“Curmudge, two years ago our holiday greeting was about being politically correct; last year we shared our concerns about homeless people and those who couldn’t get home for the holidays. What will we talk about this year?”
“It beats me, Jaded Julie. I surely don’t envy those members of the clergy who have to think up a new holiday sermon or homily each year.”
“It sounds as if the priesthood wouldn’t have been a good vocation for you, Curmudge.”
“That’s for sure, and my wife and children will certainly agree…I’ve got an idea, Julie. Instead of talking about the end-of-year holidays, let’s focus on New Years and try to make some predictions for next year.”
“Give it a try, Ancient Oracle. I believe the outcomes of your tacit forecasts for 2009 exceeded some of your gloomiest expectations.”
“Let’s start with Affinity. Renovation of St. Elizabeth Hospital, guided by Lean and LEED principles, will be under way. You and I will remain proud to be affiliated with the ‘Lean Team.’”
“One’s micro-, or personal, happiness impacts everyone around them (1). What do you see as your personal happiness in 2010, Curmudge?”
“Barring health and family adversities and as long as I can continue to come in here every day and chat with you, Julie, my micro-happiness index should stay pretty high. And I will keep trying to spread it around St. E’s. This is the friendliest place I ever worked (if that’s what one calls what I do).”
“My guess is that you don’t feel as positive about our nation and the world around us. That would be macro-happiness or macro-unhappiness, right?”
“Right, Julie. Our nation’s macro-unhappiness seems to be high and rising. We are sharply divided on many issues, and we seem to be perpetually at war.”
“To refresh your memory on perpetual war, you went back to George Orwell’s classic book, 1984 (2).”
“It was required reading when I was a college freshman in 1952. Then, I considered it to be ‘only a book.’ Now I worry that Orwell might have been, in some ways, prescient. As his novel seems to suggest, we and our way of life may be the objectives of subjugation both from within and without.”
“Hey, Curmudge! That last part of your prognostication (did I say that?) was really depressing. Well, at least it’s something that we can revisit this time next year. So what is your one-word seasonal greeting for our readers?”
“’Hope,’ Jaded Julie.”
“’Peace,’ Curmudge.”
Affinity’s Kaizen Curmudgeon
(1) Prager, D. Happiness is a Moral Obligation. (March 2007) http://www.studentnewsdaily.com/commentary/printer-friendly/article/happiness_is_a_moral_obligation/
(2) http://en.wikipedia.org/wiki/Nineteen_Eighty-Four
Thursday, December 17, 2009
Thursday, December 10, 2009
"I'm from Corporate, and I'm here to help you."
“That has a menacing tone, Curmudge. Is it intended to be that way?”
“It’s a variation on the dreaded greeting from an inspector from the Environmental Protection Agency, Jaded Julie. ‘I’m from the EPA, and I’m here to help you.’ In a pulp and paper mill, an EPA inspection would wreck your day, or more likely, your week.”
“So did you ever use the greeting, ‘I’m from Corporate, etc.’?”
“Not those exact words, Julie, but one of my jobs long ago was to visit the laboratories of my employer’s pulp mills, ascertain that they were using EPA-approved test methods, and help them correct deficiencies before the EPA or state inspectors arrived.”
“That sounds pretty valuable. Did the mill people welcome you with open arms?”
“Not always. I spent the first half-day convincing the lab technicians that I was not an officious blowhard; thereafter things in the lab went smoothly. The real problem was that the mill’s environmental manager resented my looking for—and finding—problems that he or she should have already corrected. I guess it was human nature…really quite natural. I suspect that they trashed my report as soon as I left the mill. If I found too many problems, they didn’t invite me back.”
“Enough about the good old days, Curmudge. It’s time for you to share with me what all of this has to do with Lean.”
“It’s really quite simple, Julie. Put yourself in the shoes of a middle manager who has just learned that her department will be the subject of a kaizen event. What is her natural reaction?”
“’Why my department? I’ve done the best that I can for the past ten years. We’ve always done things that way.’ Her natural response would be to resent the whole idea—just like your environmental manager in the pulp mill.”
“That’s the connection with Lean, Julie. If the middle manager has hardwired her Lean training, she will acknowledge that continuous improvement is now our way of life, and it is often initiated with a kaizen event. If the event is part of a hoshin, she will understand the event’s importance and recognize the need to suppress her initial resentment. Process improvements following the event ought to put the damper on her earlier anguish.”
“Now I understand. It’s like the small child’s learning not to take the biggest piece of cake. This is all about doing what is right rather than what is natural. Our posting back on May 8, 2008 was on this topic. Why the reprise?”
“There are two reasons. The first is that character, i.e., doing what is right, is an essential part of leadership, and we are going to teach it until everyone has it hardwired. The second is that the connection between my mill lab audits and Lean just occurred to me.”
“You’ve made it clear, Curmudge, that your earlier life—even back to your childhood—is an open book. At your age, I guess you turn the pages very slowly.”
Affinity’s Kaizen Curmudgeon
“It’s a variation on the dreaded greeting from an inspector from the Environmental Protection Agency, Jaded Julie. ‘I’m from the EPA, and I’m here to help you.’ In a pulp and paper mill, an EPA inspection would wreck your day, or more likely, your week.”
“So did you ever use the greeting, ‘I’m from Corporate, etc.’?”
“Not those exact words, Julie, but one of my jobs long ago was to visit the laboratories of my employer’s pulp mills, ascertain that they were using EPA-approved test methods, and help them correct deficiencies before the EPA or state inspectors arrived.”
“That sounds pretty valuable. Did the mill people welcome you with open arms?”
“Not always. I spent the first half-day convincing the lab technicians that I was not an officious blowhard; thereafter things in the lab went smoothly. The real problem was that the mill’s environmental manager resented my looking for—and finding—problems that he or she should have already corrected. I guess it was human nature…really quite natural. I suspect that they trashed my report as soon as I left the mill. If I found too many problems, they didn’t invite me back.”
“Enough about the good old days, Curmudge. It’s time for you to share with me what all of this has to do with Lean.”
“It’s really quite simple, Julie. Put yourself in the shoes of a middle manager who has just learned that her department will be the subject of a kaizen event. What is her natural reaction?”
“’Why my department? I’ve done the best that I can for the past ten years. We’ve always done things that way.’ Her natural response would be to resent the whole idea—just like your environmental manager in the pulp mill.”
“That’s the connection with Lean, Julie. If the middle manager has hardwired her Lean training, she will acknowledge that continuous improvement is now our way of life, and it is often initiated with a kaizen event. If the event is part of a hoshin, she will understand the event’s importance and recognize the need to suppress her initial resentment. Process improvements following the event ought to put the damper on her earlier anguish.”
“Now I understand. It’s like the small child’s learning not to take the biggest piece of cake. This is all about doing what is right rather than what is natural. Our posting back on May 8, 2008 was on this topic. Why the reprise?”
“There are two reasons. The first is that character, i.e., doing what is right, is an essential part of leadership, and we are going to teach it until everyone has it hardwired. The second is that the connection between my mill lab audits and Lean just occurred to me.”
“You’ve made it clear, Curmudge, that your earlier life—even back to your childhood—is an open book. At your age, I guess you turn the pages very slowly.”
Affinity’s Kaizen Curmudgeon
Friday, December 4, 2009
It Takes More Than a Team
“It takes more than a team to do what, Curmudge?”
“To establish a medical home, Jaded Julie. It also requires an angel.”
“Angels? Aren’t those dead people with wings?”
“No, Julie. In this case angels are live people—or organizations—with money. It’s a term used in the theater to describe people who finance a new production.”
“I must admit, Curmudge, that I was puzzled at the idea of a solo-practice doc, who has to see more and more patients to keep his head above water, hiring lots more people, proclaiming his shop to be a medical home, and suddenly becoming financially viable. There must be a ton of transitional expenses; I guess they are paid by the ‘angel.’ So why should an organization support a practice’s transition to a medical home?”
