Sometimes it’s a little bit messier, it takes more time, but I think ultimately you have a better end product, you have a better quality care that you can provide for your patients. And encouraging behavior change…physicians tend to be set in their ways, let’s be honest. But I think it’s great that there’s a process to invite people in and engage, which is just amazing. And that’s the best way to make sure that process continues to work and move forward. Are there lessons here regarding the broader health care system and what you’re doing on the National Product Council? Can we use that as a model for saving resources and improving quality within the broader health care system?

3 lessons for the broader health care system

SI: I think there are three key concepts here that we are striving to do well. One is that idea of structured collaboration. You have to have organizational support for the structure required to formally stand up these teams and resource them. You have to have collaboration between the clinical subject matter experts and the supply chain experts. Our teams are really tightly integrated and our sourcing partners are family to us and we can’t do this without them. And frankly they can’t do it without us. It’s a team sport all the way. The last thing is the concept of value-based use. You cannot drive value-based use utilization, you can’t influence that unless you have clinical champions. A clinician will not change their practice when they’re asked to do so by someone who is not like them, who doesn’t do what they do. You have to have clinical champions.

And why is that important? Well, if you look at it, let’s say we’ve already established we are all about quality and our stuff is quality stuff. But the true cost value is in the how you use the stuff, not in the price of the stuff. The best price is free, but nothing is ever free. No matter how good of a negotiator you are, and as my supply chain partners, no matter how good of a job they do, they are never going to get to free. So there’s only so far you can go on price and the least expensive product is the one that you don’t use. This is where you heard me talk about the dual source, the multi-source. We do often have more than one vendor’s product available for a given application. And the idea is that I call this the 80/20 rule.

About 80% of the things that you need to do with that tool you can do with A, but about 20% of the things you need to do are more complicated, more difficult. There’s something about it that is different. And for that you need the special version, and that’s B. A might cost 1x and B might cost 10x sometimes. So when we put those dual contracts in place, we intend our users to use A 80% of the time and use B only 20% of the time. But they’re both available, they’re both on contract, they’re both fair game for use. So how does your end user know which one should be used most of the time? If they don’t know and they don’t know the difference, then they’ll just use B because B is shiny. It’s like the Cadillac, A is the Honda, right?

So value-based use requires clinical champions and you can’t get to that goal of value-based use unless you are working as a team. So the clinicians provide the guidelines for the intended use of these contracts, not how you use the device to do that surgery or do that thing, but how we intend you to use these choices and why. And so we call that decision support. The second thing is have a clear communication process for how we get the message out, how we disseminate that. And we rely a lot on our health plan partners for doing that. It’s also chief to chief, clinician to clinician communication. The next thing is data. So in order to really be able to drive this, you need to have analytics to know where you’re going with it. And then you need to have an implementation structure at the local level, which is what we call our local product councils. And that’s a collaboration between clinicians and supply chain. Our local product councils are both. So I like to give the example of, I have an olive oil example.

AM: Okay, please.

SI: I like to cook and I have a bottle of Kirkland olive oil on my kitchen counter. I also have a very fancy clay decorative bottle of super-expensive olive oil that I got from Italy. My husband has no idea the difference of these two olive oils. He thinks that I just put the Kirkland olive oil in the fancy bottle. And so the other day I caught him pouring super gold olive oil out of my fancy clay thing into a cast iron skillet to sear some meat. Smoke is everywhere. And I was like, that’s my good olive oil, you’re not supposed to use that. He’s like, well, when do you use it? I’m like, you use it on fancy salads, right? Dipping for bread. 80/20. The workhorse for the skillet is the Kirkland. The 20% is my fancy Italian olive oil.

AM: That’s a great example. So, are there other people involved in this? I mean, I’m thinking nursing or environmental services staff, are there more than just physicians on this National Product Council?

Multidisciplinary representation on the National Product Council

SI: Yes, absolutely. I mentioned those 500 clinicians and other health care professionals? I specifically didn’t say doctors because it’s not all doctors. We have nursing representation, respiratory therapists, we have in our sterilization, SSD, we have infectious disease folks, we have environmental services folks. We have representatives from clinical technology when we need to because some of our equipment that we source is large and has a big footprint. And when we need to, we engage national facility services people on our teams because we need to make sure that what we’re sourcing is not too big to fit into the space that we have. There are a lot of details that go into this and a lot of subject matter expertise all around, not just the physicians and nurses.

AM: A great example that medicine is a team sport. My last question: What makes you most proud to be a Permanente physician?

SI: The thing that makes me the most proud is that I work with a group of people who all care about one thing. They all care about patient care and they care about being good stewards of their patient, their patient’s resources. When every time I use something, I’m spending money and I’m not spending my money, I’m spending my patient’s money. And I think that everyone I work with on the National Product Council has that same mindset, but I think it’s pervasive throughout our organization. It’s all patient focused.

AM: Perfect. Such a great way to end the chat. Well Sande, thank you so much for joining us today. We really appreciate your time, your expertise, and pulling the curtain back a little bit and explaining what this National Product Council is and why it’s important for physicians and for patient care.

SI: Absolutely. It’s my pleasure.