Yet that data have to be accurate, actionable, meaningful, reliable and valid, as well as the research sound and thorough for physicians to sit up and take notice. Or so supply chain managers continually are told by consultants and those peers who have suffered through the process with success or failure.

But is that data bulwark enough to establish a clinically integrated supply chain, if not dependable rapport with physicians? Or does the term "physician preference item" raise hackles among supply chain managers and doctors alike, fomenting battle strategies, rather than cooperative planning?

Not surprisingly, clinically integrating a supply chain may mean something different to everyone, but with some common denominators.

"For us, it would mean, when fully implemented, working hand in glove – pun intended – with clinicians to develop a process that allows for the highest level of quality at the lowest possible costs," said Joe Colonna, vice president, supply chain management, Piedmont Hospital, Atlanta.

"I define a clinically integrated supply chain as an ongoing collaborative process between supply chain, physicians, clinicians and vendors to jointly make product and technology decisions, which reduce supply costs while improving quality patient care outcomes," noted Mike Hildebrandt, associate vice president, supply chain, Scottsdale (AZ) Healthcare.

Deborah Petretich Templeton

"Clinical service line leaders are held accountable for building and leading a successful service line," said Deborah Petretich Templeton, vice president, supply chain services, Geisinger Health System, Danville, PA. "The most successful leaders recognize that supplies and equipment are a large part of their spend and a necessary part of the delivery of quality care. They also recognize that expertise found within supply chain can help them maximize the resources they have to be successful."

Christopher O’Connor, president, New York-based Nexera Consulting, indicated that "the bedrock of any clinically integrated supply chain is a strong value analysis process." This process involves the collaboration of "highly engaged physicians, caregivers and management" who "evaluate product selection and utilization, and focuses on evidence-based clinical outcomes, quality, service, reimbursement and costs, according to O’Connor. The supply chain efforts call for best practices and increased participation and accountability in terms of clinical and financial goals, he added.

David Reiter

David Reiter, M.D., MBA, FACS, Associate Chief Medical Officer at Philadelphia-based Thomas Jefferson University Hospital and Professor of Otolaryngology-Head & Neck Surgery (Facial Plastic & Reconstructive Surgery) at Jefferson Medical College, emphasized that a clinically integrated supply chain connotes "clinical input in decision-making at every relevant stage," including "market and horizon scanning, evaluation of clinical evidence support for adoptions and conversions, negotiation with manufacturers and vendors, feedback on product performance, interaction with reps and value analysis.

"I consider physicians to be integrated into the supply chain when they are educated in supply chain management methodology and local function, and they are actively and effectively participating in the efforts for which they’re responsible," Reiter told Healthcare Purchasing News. "So if they’re on the value analysis committee, their integration is evidenced by regular attendance and input. If they’re involved in new technology assessment, they maintain current knowledge of the relevant literature. 

"Another sign of successful integration is development of good working relationships between physicians and others in supply chain management," he continued. "The ultimate engagement comes with active physician gathering, analysis and reporting of outcomes data and comparative effectiveness during evaluation use in samples of statistically significant size."

In short, indicated Troy Hilsenroth, national director, vendor solutions, Omnicell Inc., Mountain View, CA, integrating physicians into the supply chain "means deploying an approach that is clinically centric, transparent and data-driven."

Achieving a clinically integrated supply chain not only is a challenge but also an ongoing challenge. Once you start – and you have to start to be fiscally responsible – you’re never finished and you never can coast on cruise control because critics can lurk and emerge when you least expect them.

Troy Hilsenroth

"Attaining alignment is difficult under perfect conditions, and I see many organizations fall back into non-desirable behaviors," Hilsenroth said. "This initiative takes time and determined leadership in order to change an organizations’ supply chain DNA."

But Reiter, Templeton and Hildebrandt acknowledge the value of their efforts, which they recognize as an evolving trend.

For example, at Geisinger, which earned HPN’s 2008 "Supply Chain Management Department of the Year" award, major clinical service lines have multi-disciplinary Clinical Use Evaluation (CUE) teams that are responsible for reviewing the utilization of current products to eliminate products no longer being used, minimize unwarranted variation and evaluating and approving requests for new products, according to Templeton.

"The teams are led by clinicians and supported by supply chain," she noted. "Decisions are based on clinical evidence and not merely preference. This process contributes to ensuring that quality and safety standards are maintained in product selection, has helped to maximize the investment in supplies and equipment and works to avoid duplication and waste. It also allows for healthy debate and discussion and to allow each person on the team to contribute their expertise to making the best final decision."

Scottsdale implemented a similar model. They established an "Executive Supply and Services Steering Committee" that oversees the work of seven teams set up to involve physicians, clinicians, vendors, supply chain, quality improvement and others in making medical supply and utilization decisions, according to Hildebrandt. These teams represent pharmacy, medical/surgical, perioperative services, support services, interventional radiology and diagnostic radiology, cardiology and spinal/total joint implants.