“An insurance company might be a good example. They would anticipate that the medical home would take better care of their members (policy holders) so they would have fewer specialists, duplicate tests, and ED visits to pay for. Their support could be in the form of capitation, i.e., dollars per member per month. Another example would be a large health care organization that envisions the medical home to be the wave of the future in primary care.”
“Let’s assume that the medical home has recruited their team, purchased their information technology, and trained everyone as we have discussed in recent weeks. What must they do to put the operation in the black?”
“My one-word answer, Julie, is ‘efficiency.’”
“Wow! That’s the first time ever that your one-word answer was not ‘Lean.’ Of course we already know that the team members gain much of their efficiency by using Lean principles and tools. Can we look at some of the ways that the medical home improves their efficiency?”
“Let’s start with an intuitive, uncomplicated look at physician compensation (of course, there isn’t such a thing). Mid-level providers will handle routine patient care; this will enable the physician to provide higher-intensity services, as measured by relative value units (RVUs). Electronic technology will reduce the physician’s non-value-added time with each patient; he/she will not have to shuffle through chart pages, can use the decision-support tool to confirm his diagnosis and treatment plan, and can generate notes for the encounter in real time. These attributes of the medical home should permit the physician to see more patients and perform more services per day. This will enable him to increase his compensation, or alternatively, maintain his compensation while working fewer hours.”
“I assume, Curmudge, that someone has investigated the financial side of the medical home more rigorously.”
“It was studied by Spann and a long list of coworkers in 2004 (1). We won’t discuss the assumptions used in their model; the list would stretch from here to Darboy. Here are some of the features of a medical home (they called it the ‘New Model’) that they studied and the outcomes predicted by their model (not all are intuitive):
Open-access scheduling (some same-day appointments)—Fewer visits per patient, but higher RVUs for services provided.
Electronic health records—Overall increase in efficiency (after training) including more accurate billing.
Online e-visits—Presently no reimbursement. If implemented, it would be at a lower level than an office visit.
Team approach (leveraging clinical staff)—The physician can serve a larger panel of patients by using clinical staff to perform routine tasks.
Clinical practice guidelines software—Allows physicians to rely more effectively on a team approach to medicine.”
“I trust you read the more recent paper by Rosenthal (2).”
“I did. He said that reimbursement policies will require reformulation in order to institutionalize the medical home, and he reported on reimbursement models recommended by several physicians’ associations. They included:
· A fee for service, including e-visits.
· A per-member per-month management fee.
· A quality incentive that recognizes achievement of standards of care.”
“Curmudge, from the financial standpoint it appears that the team approach to medicine and the use of electronic technology are going to be the big winners for the clinic. Of course, one of your ‘angels’ will be needed to help them get through the expenses of transition. You must be pleased at the essential role played by teamwork and empowerment.”
“I certainly am, Julie. The medical home should be a viable way to practice primary care if it is implemented efficiently by committed leadership and involved staff.”
“Involved? Committed? I thought those two words meant almost the same thing.”
“Not when you consider eggs and bacon, Julie. The hen was involved, but the pig was committed (3).”
Affinity’s Kaizen Curmudgeon
(1) Spann, S.J. et al. Report on Financing the New Model of Family Medicine.
http://www.annfammed.org/cgi/content/full/2/suppl_3/s1
(2) Rosenthal, T.C. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. (Sept. 2008) http://www.jabfm.org/cgi/reprint/21/5/427
(3) Hunter, J.C. The Servant, p. 120 (Crown Business, 1998)
“To establish a medical home, Jaded Julie. It also requires an angel.”
“Angels? Aren’t those dead people with wings?”
“No, Julie. In this case angels are live people—or organizations—with money. It’s a term used in the theater to describe people who finance a new production.”
“I must admit, Curmudge, that I was puzzled at the idea of a solo-practice doc, who has to see more and more patients to keep his head above water, hiring lots more people, proclaiming his shop to be a medical home, and suddenly becoming financially viable. There must be a ton of transitional expenses; I guess they are paid by the ‘angel.’ So why should an organization support a practice’s transition to a medical home?”
“An insurance company might be a good example. They would anticipate that the medical home would take better care of their members (policy holders) so they would have fewer specialists, duplicate tests, and ED visits to pay for. Their support could be in the form of capitation, i.e., dollars per member per month. Another example would be a large health care organization that envisions the medical home to be the wave of the future in primary care.”
“Let’s assume that the medical home has recruited their team, purchased their information technology, and trained everyone as we have discussed in recent weeks. What must they do to put the operation in the black?”
“My one-word answer, Julie, is ‘efficiency.’”
“Wow! That’s the first time ever that your one-word answer was not ‘Lean.’ Of course we already know that the team members gain much of their efficiency by using Lean principles and tools. Can we look at some of the ways that the medical home improves their efficiency?”
“Let’s start with an intuitive, uncomplicated look at physician compensation (of course, there isn’t such a thing). Mid-level providers will handle routine patient care; this will enable the physician to provide higher-intensity services, as measured by relative value units (RVUs). Electronic technology will reduce the physician’s non-value-added time with each patient; he/she will not have to shuffle through chart pages, can use the decision-support tool to confirm his diagnosis and treatment plan, and can generate notes for the encounter in real time. These attributes of the medical home should permit the physician to see more patients and perform more services per day. This will enable him to increase his compensation, or alternatively, maintain his compensation while working fewer hours.”
“I assume, Curmudge, that someone has investigated the financial side of the medical home more rigorously.”
“It was studied by Spann and a long list of coworkers in 2004 (1). We won’t discuss the assumptions used in their model; the list would stretch from here to Darboy. Here are some of the features of a medical home (they called it the ‘New Model’) that they studied and the outcomes predicted by their model (not all are intuitive):
Open-access scheduling (some same-day appointments)—Fewer visits per patient, but higher RVUs for services provided.
Electronic health records—Overall increase in efficiency (after training) including more accurate billing.
Online e-visits—Presently no reimbursement. If implemented, it would be at a lower level than an office visit.
Team approach (leveraging clinical staff)—The physician can serve a larger panel of patients by using clinical staff to perform routine tasks.
Clinical practice guidelines software—Allows physicians to rely more effectively on a team approach to medicine.”
“I trust you read the more recent paper by Rosenthal (2).”
“I did. He said that reimbursement policies will require reformulation in order to institutionalize the medical home, and he reported on reimbursement models recommended by several physicians’ associations. They included:
· A fee for service, including e-visits.
· A per-member per-month management fee.
· A quality incentive that recognizes achievement of standards of care.”
“Curmudge, from the financial standpoint it appears that the team approach to medicine and the use of electronic technology are going to be the big winners for the clinic. Of course, one of your ‘angels’ will be needed to help them get through the expenses of transition. You must be pleased at the essential role played by teamwork and empowerment.”
“I certainly am, Julie. The medical home should be a viable way to practice primary care if it is implemented efficiently by committed leadership and involved staff.”
“Involved? Committed? I thought those two words meant almost the same thing.”
“Not when you consider eggs and bacon, Julie. The hen was involved, but the pig was committed (3).”
Affinity’s Kaizen Curmudgeon
(1) Spann, S.J. et al. Report on Financing the New Model of Family Medicine.
http://www.annfammed.org/cgi/content/full/2/suppl_3/s1
(2) Rosenthal, T.C. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. (Sept. 2008) http://www.jabfm.org/cgi/reprint/21/5/427
(3) Hunter, J.C. The Servant, p. 120 (Crown Business, 1998)
Thursday, November 19, 2009
The Medical Home Team Comes Together
“Curmudge, you seem so delighted at all of the changes that occur when the medical home staff come together as a functioning team. How is it that an old guy like you has become a change zealot?”
