Ch-Ch-Ch-Ch-Changes (photo in post)

Today at the Northshore Medical Center the Front Line Improvement (FLI) team set about discussing the sticky issue of change. They have been doing small team-based improvements for a couple months now and having a lot of fun! Not surprisingly this has brought up conversation around change because every experiment they run represents some level of change in the teams. Change–even when it’s an improvement–is not always easy.  Sometimes it can even lead to resistance. So they asked their leaders to provide them with some education to understand how to deal with this themselves and how to better understand and support their colleagues as they experience the changes that the FLI team experiments are generating.

Before the meeting the team all read through some helpful materials from our HR department regarding the path that people may go through as they transition through change. Alicia Eng, Administrative Director, and Steve Hockheiser, Medical Center Chief, led the team through a discussion and exercise to better understand the four phases on the transition path; Denial, Resistance, Exploration and Commitment. They discussed what it means to be in the various phases and what a person might need to help move them through the transition path from denial to commitment.

They talked about their own role versus that of management and were honest with each other about their personal experience of transition that has resulted from being part of the FLI team.

On the floor of their meeting room was a large cross made of blue painter’s tape representing the four quadrants on the transition path. They each got up from their chairs and stood in the quadrant they felt represented their current experience related to the FLI process. Although you cannot tell from the photo which square corresponds to which phase each team member was in one of these three places: Commitment (as seen in the left of the photo), on the line between Commitment and Exploration, or in Exploration (the right side of the photo).

Congratulations to our teams at both Northshore and Redmond who have braved the world of front line improvement and all the change it represents for themselves and their clinics. And thanks to the rest of the clinic staff who have been willing to run the experiments designed by the FLI team and give them honest feedback to help ensure that their experiments result in improvement, not just change. To quote a famous British pop icon they have been willing to “turn and face the strain” on the path toward continuous improvement at Group Health.

Feet In Transition

Evidence-Based Baseball

I was at a conference in June and ran into a doctor from Boston who suggested I read Michael Lewis’s Moneyball, a 2004 nonfiction book about baseball. He thought it would influence the way I think about health care.

Because baseball and health care are exactly the same, right?

I like baseball so, I read it. And it did change the way I think about health care and how we do it at Group Health. To explain, I have to give you a “bullet presentation” of the Moneyball story:

  • Baseball is full of things to measure. Most of what people currently measure doesn’t help teams win games;
  • The Oakland Athletics (A’s) baseball club has a limited budget to spend on players (compared to other teams);
  • The A’s think measuring the right things (that others don’t) will help them win more games than richer teams that can buy star players;
  • The A’s are right.

Oakland players focus on key behaviors that link, step by step, to the ultimate goal of winning enough games to make the playoffs. Players practice patience when batting, they wear out pitchers, and they don’t take low-yield risks. Mastering these critical behaviors is difficult for players, who have risen to the highest levels of baseball by doing just the opposite (heroic acts and big risks).

What about this baseball story resembles health care? Lots:

  • Health care is full of things to measure. Most of what we currently measure doesn’t help patients to be healthier;
  • Health care has a limited budget to spend on making patients healthier (though we haven’t yet learned to live within our means);
  • Group Health knows that measuring the right things will help us help patients be healthier, and we’ll do it more affordably than everybody else;
  • We’re right. Right?

By developing our Medical Home Model of care and managing it with Lean methods, we link day to day behaviors of primary care teams to the ultimate goal of affordable excellence. We seek out care gaps, develop care plans to manage disease, encourage prevention, and give patients multi-modal access to our whole team. And team members talk—in person—about patients, processes, and outcomes. We’re learning what is effective as we go.

But this is hard work! The skills we are asking one another to master are not what got us here. We have to work against our training, conventional wisdom, and—hardest of all—our habits. I am awed by the size of the challenge and the enthusiasm my colleagues show for taking it on.

Primary Care is unique in its complexity: breadth of scope, information volume, rapid scientific change, and human (patient) variability. There is so much to measure. As in baseball, conventional wisdom encourages health care folks to measure things that don’t matter much. Even our current Medical Home systems follow flawed metrics. We can improve our metrics and our processes by careful observation, respectful questioning, and incessant experimentation. We reinvent the work as we do it, share what we learn, and script—temporarily—the moves we believe critical to achieving affordable excellence.