"During the past year, these teams have implemented over 380 cost-savings initiatives resulting in a cost savings of $13 million," Hildebrandt enthused. "In addition to the cost savings, the teams have involved physicians, vendors and clinicians in the process, which has improved communication, quality processes, physician choice and clinical outcomes. I believe that many hospitals are in the process of involving physicians and clinicians in medical supply decisions at a significant level."

Clinically integrating a supply chain can be fraught with road hazards commonly found in soap operas, including confusion, ego, misunderstanding and seduction.

"Active clinical input cuts through much of the marketing hype and dazzling array of product ‘features’ that may impress but have no clinical relevance and/or return no added value," Reiter contended. "It also enables identification of meaningful metrics by which to measure and monitor clinical outcomes affected by supply chain decisions. Clinical support for product decisions is a powerful tool in price negotiations as well. Pay-for-performance purchasing works when the added clinical value of a requested product can be measured and compared to substitutes."

But Reiter acknowledged that these efforts can be labor intensive and often requires input from highly knowledgeable and specialized physicians.

"Our approach sometimes takes more time and requires the ability and resources to access data and information," agreed Templeton. "Sourcing specialists and buying teams are encouraged to spend time in their assigned clinical areas to understand what goes on, how supplies and equipment are used and what the environment is like. We have also made the investment of having a nurse on the supply chain staff that acts to help ‘translate’ issues and is a valuable part of the communication necessary to have a good understanding of issues and requests.

"The outcomes that can be achieved by building this kind of collaboration become a very powerful process in ensuring that we are maximizing the resources allocated to patient care," she continued. "It contributes to the overall success of the organization. It also allows information to be shared between services lines so that we all learn from each other."

Hildebrandt indicated that strongly involving doctors and nurses in supply chain decisions can improve communication between the clinical, financial and operational areas that can lead to mutual trust and understanding of departmental challenges and needs. "This strong relationship between supply chain and physicians can result in a unified approach to focus on improving patient care outcomes," he added.

However, such efforts require more time, including supply chain leaders working longer hours to accommodate busy physician schedules, which can slow down the implementation schedule, Hildebrandt cautioned.

Christopher O'Connor

O’Connor concurred that because "the collective group must reach conclusions together" the decision-making process is lengthened, but establishing a sustainable process that drives supply chain savings shouldn’t be skirted.

"As a unit, working together, you can achieve much more than if you are working at odds with each other," Colonna concluded. "You can also tackle more than just price. You can look at processes and opportunities for greater efficiencies."

But Colonna, too, admitted that clinical integration "can be more of a marathon than a sprint.

"At least in the early projects, there must be time allotted for education, information and exploring ideas that may or may not work," he indicated. "I feel this is necessary, to allow the clinicians to truly feel like they are part of the process and develop ownership of the outcomes."

While data may be key in supply chain leaders establishing, cementing and maintaining active working relationships with clinicians it may not be a panacea.

"First, you have to have the systems in place to capture the pertinent transactional data that provides the who, what, where and when," Hilsenroth said. "Usually, the organization has committed to promote and support the use of automation to capture this data. Then you need the necessary data to analyze utilization by diagnosis, procedure, or case, and you can start correlating true utilization with outcome to find out the why. Clinicians are very data-driven. In most cases, presenting procedural- and outcomes-based analysis through data increases engagement and buy-in to these initiatives. Automation also brings increased efficiencies into operational workflows that stimulate the desire for change. 

"When presented with data, clinicians understand the financial burden of appropriate PAR levels based on utilization, stocking similar products from several vendors with no clinical benefit between them, expiration of supplies, and case-cost analysis compared to internal and external benchmarks, just to name a few," he added.

Colonna countered that data may be important, "but the vendors have their own data and often, at the beginning, a stronger relationship with the vendors.

"Your data may show savings," he continued, "while the vendors are showing how much revenue the facility is making. You have to know your battlefield, the other alliances and history of the relationships. Data will help but you are going to have to have a good reason for why the clinician is needed and must be part of the process."

Reiter noted that his organization tries to keep a tight rein on the data used in discussions and negotiations. "We use only high quality published evidence – GRADE level 1 or 2, if available – and use pro forma models based on both published evidence and our own outcomes and financial data to project clinical and financial performance of contemplated purchases," he said. "We only use manufacturer- or vendor-sourced data when it comes from independent peer-reviewed or otherwise authoritative sources."

Supply chain leaders should learn what information is most important and relevant to pull together for a particular discussion, according to Templeton. "We respect that the clinician’s time is important," she said. "They do not have the time to weed through mountains of data and lengthy spreadsheets. Supply chain does the initial data aggregation and then puts it into a standard format that is concise, well-organized, unbiased, accurate and contains timely information to support decision making."