“Julie, I have to accommodate continual change. It’s called the frailties and foibles of aging. Mrs. Curmudgeon has the frailties and I have the foibles.”
“(Foibles? Well, if they are only eccentricities, they shouldn’t be contagious.) So just like other major changes, the medical home leader has to establish a sense of urgency, create a guiding coalition, develop a vision and strategy, and communicate the change vision (1).”
“That’s it, Jaded Julie. Missions or visions for a medical home usually contain statements like ‘personalized patient-centered care provided with collaborative team interactions with defined roles and delivered with physician leadership.’”
“Perhaps the medical home uses a 21st century version of the old proverb, ‘many hands make light work,’ only now the hands (and minds) are appropriately skilled and coordinated to fulfill the patient’s needs completely, efficiently, and with effective listening and respect.”
“Julie, you are indeed a fast learner. Of course, to find the appropriate hands and minds for the medical home team, one must use behavior-based interviewing. Team members must be communicative and collaborative by nature and willing to cross-train and participate in continuous improvement.”
“Continuous improvement! That sounds like Lean. No wonder you’re so enthusiastic about this. Any team—in health care, sports, or manufacturing—must find and eliminate waste and inefficiencies in their processes or someone else will come along and ‘eat their lunch.’ So how is this done in a medical home?”
“’Huddles’ sound a lot more productive than meetings, perhaps because they are usually conducted standing up. These, lasting from 5 to 15 minutes, are held every morning before patients arrive. Topics include problems from yesterday, today’s patient load, and who needs additional help (level loading). A 30-second huddle involving the medical assistant and the provider outside the exam room brings the provider up to speed on the patient he/she is going to see. That really helps the provider’s efficiency.”
“I’m certain, Curmudge, that the whole team has weekly or monthly meetings for training, keeping everyone on the same page, and for using the whole Lean toolkit to solve problems and improve and standardize processes.”
“Speaking of standard work, the medical home strives for consistent application of quality care through applied evidence-based medicine. Decision-support systems should enable mid-level clinicians to offer routine care to established patients (2). For the providers, evidence-based standards are accepted by the Physician Governance Committee and Medical Executive Committee.”
“A patient can usually perceive the results of these Lean, empowerment, and collaborative initiatives. She should be able to sense that her care is now provided by a team of which her physician is the leader. So what do the patients experience directly?”
“Overall, their medical needs are satisfied promptly and efficiently in ways that meet all of the criteria of patient-centered personalized care. Specifically, the patient phones the clinic and describes her problem. The patient service representative knows the patient, performs a limited triage, identifies the provider the patient will see, and can usually indicate any testing that will be needed before or during the visit. Phone calls that are questions for staff will receive a response the same day. When the patient arrives for an appointment, the medical assistant will help her document her current complaint, issues to discuss, medical record and medications, and will check vitals. Usually the patient will see the provider promptly. Time with the provider will be commensurate with the patient’s needs. The patient and provider will jointly develop an agreed-upon plan of care including needed appointments with specialists and a path forward for dealing with chronic conditions. The patient may also see the provider type or dictate his notes for the encounter. These processes will be enhanced with the implementation of advanced information technology.”
“All of this sounds great, Curmudge. I can hardly wait to get sick. By the way, when we began today’s discussion you spoke of foibles. I sort of know what they are, but can you give me an example?”
“With pleasure, Jaded Julie. Many years ago I wrote technical papers that were published in scientific journals. It seems as if I can’t write those anymore. Everything that I write now comes out looking like a conversation between two fictional people.”
Affinity’s Kaizen Curmudgeon
(1) Kotter, John P. Leading Change (Harvard Business School Press, 1996)
(2) http://www.annfammed.org/cgi/content/full/2/suppl_3/s1 Page S8.
“Julie, I have to accommodate continual change. It’s called the frailties and foibles of aging. Mrs. Curmudgeon has the frailties and I have the foibles.”
“(Foibles? Well, if they are only eccentricities, they shouldn’t be contagious.) So just like other major changes, the medical home leader has to establish a sense of urgency, create a guiding coalition, develop a vision and strategy, and communicate the change vision (1).”
“That’s it, Jaded Julie. Missions or visions for a medical home usually contain statements like ‘personalized patient-centered care provided with collaborative team interactions with defined roles and delivered with physician leadership.’”
“Perhaps the medical home uses a 21st century version of the old proverb, ‘many hands make light work,’ only now the hands (and minds) are appropriately skilled and coordinated to fulfill the patient’s needs completely, efficiently, and with effective listening and respect.”
“Julie, you are indeed a fast learner. Of course, to find the appropriate hands and minds for the medical home team, one must use behavior-based interviewing. Team members must be communicative and collaborative by nature and willing to cross-train and participate in continuous improvement.”
“Continuous improvement! That sounds like Lean. No wonder you’re so enthusiastic about this. Any team—in health care, sports, or manufacturing—must find and eliminate waste and inefficiencies in their processes or someone else will come along and ‘eat their lunch.’ So how is this done in a medical home?”
“’Huddles’ sound a lot more productive than meetings, perhaps because they are usually conducted standing up. These, lasting from 5 to 15 minutes, are held every morning before patients arrive. Topics include problems from yesterday, today’s patient load, and who needs additional help (level loading). A 30-second huddle involving the medical assistant and the provider outside the exam room brings the provider up to speed on the patient he/she is going to see. That really helps the provider’s efficiency.”
“I’m certain, Curmudge, that the whole team has weekly or monthly meetings for training, keeping everyone on the same page, and for using the whole Lean toolkit to solve problems and improve and standardize processes.”
“Speaking of standard work, the medical home strives for consistent application of quality care through applied evidence-based medicine. Decision-support systems should enable mid-level clinicians to offer routine care to established patients (2). For the providers, evidence-based standards are accepted by the Physician Governance Committee and Medical Executive Committee.”
“A patient can usually perceive the results of these Lean, empowerment, and collaborative initiatives. She should be able to sense that her care is now provided by a team of which her physician is the leader. So what do the patients experience directly?”
“Overall, their medical needs are satisfied promptly and efficiently in ways that meet all of the criteria of patient-centered personalized care. Specifically, the patient phones the clinic and describes her problem. The patient service representative knows the patient, performs a limited triage, identifies the provider the patient will see, and can usually indicate any testing that will be needed before or during the visit. Phone calls that are questions for staff will receive a response the same day. When the patient arrives for an appointment, the medical assistant will help her document her current complaint, issues to discuss, medical record and medications, and will check vitals. Usually the patient will see the provider promptly. Time with the provider will be commensurate with the patient’s needs. The patient and provider will jointly develop an agreed-upon plan of care including needed appointments with specialists and a path forward for dealing with chronic conditions. The patient may also see the provider type or dictate his notes for the encounter. These processes will be enhanced with the implementation of advanced information technology.”
“All of this sounds great, Curmudge. I can hardly wait to get sick. By the way, when we began today’s discussion you spoke of foibles. I sort of know what they are, but can you give me an example?”
“With pleasure, Jaded Julie. Many years ago I wrote technical papers that were published in scientific journals. It seems as if I can’t write those anymore. Everything that I write now comes out looking like a conversation between two fictional people.”
Affinity’s Kaizen Curmudgeon
(1) Kotter, John P. Leading Change (Harvard Business School Press, 1996)
(2) http://www.annfammed.org/cgi/content/full/2/suppl_3/s1 Page S8.
Thursday, November 12, 2009
Change Your Primary Care Mindset--the Rest of the Team
“Gosh, Curmudge, I haven’t seen you this excited since you last had your hearing aid adjusted. What’s up?”
“Jaded Julie, it’s really gratifying to learn that a simple concept, which we now call ‘empowerment,’ is being used in health care. Many years ago I worked in an organization where empowerment and respect were a way of life but were never verbalized. I first learned a name for this concept when the Army used it as a recruiting slogan, ‘Be all you can be.’ Now the concept is an essential element of the primary care medical home leading to enhanced patient care and staff professional fulfillment.”