We are in the infancy of our work with Medical Home and Lean. In 2013 we’ll look back at our 2010 processes and metrics and say: “Why did we measure that? We’re so much better at this now.” And in 2015? We’ll be better still, our work will look different, improvement cycles will be shorter; 2010 will look like the Middle Ages.

Several major league teams have adopted Oakland’s “evidence-based baseball” methods. As we get better, others will adopt ours. This is good news. Health care needs change. And Group Health has to lead it, because we can.

MOELLER IN OLYMPIA

It is not uncommon for us to have neighbors and friends ask for medical advice.

Translating how things work, “out there” and how we do things can sometimes be problematic, and sometimes, in describing how we doing things, an object of pride.

Jane, an old friend who has a complicated medical history with regards to asthma and hay fever recently called a few weeks before her daughter’s wedding with the following plea:

“I have not been able to smell or taste anything for weeks. The last time this happened, I was prescribed prednisone and it worked pretty well; any chance you could call me in a prescription?”

Jane is not a Group Health patient. When I asked how it was that her physician was not able to help, she told me that her primary care doctor refused to treat her as she was, “too complicated” and that the pulmonologist that had consulted needed to weigh in. The pulmonologist, a quality doctor in our community, had received three calls from Jane with promises from the office that someone would get back to her over a two week period. She was calling me in desperation as no one had responded.

I let Jane know, this could not happen in the system of care I work in and that it should not happen in hers. I asked her to make another call and be clear about the time frame and the need. Her system of care has to do the right thing. And I let her know the Medical Home was designed for people with problems like those troubling her.

Reflections on two days with the Leanerati

I had the opportunity this week to travel with an impressive group of colleagues to Orlando, Florida, for the Lean Enterprise Institute (LEI) Healthcare Transformation Summit. Group Health had the opportunity to present our experience in piloting, spreading, and stabilizing the Medical Home, as well as to demonstrate how we use lean to maintain and improve what we’ve built. Our group also got to hear several fantastic presentations from other organizations doing similar work. These are a few observations I brought home with me.

1. My conference name tag had no letters after my name. No one’s did. No MD, MPH, PhD, MBA, CEO. None of that. It was refreshing. Everyone was, at first impression, simply someone with enthusiasm for doing health care better. Removing the pretenses that titles haul into the mix made for refreshing, fun, frank discussions. This reminded me of some of the “just culture” discussions I’ve had around Group Health: each of us deserves a voice and should not feel intimidated by the title of coworkers.

2. “If a problem is well-defined, it is half solved.” I heard someone say this in a presentation and missed the next ten minutes of the talk while thinking this over. I like a good solution to a tough problem, and am quick to jump to the solving part of problem solving, usually before I’ve nailed down the actual problem. How many solutions have not worked out because I didn’t spend enough time learning what problem I was really trying to solve? Lots.

Jumping too soon to solutions tricks us into treating symptoms instead of causes. In return we get more symptoms to treat. It keeps us busy, but not successful. I’m going to spend more time defining problems.

3. We can’t improve until we learn to see. When I wanted to increase the amount of exercise I was getting, I had to step well back from my daily patterns to really understand them, to see how an intention to run six miles became, instead, “running” an errand, making another throw-away spreadsheet, or writing a blog post. Seeing the patterns took some right brain work–journaling, drawing pictures–before I could develop a useful approach to getting my running shoes on and making them go.

Likewise, we’ve got to see our work before we can do it better. Day to day, we follow familiar patterns with results that don’t satisfy completely, but we’re so used to the path, because it is familiar, that we don’t look for or create a new one. I’m afraid to draw a picture of how much wandering I do around my clinic looking for things, but it would certainly help me see how much time I could be spending doing things that matter. I’ll give it a try. (Maybe there’s an app for that.)

Okay, one more…

4. If this work isn’t fun, we’re not doing it right. The only way to make meaningful improvements is to think differently. And to do that, we have to agree to play. Play nicely, yes, but PLAY. New insights come when we follow our ideas in amusing, creative ways. The most inspired problem solving examples presented at the LEI Summit were developed with pictures and games. Play will get people listening to our stories, and if we give it a try, someone might have fun.

Health care co-ops? Medical homes? Which is the answer?

This will make you smile.

Aaron Katz, local health policy guru and University of Washington public health faculty wrote the following post about Group Health’s Medical Home year two results on the Seattle PI’s Blog:

“Remember the frenzy around health care co-operatives last year? North Dakota Senator Kent Conrad was pushing the idea as an alternative to the public health insurance option, one of many hot-button issues that led – tortuously, painfully – to what became the Patient Protection and Affordable Care Act (PPACA) … aka “health care reform.”