Mike Hildebrandt

Hildebrandt acknowledged the complexity and daunting nature of collecting accurate data to present to physicians and clinicians, which is why his facility relies on its group purchasing organization for external benchmarking data and software tools.

"Assembling and showing the data are really an outcome of good planning and defining objectives," O’Connor advised. "You need to identify your objectives and the strategies to achieve them before you assemble data. If your objectives are to influence utilization and reduce costs through increased competition, then you need to assemble the information in a way that will organize the data along those lines. To minimize the potential for miscommunication and misunderstanding, and to foster a sense of collective ownership of the process, this should be done in collaboration with clinical stakeholders who are engaged from the outset. Including clinical stakeholders can also illicit unique insights into the products or services in question.

"Once you complete this phase, you can begin to assemble the data in the agreed manner. You have already established expectations that can be reviewed with stakeholders to close the deal, so to speak, subject to any modifications that would be made upon review to enhance the quality of the data presentation," he added. 

When supply chain leaders try to influence and potentially modify clinician behavior in terms of product usage, their efforts can go disastrously off track. Many derailments can be attributed to communication and timing problems.

Reiter listed the egregious: "[Supply chain managers] fail to engage the medical staff at the strategic planning level, bringing them in only for adjunct assistance with operational issues. And they fail to provide the relevant business knowledge, skills and experience that most physicians lack but that greatly aids physician input into planning, negotiating, contracting and other supply chain management functions.

But Reiter offered this ray of hope. "Most supply chain managers I know do understand the benefits of physician integration and are structuring workflow around conflicting schedules such as procedures and office hours," he added.

Geisinger promotes clinical collaboration with finance and operations, according to Templeton.

"We recognize that we are all working for the same goal – the provision of safe, quality and cost-effective care of the patient," she indicated. "Managers that expect someone to make clinicians use particular supplies, make proposals that are not backed by accurate information or do not contain clinical input, or those that try to impose sanctions for non-compliance will most likely not be successful in the long term. Credibility that is built by working together is one of the best long term approaches."

Hilsenroth concurred. "To succeed, supply chain managers realize that it takes a different skill set than what has made them successful in the past. Supply chain managers typically do not follow general change management principals such as developing a sense of urgency, building a coalition of support, communicating the vision, and empowering others to act on the vision. The managers that succeed develop the strategy and deploy the operating structure to support the attainment of organizational goals," he said.

Recruiting and involving all relevant clinical team members helps get the right data to the right people for a quicker and better decision, O’Connor emphasized. "Managers can run into barriers by either developing the committee alone or getting the wrong people involved," he said. "A decision to implement value analysis has to be made at the executive leadership level and then trickle down through the organization to be effective."

For supply chain leaders, earning and maintaining clinician trust should be one of their most valuable commodities and sustainable qualities.

"Physician trust in supply chain personnel must be earned up front by demonstrating a primary concern with outcomes," Reiter urged. "Focus on budgetary targets and arbitrary comparative performance measures rather than clinical outcomes will erode that trust, and it is harder by far to regain than it was to gain. One loss can offset the value of a hundred wins in this area."

Joe Colonna

Colonna agreed. "You have to consistently do what you say you will each and every time. This, by the way, means calling out physicians when they do not live up to their promises," he added. "When you can do this, you are operating as a true team and have a much deeper level of trust."

Templeton deflected the term trust in favor of credibility and transparency as key indicators. "This credibility comes from being prepared for discussions, having good follow-through on initiatives and providing feedback on progress," she said. "Providing education to clinicians on the impact of different factors on the total cost of ownership for choices that are offered is important. Sharing knowledge on how the supply chain works is also helpful."

Earning and maintaining trust with its independent physician practitioners remains an ongoing effort at Scottsdale, according to Hildebrandt. Efforts include conducting annual physician surveys to gauge satisfaction levels and identify areas of improvement and installing physician compact agreements to solidify mutual goals and objectives.

"Supply chain has reached out to physicians at medical staff section meetings and in one-on-one meetings to gain their input and support." Hildebrandt said. "Supply chain has teamed with our GPO physician office practices through its physician purchasing programs. We also try to provide our physicians as much choice as possible by negotiating capitated pricing programs for spinal implants and total joints. Successes are celebrated and physicians are recognized by name."

Fundamentally, it’s a cultural thing, Hilsenroth observed.

"Trust comes by changing the culture from the way things were previously done and integrating the supply chain as a partner in the clinical process," he noted. "The consistency of a multi-disciplinary team working toward common goals will provide a better understanding between the different stakeholders and create an environment that is conducive for collaboration."