“It’s a big leap from the military to primary care, but I’m sure that you will help me make the connection. As usual, we’ll start by describing what the staff—other than the physician—did in the traditional primary care clinic.”
“Traditionally, nurse practitioners (NPs) and physician assistants (PAs) worked fairly independently or otherwise in close collaboration with physicians, as allowed by state regulations. In some instances there was even an element of competition with primary care physicians.”
“I know about the clinic nurses, Curmudge. They roomed the patients, did histories and vitals, and performed straightforward procedures like injections. If I had been in that situation, I would have wondered why I studied so hard in nursing school. Of course, for older nurses it was easier on the back and feet than working in a hospital’s patient care units.”
“And the clerical help in the traditional clinic were not much different from a receptionist or a filing clerk in a law firm. That situation would be difficult for a person who wants a job with a purpose, in which she can do worthwhile work, and make a difference.”
“Curmudge, for an old guy who forgets a lot, you seem to remember Quint Studer’s Healthcare Flywheel (1) pretty well. So how does the medical home get these people out of the ruts they are in, change their mindset, and allow them to ‘be all they can be’?”
“As I said last week, Julie, the leader (physician) empowers his or her colleagues (the rest of the team) by giving them permission to reach their potential. This, in addition to its primary focus on the patient, is what a medical home is all about. Let’s start with the NPs and PAs, the so-called midlevel providers. In a medical home team they work closely with the physician and sometimes near the limit of their ability and certification. In doing so, they free up the physician to treat those cases that require the full scope of his/her training and experience.”
“Maybe I’m as old fashioned as you are, but if I’m going to see a midlevel provider, I’d prefer it to be in a clinic with a doc in the next room than in a store front or a drugstore. Although clinical decision-support resources are expanding the capabilities of midlevel providers, the medical home—where I know everybody and everybody knows me—is where I’ll find personalized care. So, Curmudge, what about the RNs, LPNs, and medical assistants (MAs)?”
“In the medical homes that I’ve read about the RN no longer rooms patients. He or she is often the clinic’s principal contact with patients with chronic diseases. Only rarely do these patients need to see the physician, and sometimes a phone call or an e-mail note to their RN will resolve their problem. In clinics where the RN works closely with the physician, she can become the physician’s surrogate and provide the same answers to patient questions as the physician would (recall our 9/03/09 posting). The bottom line is that in a medical home, the patient sees or communicates with the best clinician equipped to handle his/her problem; and that’s not always the physician.”
“I can see how this saves a lot of the physician’s time.”
“The LPNs or MAs, sometimes called Health Care Associates, perform the rooming duties formerly done by the RN. That would include medication reconciliation, history, and perhaps part of the physical exam. The extent of their involvement in patient care depends on their interests, demonstrated capabilities, and the systems established at the clinic.”
“I can tell you about the clerical staff, Curmudge. A better name is Patient Service Representative. In addition to their traditional role, they manage record-keeping and inter- and intra-clinic communications and may have an expanded role in telephone triage. Much depends on the clinic’s electronic systems. Those with broader interests can become cross-trained with Health Care Associates.”
“So you see, Julie, a lot of good things can happen in a clinic with a well-led, empowered staff.”
“As we said back on February 18, 2008, ‘Hoo-ah, sir.’ ‘Be all you can be.’”
Affinity’s Kaizen Curmudgeon
(1) Studer, Quint. Hardwiring Excellence. (2003, Fire Starter Publishing)
“Jaded Julie, it’s really gratifying to learn that a simple concept, which we now call ‘empowerment,’ is being used in health care. Many years ago I worked in an organization where empowerment and respect were a way of life but were never verbalized. I first learned a name for this concept when the Army used it as a recruiting slogan, ‘Be all you can be.’ Now the concept is an essential element of the primary care medical home leading to enhanced patient care and staff professional fulfillment.”
“It’s a big leap from the military to primary care, but I’m sure that you will help me make the connection. As usual, we’ll start by describing what the staff—other than the physician—did in the traditional primary care clinic.”
“Traditionally, nurse practitioners (NPs) and physician assistants (PAs) worked fairly independently or otherwise in close collaboration with physicians, as allowed by state regulations. In some instances there was even an element of competition with primary care physicians.”
“I know about the clinic nurses, Curmudge. They roomed the patients, did histories and vitals, and performed straightforward procedures like injections. If I had been in that situation, I would have wondered why I studied so hard in nursing school. Of course, for older nurses it was easier on the back and feet than working in a hospital’s patient care units.”
“And the clerical help in the traditional clinic were not much different from a receptionist or a filing clerk in a law firm. That situation would be difficult for a person who wants a job with a purpose, in which she can do worthwhile work, and make a difference.”
“Curmudge, for an old guy who forgets a lot, you seem to remember Quint Studer’s Healthcare Flywheel (1) pretty well. So how does the medical home get these people out of the ruts they are in, change their mindset, and allow them to ‘be all they can be’?”
“As I said last week, Julie, the leader (physician) empowers his or her colleagues (the rest of the team) by giving them permission to reach their potential. This, in addition to its primary focus on the patient, is what a medical home is all about. Let’s start with the NPs and PAs, the so-called midlevel providers. In a medical home team they work closely with the physician and sometimes near the limit of their ability and certification. In doing so, they free up the physician to treat those cases that require the full scope of his/her training and experience.”
“Maybe I’m as old fashioned as you are, but if I’m going to see a midlevel provider, I’d prefer it to be in a clinic with a doc in the next room than in a store front or a drugstore. Although clinical decision-support resources are expanding the capabilities of midlevel providers, the medical home—where I know everybody and everybody knows me—is where I’ll find personalized care. So, Curmudge, what about the RNs, LPNs, and medical assistants (MAs)?”
“In the medical homes that I’ve read about the RN no longer rooms patients. He or she is often the clinic’s principal contact with patients with chronic diseases. Only rarely do these patients need to see the physician, and sometimes a phone call or an e-mail note to their RN will resolve their problem. In clinics where the RN works closely with the physician, she can become the physician’s surrogate and provide the same answers to patient questions as the physician would (recall our 9/03/09 posting). The bottom line is that in a medical home, the patient sees or communicates with the best clinician equipped to handle his/her problem; and that’s not always the physician.”
“I can see how this saves a lot of the physician’s time.”
“The LPNs or MAs, sometimes called Health Care Associates, perform the rooming duties formerly done by the RN. That would include medication reconciliation, history, and perhaps part of the physical exam. The extent of their involvement in patient care depends on their interests, demonstrated capabilities, and the systems established at the clinic.”
“I can tell you about the clerical staff, Curmudge. A better name is Patient Service Representative. In addition to their traditional role, they manage record-keeping and inter- and intra-clinic communications and may have an expanded role in telephone triage. Much depends on the clinic’s electronic systems. Those with broader interests can become cross-trained with Health Care Associates.”
“So you see, Julie, a lot of good things can happen in a clinic with a well-led, empowered staff.”
“As we said back on February 18, 2008, ‘Hoo-ah, sir.’ ‘Be all you can be.’”
Affinity’s Kaizen Curmudgeon
(1) Studer, Quint. Hardwiring Excellence. (2003, Fire Starter Publishing)
Thursday, November 5, 2009
Change Your Primary Care Mindset--the Physician 2
“Curmudge, when we last talked about the medical home, we left the traditional primary care doc on a treadmill. He’s probably getting pretty tired by now.”
“He certainly is, Jaded Julie. Fortunately the medical home should enable him to get off the treadmill and enjoy practicing medicine again.”