Conrad and his allies argued that co-ops could induce the health insurance market to behave better, produce better outcomes, lower costs. The evidence to support this argument? Nowhere to be found. Doesn’t’ exist.

But it was a warm and fuzzy alternative to the idea of BIG GU’MENT offering its own health plan in competition with private insurers, so it got some attention.

Over a two or three week period, (even) I got a bevy of calls from the media (Fox Business “News,” NPR, CBS radio in San Francisco, PBS’s The Lehrer Report) asking about this idea; specifically, is Group Health Cooperative – the co-op in Seattle where I live that’s been around since the mid-1940s – a model for health care reform. Much to the chagrin of many of my friends, who are also devotees of GHC, I said “no.”

I said that, whatever its virtues – salaried physicians, strong care management model, world-class research – it is still only the #3 insurer in the region. If GHC, by its very co-op existence was transformative, why – I asked – why doesn’t it own Seattle, Washington state, the Northwest? It’s had enough time to prove itself, hasn’t it?

Well, maybe some evidence is beginning to accumulate. A May 2010 Health Affairs article found that a “medical home model” experiment at GHC saved $10 per patient per month after nearly two years of operation. And, for every $1 needed to implement the model, GHC received $1.50, a pretty good return on investment. For those of you who haven’t heard the buzz around medical homes, it’s really an updated version of good ole primary care, with comprehensive services, long term relationships, and strong care coordination (yes, this does sound like what Community Health Centers have been doing for decades!).

After going over the results of the evaluation, the article provides some important policy recommendations:

• Invest more in primary care (PPACA makes a start)
• Change how we finance care so that savings can be captured
• Pay for care in ways that promote continuity, team-based care, and population management

How do we do all that? PPACA makes a little baby step in this direction, but many more policy changes will be needed if the benefits of GHC’s model are to accrue throughout the system.”

Final RPIW Update: Live from the MGT Report Out

Hi everyone. First of all, let me send my apologies for the various spelling errors in my last post. If you have ever been in an RPIW you know how crazy the last day can get. I’ve never attempted to blog while helping to facilitate a work group. Apparently, it’s the spelling that suffers.

Right now I’m sitting in our Management Guidance Team Report Out. The team is updating the Sponsors and Management Team members on all the great work and improved processes.  I’ve been to a lot of MGT report outs. They are always exciting because the front line teams get to ’show off’ their great work. There is a lot of positive energy in the room and this group is no exception.

I am watching the nods and smiles of the Managers as they hear the details. 10 minutes before the report out I got an email from one of our team members who had to stay home today with a sick child.  She was so engaged that we were calling her and emailing her documents at home so she could stay connected to the process. From home she had found an opportunity to reduce another process step and handoff and wanted us to know about it so we could include it in the final product. I can say in my experience of RPIWs this is a first!

The team has solved many small problems and a couple big ones. Together we believe these will add up to a greatly improved experience for our patients as well as our staff. 

Congratulations to all the team members from our Primary Care clinics, Customer Service and Primary Care Appointing Center. You all did a great job!

RPIW Update: Reducing Waste Leads to Improved Patient Experience

Let me tell you a story. On Wednesday, when we started this workshop I received an email from one of our Primary Care leaders about a new medicare patient complaint regarding–you guessed it–their experience of being paneled with the wrong Doctor at the wrongclinic. The situation for the patient was a confusing mess. In a nutshell, her experience went something like this: Patient enrolls in Group Health on February 1. The address we had on record was for a power of attorney somewhere near Factoria. She was paneled within 10 business days to a Doctor in Factoria. The letter was generated and left sitting in a batch in one of our systems, somewhere. It did not get sent to the patient until March 9. In the meantime the patient went to see the doctor. Not in Factoria, where she had been paneled but in Olympia where she lived.  When the letter arrived almost 6 weeks after her enrollment and three weeks after her appointment in Olympia telling her, contrary to her experience and wishes,  that she had actually been paneled in Factoria, you can imagine the result. Confusion. Frustration.

I can happily report that our team spent yesterday improving the process for how these patients are assigned and how the letters are generated and sent. We had front line staff from customer service and the clinics working out the process details. They had gotten far and reduced waste. But then they decided to call in their technical resource rep from ISD.  He took one look at the new process and immediately identified an opportunity to reduce process steps and ensure that the letter generation part of the process happened within days, not weeks, of a patient being assigned a new provider.  The team and managers involved were quickly able to incorporate the new information and adjust the process. The work request was submitted and we are on our way to having an improved process that will directly improve our patient experience and help avoid situations like the one in the story.

This is just one small example of the improvements that this team has been working on these last few days. This afternoon the Management Guidance Team is coming in person to hear about all the great work of the team. More to come!

How do we get patients to ask more questions?

While doctors often take pride in how open they are to patient questions, our self assessment doesn’t match up very well with empirical evidence.    A recent post (http://bit.ly/c47tHj)summarizes a small study that is relatively terrifying to me – the take home is that doctors spend very little time explaining their recommendations, and that patients rarely ask questions.

So what would it take to do better?  For me,  my list for this includes:

1.  a shared electronic health record that allows patients to access the same information that their care teams use online.

2.  have after visits summaries available both in print and online that summarize the visit and any changes in medicines, referrals, diagnoses, care plans, etc.

3.  build collaborative care plans – built with the patient’s active participation – for all patients

4.  promote access to personal physicians and health care teams with online messaging (basically secure Email) and phone (where doctors answer their own phone)

5.  extend the time of in person visits to make sure that there is time to listen to the story and work together to make sure that a patient’s needs are fully met.

And the good news is that all of these are part of what we are doing in the patient centered medical home implementation.

And – we will keep trying new ideas that might help us all do better.

Panel RPIW Update #3: Design & Test

The team is hard at work. This morning the Lean facilitators used the Hoopla to actually train some concepts on standard work. They team had completed visioning yesterday and quickly moved into project work to hammer out all the details of the new standard work and processes to support the vision. They have been working really well together, having engaged discussion, gaining alignment and documenting new standard work. In fact, they are ahead of schedule and already moving into testing some of the new processes.

For example, one of our team members drove over to the Renton clinic this afternoon to test part of the new clinic tracking process with the Admin staff there. These particular Admin were not in the workshop and had no knowledge of what we were creating. Our team member took the process and tools and walked it through with them to make sure that it really works for people who will be doing the job. He came back with their feedback and the team incorporated it into the final documentation.

The Medical Center Chiefs and Primary Care leaders have had engaged discussions about the implications of the new panel open/closed standards and what processes are needed to make status and problems visible in a more timely manner, support Medical Home principles, and most importantly, meet patient needs.

Right now the team is mocking up and testing the revisions to the Physician Selection Index on InContext. We have PCRs and Customer Service Reps who are checking the changes and making sure the tools support the new standard process.

There is more work to do but they are on track to achieving the vision created on Wednesday. Great Work team!

Panel RPIW Update #2

Wow! The team is moving fast. They have doumented their current state. Here is a look at just how complex and wasteful it is.

Our Current State

Our Current State

The vast number of panel restrictions we use in our current state

The vast number of panel restrictions we use in our current state

Our team hard at work

Our team hard at work

The teams took this information and spent time walking through what the future state might look like. How can we reduce waste and improve our experience for our patients and staff? Here is what they came up with for a vision.

Future State Vision

Future State Vision

Much improved! The team certainly believes this will result in an improved experience for our patients and staff. Now they are in the process of taking this vision and breaking it out into project work to figure out the detail.

Live from Panel Status RPIW

I’m writing live from the cross-functional RPIW to improve our panel status and update process. Team members–front line staff and leaders– from Customer Service, Primary Care Appointing Center, Finance, and four Primary Care clinics are here getting deeply immersed in the current state. They are looking at a variety of cross-functional processes that affect our patients and how they end up paneled to a primary care physician. For instance,

  • how our clinics decide what a doctor’s panel status should be
  • how that status gets communicated, changed and updated
  • how patients calling into PCAC or Customer Service get matched to a provider
  • how the very manual process currently called ‘auto-paneling’ assigns all our Medicare  and Healthy Options members to a PCP
  • how all the systems that reflect panel status (MyGroupHealth, InContext) get updated each time a change is made

What I can say so far is that the team is very engaged, insightful and amazed at the challenges and opportunities they have uncovered just by observing the processes and those who do the actual work. They are hearing the voice of the customer and listening to the various stakeholders who are invested in these processes.