“Sounds great; but as we said in our recent discussion, this requires a change in the physician’s mindset. All through his/her years of training and previous practice, the physician had to think and perform independently and bear personal responsibility for the outcomes of his patients. He communicated little with his colleagues, minimally with his nurse, and often inadequately with his patients. To function in a medical home, he has to practice leadership, communication, and shared responsibility. That’s quite a personal transformation.”
“We’ve talked about leadership, communication, and change management in the past, Julie. Perhaps now we should just touch on a few points as they apply to a physician in a medical home. With respect to changes in the role of the doctor, he or she often has to go so far as to reexamine his/her identity as a physician. ‘This transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared staff. To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones (1).’”
“That sounds pretty profound (probably because it’s a quotation). Where does one go to learn all of this good stuff?”
“Formal in-house instruction, e.g., Affinity Learning Center, almost any bookstore, and for one pushed for time, the Kaizen Curmudgeon postings in April and May 2008. Of course, many physicians already have the requisite leadership skills if their background includes experience in business or the military.”
“As you recommended, Curmudge, I looked up TransforMed’s leadership tips for physicians (2). These look really valuable:
’Exemplary leaders first lead themselves.’ ‘The culture of the practice is always modeled by the leaders for better or for worse.’
‘The basic challenge of leadership is to engage the minds and efforts of the staff to work with enthusiasm toward a specific goal.’
‘An Achilles heel of many physicians is trying to do too much alone. Great leaders get things done through other people. Sharing power has two main advantages: 1) the leader is not overburdened by work that never gets done or gets done poorly, and 2) an empowered staff means leadership at all levels of the practice.’
‘The leader sets the tone for how communication will be disseminated throughout the practice.’ ‘Have meetings of both the leadership and of sub-groups.’
‘It is part of a leader’s job to show appreciation.’ A leader’s two most important words are ‘thank you.’
The leader’s number one success factor is relationships with subordinates. These relationships must motivate staff at all levels of the medical practice.”
“I hope you recall, Julie, that empowerment—noted above—is an important principle of Lean.”
“Of course I do. And intuitively I know what empowerment means, but how do you define it?"
“A leader empowers his or her colleagues by giving them permission to reach their potential (3). I hope you realize how central this concept is to the success of the medical home.”
“I also recognize that empowerment is an essential of servant leadership, and for that matter, the whole medical home list sounds like servant leadership. Back on May 8 and 15 of 2008 we wrote two postings on this. I trust you remember, Curmudge. Servant leadership is too important not to be revisited.”
“We’ll do it, Julie, but you’ll have to remind me. Meanwhile, in our next conversation let’s continue talking about the changing mindset of the folks in the medical home.”
Affinity’s Kaizen Curmudgeon
(1) Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home (06/09/09)
http://www.medscape.com/viewarticle/703460_print (One must log in--free.)
(2) Johnson, Barbara. Leadership Excellence
http://www.transformed.com/workingPapers/LeadershipTipsPhysicians.pdf
(3) Clark, Keith and Panther, Mike. Leadership, the Art of Empowering. (2009, Monte Alverno Retreat & Spirituality Center)
“He certainly is, Jaded Julie. Fortunately the medical home should enable him to get off the treadmill and enjoy practicing medicine again.”
“Sounds great; but as we said in our recent discussion, this requires a change in the physician’s mindset. All through his/her years of training and previous practice, the physician had to think and perform independently and bear personal responsibility for the outcomes of his patients. He communicated little with his colleagues, minimally with his nurse, and often inadequately with his patients. To function in a medical home, he has to practice leadership, communication, and shared responsibility. That’s quite a personal transformation.”
“We’ve talked about leadership, communication, and change management in the past, Julie. Perhaps now we should just touch on a few points as they apply to a physician in a medical home. With respect to changes in the role of the doctor, he or she often has to go so far as to reexamine his/her identity as a physician. ‘This transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared staff. To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones (1).’”
“That sounds pretty profound (probably because it’s a quotation). Where does one go to learn all of this good stuff?”
“Formal in-house instruction, e.g., Affinity Learning Center, almost any bookstore, and for one pushed for time, the Kaizen Curmudgeon postings in April and May 2008. Of course, many physicians already have the requisite leadership skills if their background includes experience in business or the military.”
“As you recommended, Curmudge, I looked up TransforMed’s leadership tips for physicians (2). These look really valuable:
’Exemplary leaders first lead themselves.’ ‘The culture of the practice is always modeled by the leaders for better or for worse.’
‘The basic challenge of leadership is to engage the minds and efforts of the staff to work with enthusiasm toward a specific goal.’
‘An Achilles heel of many physicians is trying to do too much alone. Great leaders get things done through other people. Sharing power has two main advantages: 1) the leader is not overburdened by work that never gets done or gets done poorly, and 2) an empowered staff means leadership at all levels of the practice.’
‘The leader sets the tone for how communication will be disseminated throughout the practice.’ ‘Have meetings of both the leadership and of sub-groups.’
‘It is part of a leader’s job to show appreciation.’ A leader’s two most important words are ‘thank you.’
The leader’s number one success factor is relationships with subordinates. These relationships must motivate staff at all levels of the medical practice.”
“I hope you recall, Julie, that empowerment—noted above—is an important principle of Lean.”
“Of course I do. And intuitively I know what empowerment means, but how do you define it?"
“A leader empowers his or her colleagues by giving them permission to reach their potential (3). I hope you realize how central this concept is to the success of the medical home.”
“I also recognize that empowerment is an essential of servant leadership, and for that matter, the whole medical home list sounds like servant leadership. Back on May 8 and 15 of 2008 we wrote two postings on this. I trust you remember, Curmudge. Servant leadership is too important not to be revisited.”
“We’ll do it, Julie, but you’ll have to remind me. Meanwhile, in our next conversation let’s continue talking about the changing mindset of the folks in the medical home.”
Affinity’s Kaizen Curmudgeon
(1) Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home (06/09/09)
http://www.medscape.com/viewarticle/703460_print (One must log in--free.)
(2) Johnson, Barbara. Leadership Excellence
http://www.transformed.com/workingPapers/LeadershipTipsPhysicians.pdf
(3) Clark, Keith and Panther, Mike. Leadership, the Art of Empowering. (2009, Monte Alverno Retreat & Spirituality Center)
Thursday, October 29, 2009
101 Curmudgeons
“Hooray, Jaded Julie! We’ve reached 101.”
“You’re 101 years old, Curmudge? Congrats! You don’t look a day over 95.”
“No, no, Julie. We’re celebrating 101 postings of the Kaizen Curmudgeon blog. Perhaps we should buy a big birthday cake at Manderfields and invite all of our readers to come to 3 North to share it.”
“Sure, Curmudge. We can invite both of our readers. For them we can buy a cupcake and cut it in half.”
“Well then, we might do something of real value for our readers like publishing a table of contents of all of our postings, but that would be several pages long.”
“I’ve got it, Curmudge. Let’s list the general topics that we have discussed and indicate when in the past two-and-one-half years our readers can find relevant postings. Of course you don’t remember, but they’re in your records. You look them up, and I’ll type them.”
Brand and Generic Drug Names—May 14, 2009.
Branding and Personalized Care—March-April 2009.
Lean Basics—May-December 2007.
Lean Tools—July-October 2008.
Management and Leadership—March-June 2008.
Medical Home—September-October 2009.
Nursing—July 2007, July 2008.
Patient Safety—October 2008-March 2009.
Physicians—June, August, and September 2009.
Primary Care—August-September 2009.
Queues and Workload Variability—July 2009.
Toyota Production System—January-February 2008.
“There! We’ve done it. I hope people find the list helpful.”
“When we started this, Curmudge, I never expected you to come up with 100 ideas to write about. Are you concerned that the well might run dry?”
“I doubt that the blog will terminate because of lack of ideas. A bigger threat is our fragile creative spirit. When that goes kaput, we’ll turn off the computer.”
“So what do we do for an encore? Will the second hundred postings be just like the first?”
“Well, Jaded Julie, we might change our posting frequency from weekly to every other week, and I certainly hope we can collect more Lean Success Stories here at Affinity. One thing is for certain, and that is as long as I am writing this blog, you will be a part of it. Our conversational format might not be unique, but your presence surely makes it distinctive.”
“That’s great, Curmudge. I’ll go home and tell my couch-potato husband that I have a permanent job.”
“Don’t rely on a long-term commitment from an old guy, Julie. Remember that I have to pre-pay whenever I order a three-minute egg.”
Affinity’s Kaizen Curmudgeon
“You’re 101 years old, Curmudge? Congrats! You don’t look a day over 95.”
“No, no, Julie. We’re celebrating 101 postings of the Kaizen Curmudgeon blog. Perhaps we should buy a big birthday cake at Manderfields and invite all of our readers to come to 3 North to share it.”
“Sure, Curmudge. We can invite both of our readers. For them we can buy a cupcake and cut it in half.”
“Well then, we might do something of real value for our readers like publishing a table of contents of all of our postings, but that would be several pages long.”
“I’ve got it, Curmudge. Let’s list the general topics that we have discussed and indicate when in the past two-and-one-half years our readers can find relevant postings. Of course you don’t remember, but they’re in your records. You look them up, and I’ll type them.”
Brand and Generic Drug Names—May 14, 2009.
Branding and Personalized Care—March-April 2009.
Lean Basics—May-December 2007.
Lean Tools—July-October 2008.
Management and Leadership—March-June 2008.
Medical Home—September-October 2009.
Nursing—July 2007, July 2008.
Patient Safety—October 2008-March 2009.
Physicians—June, August, and September 2009.
Primary Care—August-September 2009.
Queues and Workload Variability—July 2009.
Toyota Production System—January-February 2008.
“There! We’ve done it. I hope people find the list helpful.”
“When we started this, Curmudge, I never expected you to come up with 100 ideas to write about. Are you concerned that the well might run dry?”
“I doubt that the blog will terminate because of lack of ideas. A bigger threat is our fragile creative spirit. When that goes kaput, we’ll turn off the computer.”
“So what do we do for an encore? Will the second hundred postings be just like the first?”
“Well, Jaded Julie, we might change our posting frequency from weekly to every other week, and I certainly hope we can collect more Lean Success Stories here at Affinity. One thing is for certain, and that is as long as I am writing this blog, you will be a part of it. Our conversational format might not be unique, but your presence surely makes it distinctive.”
“That’s great, Curmudge. I’ll go home and tell my couch-potato husband that I have a permanent job.”
“Don’t rely on a long-term commitment from an old guy, Julie. Remember that I have to pre-pay whenever I order a three-minute egg.”
Affinity’s Kaizen Curmudgeon
Wednesday, October 21, 2009
Change Your Primary Care Mindset--the Physician
“There you go again, Curmudge, trying to discuss a subject about which you don’t know diddly.”
“Now, Jaded Julie, you’ve known for a long time that I compensate for my lack of expertise by quoting material from reliable sources—literature that most people don’t have time to find and read. So may I have your permission to examine the duties and mindset of a primary care physician in his/her traditional role and then after he joins a medical home?”
“Have at it, Curmudge. I’ll follow along to keep you honest.”
“Okay, let’s consider a traditional office visit for episodic care (1). The patient arrives and is checked in by the receptionist who verifies contact and insurance information and collects the co-pay. After the patient sits in the waiting room for awhile, the nurse takes her back to the exam room and checks her vital signs. Ultimately, the physician arrives and he/she does most or all of these things: medication reconciliation, history and physical, data gathering and entry, decision making, prescription writing, documentation and paperwork, behavior modification, results reporting and order entry.”
“But Curmudge, several of those things could have been done by someone other than the physician.”
“That’s it, Julie. As we’ll learn later, having someone else do some of these things is the key to a solution. But first, let’s more fully examine the present situation. Here are some shocking numbers regarding the primary care physician in his traditional role (2): ‘It would take 18 hours per day to provide all evidence-based chronic care and preventive care to the average 2,500-patient panel. This doesn’t include acute care.’ Other sources estimate the total, including acute care, to be 19-25 hours per day.”
“Twenty-five hours per day! Someone once told me that if 24 hours a day were not enough, there’s always nights.”
“Get serious, Julie. ‘Many primary care physicians are stressed, some are exhausted physically and emotionally, and almost all are overwhelmed with crammed schedules…and unrewarding administrative tasks (3).’ ‘…they feel like hamsters on a treadmill.’”
“Wow, Curmudge! I feel badly for those physicians, and I would not want to be a patient of such a frenetic practice. The last thing Jaded Julie needs is a jaded primary care physician.”
“And that’s why physicians in recent years have developed ways to make their practices more efficient; these improvements evolved into the Patient-Centered Medical Home.”
“So the doc’s mindset has changed from frantic to relaxed?”
“Not entirely, Julie. In the traditional clinic, the people working for the physician were his/her subordinates. In the medical home, the physician is the leader of a team of quasi-peers.”
“Curmudge, I’d understand you a lot better if you called them almost-peers. But go on…”
“It’s not always easy for a physician to make the transition from absolute chief to leader of a team. In fact, consideration of that will be the second half of our exploration of the changing mindset of the primary care physician.”
“We can’t explore someone’s mindset, Old Guy. You’re not a psychologist.”
“Not a problem, Julie. All we do is read and write.”
“If you say so, Curmudge, but that can be done by any second-grader.”
Affinity’s Kaizen Curmudgeon
(1) Sinsky, C.A. Improving office practice: Working smarter, not harder.
http://www.aafp.org/fpm/20061100/28impr.html
(2) Framing the medical home model of care: blueprint from early adaptors. (book)
http://store.hin.com/Framing-the-Medical-Home-Model-of-Care-Blueprint-from-Early-Adopters_p_3791.html
(3) Primary Care at the Crossroads: Preconference Papers
http://www.familymedicine.medschool.ucsf.edu/pdf/cepc/0406_pres/preConfPapers.pdf
“Now, Jaded Julie, you’ve known for a long time that I compensate for my lack of expertise by quoting material from reliable sources—literature that most people don’t have time to find and read. So may I have your permission to examine the duties and mindset of a primary care physician in his/her traditional role and then after he joins a medical home?”
“Have at it, Curmudge. I’ll follow along to keep you honest.”
“Okay, let’s consider a traditional office visit for episodic care (1). The patient arrives and is checked in by the receptionist who verifies contact and insurance information and collects the co-pay. After the patient sits in the waiting room for awhile, the nurse takes her back to the exam room and checks her vital signs. Ultimately, the physician arrives and he/she does most or all of these things: medication reconciliation, history and physical, data gathering and entry, decision making, prescription writing, documentation and paperwork, behavior modification, results reporting and order entry.”
“But Curmudge, several of those things could have been done by someone other than the physician.”
“That’s it, Julie. As we’ll learn later, having someone else do some of these things is the key to a solution. But first, let’s more fully examine the present situation. Here are some shocking numbers regarding the primary care physician in his traditional role (2): ‘It would take 18 hours per day to provide all evidence-based chronic care and preventive care to the average 2,500-patient panel. This doesn’t include acute care.’ Other sources estimate the total, including acute care, to be 19-25 hours per day.”
“Twenty-five hours per day! Someone once told me that if 24 hours a day were not enough, there’s always nights.”
“Get serious, Julie. ‘Many primary care physicians are stressed, some are exhausted physically and emotionally, and almost all are overwhelmed with crammed schedules…and unrewarding administrative tasks (3).’ ‘…they feel like hamsters on a treadmill.’”
“Wow, Curmudge! I feel badly for those physicians, and I would not want to be a patient of such a frenetic practice. The last thing Jaded Julie needs is a jaded primary care physician.”