In a few minutes the team will be spending time with their Primary Care sponsor to talk in more detail about the standards that are being put in place in order to ensure that our systems are coming together to match our resources and principles with our patients needs. The teams need this information before they move into visioning this afternoon. From there, they will take their future state vision, as well as the standards and guardrails set by the sponsors, and start to improve and standardize the current processes by removing waste and rework, reducing hand-offs and queues and increasing up and downstream visibility across functions.

I’m looking forward to reporting out on the progress of this group over the next three days.  More to come!

Returning practitioner

I returned to primary care as a practitioner on January 4th.

You can imagine that I was dead set on practicing all the elements of the Medical Home as Standard Work from day one.

Within the first week, while “available” on call management, I got a call just at the end of lunch break.

A patient identified his wish to talk to Cheryl, the long-time nurse for the practice I am covering.

I let him know she was not available but identified myself about three times before he realized I was a doctor covering for his usual doctor, on sabbatical for a year.

I asked him, “what exactly can I do for you?”

Well, he said, Read more »

Huddles for physicians – work or waste?

Are morning huddles of interest to physicians?  Often, not.  “A waste of time” or “I need to get on with my real work” are two comments I have heard.  I was at a daytime conference at Northgate and asked Marty Levine to give me a tour.  We cruised into one of the FP clusters and spoke with the flow staff there. They were re-writing their Tier 1 board for weekday tasks.  Read more »

Patient Satisfaction

I attend “clinic huddles” every chance I get - and - I heard this story from Dr. Scott McAfee at the Northshore clinic huddle a few weeks ago. I thought we all could benefit from it so I  asked him to recap  in an e-mail, which is below:
“I thought I would share with you a comment from one of my patients this morning and if you like share it with all staff. This is a woman who has been with Group Health through 3 children’s births, and her husband comes here as well who last year were planning on changing Health Care Plans. Read more »

Your Stories: clinical pharmacist saves a life

A while back I sent out a blog post called  “Story Hunting” I got some amazing stories from doctors, nurses and clinical pharmacist.

Here’s a story that Sue Lasicka, Clinical Pharmacist at Factoria Medical Center sent in about saving a man’s life with an inhaler!

DW is a 62 year old male who has had asthma for many years. Initially, I was asked by his primary care physician to contact him regarding his elevated potassium levels, to see if we could identify a medication side effect. In my review, I noticed he was using a long acting beta agonist (salmetrol) without the benefit of any preventative steroids or quick acting bronchodilator medications.

Read more »

Medical Home-patient experience

I wanted to post a synopsis of two conversations I had with a patient. She has been with GH for a long time before moving to the east coast to follow her husband in the military. Her conversations demonstrated to me that she felt home here for a long time.

She is pregnant and about 7 months along and called to ask some questions because she didn’t feel comfortable with her new doctor. Hadn’t developed the trust she had with her GH providers. She was very surprised I took her call and appreciative of the time I took with her. She said at that time she missed GH very much. Read more »

Drive-thru flu clinic

You may have heard by now, Burien did the first drive-thru flu clinic and served more than 300 people in one day! Check out this video that chief, Wellesley Chapman, sent over of the event.

What do you think of drive-thru flu clinics?

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Medical Home Works!

We asked our fabulous Burien RN, Sherrie Elmer, to share her thoughts on what Medical Home means for her and our patients. These are her words.

IS THIS THE RIGHT WORK?

This question has been asked of me since the recent changes made to the FP RN roles at the initiation of the Medical Home here at Burien. The changes that impact my role include Call Management, ED/UC discharge follow up, hospital dc f/u and, most importantly, Chronic Disease Management. Read more »

Myths and Realities of Meaningful Care Plans

Let’s clear the air right up front.  You do NOT have to use the infamous “.CHR…” dot-phrases if you don’t want to! No one is trying to turn you into a robot using the same cookie-cutter, boiler-plate lingo as everyone else.  Those dot-phrases were designed by your peers (docs, nurses, clinic staff) and were meant to be helpful (in fact many of your peers think they are).  You can customize them or ditch them as you see fit.  I don’t really care. As physicians we can use as much creativity as we like in our care plans. Read more »

Much to celebrate: year one data published

American Journal of Managed Care published the one-year results of our medical home pilot  September 1 . Some of you may have heard, we’ve gotten great local and national press, including this stellar story on KING5 News yesterday: Play and Download Video.

A large part of the success was in the partnership between the Group Health care-delivery system and Group Health Center for Health Studies, Read more »

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