“And that’s why physicians in recent years have developed ways to make their practices more efficient; these improvements evolved into the Patient-Centered Medical Home.”
“So the doc’s mindset has changed from frantic to relaxed?”
“Not entirely, Julie. In the traditional clinic, the people working for the physician were his/her subordinates. In the medical home, the physician is the leader of a team of quasi-peers.”
“Curmudge, I’d understand you a lot better if you called them almost-peers. But go on…”
“It’s not always easy for a physician to make the transition from absolute chief to leader of a team. In fact, consideration of that will be the second half of our exploration of the changing mindset of the primary care physician.”
“We can’t explore someone’s mindset, Old Guy. You’re not a psychologist.”
“Not a problem, Julie. All we do is read and write.”
“If you say so, Curmudge, but that can be done by any second-grader.”
Affinity’s Kaizen Curmudgeon
(1) Sinsky, C.A. Improving office practice: Working smarter, not harder.
http://www.aafp.org/fpm/20061100/28impr.html
(2) Framing the medical home model of care: blueprint from early adaptors. (book)
http://store.hin.com/Framing-the-Medical-Home-Model-of-Care-Blueprint-from-Early-Adopters_p_3791.html
(3) Primary Care at the Crossroads: Preconference Papers
http://www.familymedicine.medschool.ucsf.edu/pdf/cepc/0406_pres/preConfPapers.pdf
Thursday, October 8, 2009
Change Your Primary Care Mindset--the Patient
“Change my mind? I’m as much a stick-in-the-mud as you are, Curmudge. The only time you change your mind is when you forget what was in it. Of course, that happens every 15 minutes.”
“You know very well, Jaded Julie, that primary care is changing. It’s no longer the solo-practice doctor with his combination nurse/bookkeeper. Over the years physicians have developed a variety of efficient team-based practice models. These have become the basis for what is now called the Patient-Centered Medical Home.“
“So I guess everyone has to change the way they think about primary care—the caregivers and even the patients. Change implies going from a condition to a different—hopefully better—condition. Modern health care is focused on the patient, so let’s start by considering what the patient will be changing from and then what he or she will change to.”
“In the recent past, Julie, a patient with an acute problem would call a doctor’s office for an appointment and then hope the appointment date arrived before the problem resolved itself, possibly to return again. At the appointed time, the patient would show up at the office of the doctor who might or might not know the patient well. Prior to seeing the doc, a nurse might check the patient’s b.p. and temperature and ask about current medications.”
“I think I know what’s next, Curmudge. The patient would wait—seemingly forever—in a chilly exam room. With luck, the nurse might pop in to say, ‘He’s running late.’ Ultimately the doc would hurry in, his white coattails flapping behind him. After a quick history and physical, the physician would make his diagnosis, scribble a prescription, and hurry on to the next patient, white coattails still flapping. In this extreme example the physician is not typical, and it’s evident that he had not read the books by Studer or Beeson that we discussed in recent weeks. If the patient needed to see a specialist, she might even have to pick up the phone book and turn to the yellow pages after she got home. And if the problem recurred, the patient would be tempted to go to the nearest hospital’s emergency department or a store-front urgent care clinic.”
“You make it sound pretty grim, Julie, but it’s something that does occur occasionally. Fortunately, the patient can now receive personalized care in a more efficient clinic or become affiliated with a medical home. Her mind as well as her experience will change. Let’s talk about how a medical home will change the patient’s mindset.”
“In the medical home, Curmudge, the patient will have one primary care physician who knows her well, and he or she will be the leader of the patient’s care team. And here’s a big difference; the patient will be a member of her team as an active participant in her own care and decision making. She must realize that her care is provided not by an individual but by a system comprised of a multidisciplinary team responsible for delivering and continuously improving care for her and the other members of an identified patient population (1). The patient must recognize that members of the team other than the physician may be the most appropriate to resolve some of her health care issues. And that some of these issues will be handled by telephone or e-mail without her needing to come to the clinic.”
“As we said back on September 10 when we introduced the medical home concept, the patient will no longer have to face the whole health care delivery system alone. That certainly sounds beneficial, but some patients could see it as a limitation. These patients might not want any limit on their choice of primary care providers or specialists, but they will need to alter this mindset to participate in a medical home. ‘Medical homes are likely to have a ‘soft gatekeeper’ function (2).’ ‘The medical home will help patients decide when to see a specialist and select a specialist that will both serve the patient’s clinical needs and coordinate with the medical home physician.’ ‘The medical home will identify redundant tests and services before they occur and counsel patients to avoid redundant services.’”
“On September 10 we also mentioned the medical home’s coordination of care for those patients with chronic conditions. What’s not to like about a system that improves the patient’s quality of life? By the way, Curmudge, I have always wondered whether old age should be considered a chromic condition. You should certainly know a lot about that.”
“Well, Julie, it depends on your mindset. I believe that old age is a chronic condition only if one allows it to be. Eventually, of course, old age is most certainly terminal. By the way, next time we’ll discuss the role—and the mindset—of the physician in the medical home team.”
Affinity’s Kaizen Curmudgeon
(1)http://www.transformed.com/components.cfm
(2)http://www.hschange.org/CONTENT/1030/?PRINT=1
“You know very well, Jaded Julie, that primary care is changing. It’s no longer the solo-practice doctor with his combination nurse/bookkeeper. Over the years physicians have developed a variety of efficient team-based practice models. These have become the basis for what is now called the Patient-Centered Medical Home.“
“So I guess everyone has to change the way they think about primary care—the caregivers and even the patients. Change implies going from a condition to a different—hopefully better—condition. Modern health care is focused on the patient, so let’s start by considering what the patient will be changing from and then what he or she will change to.”
“In the recent past, Julie, a patient with an acute problem would call a doctor’s office for an appointment and then hope the appointment date arrived before the problem resolved itself, possibly to return again. At the appointed time, the patient would show up at the office of the doctor who might or might not know the patient well. Prior to seeing the doc, a nurse might check the patient’s b.p. and temperature and ask about current medications.”
“I think I know what’s next, Curmudge. The patient would wait—seemingly forever—in a chilly exam room. With luck, the nurse might pop in to say, ‘He’s running late.’ Ultimately the doc would hurry in, his white coattails flapping behind him. After a quick history and physical, the physician would make his diagnosis, scribble a prescription, and hurry on to the next patient, white coattails still flapping. In this extreme example the physician is not typical, and it’s evident that he had not read the books by Studer or Beeson that we discussed in recent weeks. If the patient needed to see a specialist, she might even have to pick up the phone book and turn to the yellow pages after she got home. And if the problem recurred, the patient would be tempted to go to the nearest hospital’s emergency department or a store-front urgent care clinic.”
“You make it sound pretty grim, Julie, but it’s something that does occur occasionally. Fortunately, the patient can now receive personalized care in a more efficient clinic or become affiliated with a medical home. Her mind as well as her experience will change. Let’s talk about how a medical home will change the patient’s mindset.”
“In the medical home, Curmudge, the patient will have one primary care physician who knows her well, and he or she will be the leader of the patient’s care team. And here’s a big difference; the patient will be a member of her team as an active participant in her own care and decision making. She must realize that her care is provided not by an individual but by a system comprised of a multidisciplinary team responsible for delivering and continuously improving care for her and the other members of an identified patient population (1). The patient must recognize that members of the team other than the physician may be the most appropriate to resolve some of her health care issues. And that some of these issues will be handled by telephone or e-mail without her needing to come to the clinic.”
“As we said back on September 10 when we introduced the medical home concept, the patient will no longer have to face the whole health care delivery system alone. That certainly sounds beneficial, but some patients could see it as a limitation. These patients might not want any limit on their choice of primary care providers or specialists, but they will need to alter this mindset to participate in a medical home. ‘Medical homes are likely to have a ‘soft gatekeeper’ function (2).’ ‘The medical home will help patients decide when to see a specialist and select a specialist that will both serve the patient’s clinical needs and coordinate with the medical home physician.’ ‘The medical home will identify redundant tests and services before they occur and counsel patients to avoid redundant services.’”
“On September 10 we also mentioned the medical home’s coordination of care for those patients with chronic conditions. What’s not to like about a system that improves the patient’s quality of life? By the way, Curmudge, I have always wondered whether old age should be considered a chromic condition. You should certainly know a lot about that.”
“Well, Julie, it depends on your mindset. I believe that old age is a chronic condition only if one allows it to be. Eventually, of course, old age is most certainly terminal. By the way, next time we’ll discuss the role—and the mindset—of the physician in the medical home team.”
Affinity’s Kaizen Curmudgeon
(1)http://www.transformed.com/components.cfm
(2)http://www.hschange.org/CONTENT/1030/?PRINT=1
Thursday, October 1, 2009
AIDET for Physicians
“Curmudge, I think you made a poor assumption a week ago when you said that everyone had already learned about AIDET from Studer’s book (1).”
“If so, Jaded Julie, it wouldn’t be the first time. When I first taught general chemistry in 1965, I assumed that all of the students could work with logarithms on a slide rule.”
“(Logarithms? Slide rule? What’s the Old Guy talking about now?) So what did you do?”
“We taught people what they needed to know, and that’s what we’ll do here. Of course, the blog limits how much detail about AIDET we can provide. The quoted material will come from Beeson’s book (2), and imperative statements should be considered to be directed to the physician.”
Acknowledge
Confer with the nurse and/or review the patient’s chart before entering the exam room.
Make eye contact with the patient and any relatives in the exam room. The relative may be your main ally in understanding and implementing your plan of care.
Introduce
Introduce yourself and describe your exact role in the care of the patient (especially when entering an inpatient hospital room).
In your first encounter with a patient, describe your experience and expertise. This will reduce the patient’s anxiety and increase her confidence in you.
“Manage up” (a Studer term). Express your confidence in the other members of the care team.
Duration
To the greatest extent possible, keep the patient informed regarding the length of a procedure, when test results will be available, the length of stay in the hospital, and any other wait times.
Explanation
Areas requiring explanations include diagnosis, medications, treatment options, and follow-up care.
If the diagnosis is not definitive, provide a list of possibilities. Explain the nature of tests to be performed and what is being sought. “A patient’s diagnosis ignorance creates treatment indifference and compromises compliance, and can unravel evidence-based treatment plans.”
“It has been shown that those patients who understand the purpose, potential side effects, duration of therapy, and anticipated outcomes of medications are more likely to take them.”
“Physicians should convey their (treatment) recommendation based on evidence.”
Thank you
“I’m glad you came in today; I know we can help.”
“As you recommended, Curmudge, I skimmed through Beeson’s earlier book, Practicing Excellence (3). To my surprise, AIDET wasn’t there.”
“The lessons for physicians were there all right. They just had not been collected into the AIDET acronym. Practicing Excellence is a must read for physicians.”
“Curmudge, the advice from Studer and Beeson is really essential, but it’s not going to happen unless it’s hardwired.”
“Don’t worry, Julie. Once physicians become convinced that something is important, they are the world’s experts at hardwiring. In addition to Beeson’s comments for physicians, here is his suggestion that all of us should hardwire:
‘Eye contact, a smile, and a ‘hello’ from everyone wearing an ID badge as patients and families walk your facility creates a favorable impression and speaks to the character of the institution.’”
Affinity’s Kaizen Curmudgeon
(1) Studer, Quint. Hardwiring Excellence. (Fire Starter Publishing, 2005)
(2) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(3) Beeson, Stephen C. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. (Fire Starter Publishing, 2006)
Thursday, September 24, 2009
Engaging Physicians--2
“Curmudge, other than giving your ancient brain its daily exercise, why are we writing another posting on Beeson’s Engaging Physicians (1)?”
“Because not everyone will read the book, Jaded Julie. I at least want to share with them a few of Beeson’s most important teachings. Perhaps we can do that with a quotation or two from each of the most critical chapters.”
“Have at it, Curmudge. I’ll just sit over here and take notes.”
Create and Communicate Organizational Vision and Goals
“Physicians care about clinical quality, practice efficiency, the quality and training of the nurses they work with, profitability, their reputation among patients, staff, and colleagues, their input on issues, appreciation for what they do, and responsiveness to practice concerns.”
“If leaders are unable to clearly communicate how an organizational effort will benefit physicians, then the strategy should be redesigned.”
“The leadership message to physicians should be: ‘Our goal is to eliminate barriers to care and to eliminate those things that waste your time.’”
Establishing Physician Confidence and Trust
“The importance of building trust with physicians cannot be overestimated.” “Trust in the leadership team precedes physician collaboration, participation, and alignment, and will be a vital element to the physician engagement process.”
Building Physician Leadership
“Perhaps the most important goal of physician leaders is to facilitate and execute the hospital’s transition from individual physician autonomy to system-based care delivery. System protocols, order sets, and evidence-based medicine outperform individual physician decision making in nearly all clinical circumstances.”
“Improving patient satisfaction and physician communication is the most common goal of a physician champion.” “Historically, physicians significantly underestimate the true impact of their own behavior on a nurse’s work experience.”
Training Physicians
“Leveraging the influence of the engaged physician who leads by example is perhaps the greatest catalyst of change in the behaviors of the healthcare workforce.”
“A physician’s technical ability to diagnose and treat a medical condition did not rank in the top six physician attributes that patients ranked as most important.” “In order for physicians to be successful, to grow business, to expand revenue, and to establish a reputation in the community, physicians must deliver the patient’s definition of a great physician.”
“Physicians are the smartest and best students in the world.”
“The reality is that trained, consistently executed communication behaviors will drive every measure of performance that physicians consider to be important—patient loyalty, malpractice risk, patient compliance, clinical outcomes, patient safety …and the quality of a physician’s work life.”
Physician Measurement and Balanced Scorecards
“If there is distrust, animosity, or significant ‘issues’ between leadership and physicians, then measuring and reporting physician performance will come under intense heat, protest, and rejection from physicians.”
Recognizing Physicians
“Recognition changes people, changes physicians, replicates behaviors, creates physician loyalty, and builds partnership and trust with a system and its leaders.”
“Curmudge, you didn’t include anything from Beeson’s discussion of AIDET* for physicians.” (*Acknowledge, Introduce, Duration, Explanation, Thank you.)
“I just assumed that everyone had read about AIDET in Studer’s book, Hardwiring Excellence (2). Which brings me to my final word about Engaging Physicians: READ THE BOOK.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Studer, Quint. Hardwiring Excellence. (Fire Starter Publishing, 2005)
“Because not everyone will read the book, Jaded Julie. I at least want to share with them a few of Beeson’s most important teachings. Perhaps we can do that with a quotation or two from each of the most critical chapters.”
“Have at it, Curmudge. I’ll just sit over here and take notes.”
Create and Communicate Organizational Vision and Goals
“Physicians care about clinical quality, practice efficiency, the quality and training of the nurses they work with, profitability, their reputation among patients, staff, and colleagues, their input on issues, appreciation for what they do, and responsiveness to practice concerns.”
“If leaders are unable to clearly communicate how an organizational effort will benefit physicians, then the strategy should be redesigned.”
“The leadership message to physicians should be: ‘Our goal is to eliminate barriers to care and to eliminate those things that waste your time.’”
Establishing Physician Confidence and Trust
“The importance of building trust with physicians cannot be overestimated.” “Trust in the leadership team precedes physician collaboration, participation, and alignment, and will be a vital element to the physician engagement process.”
Building Physician Leadership
“Perhaps the most important goal of physician leaders is to facilitate and execute the hospital’s transition from individual physician autonomy to system-based care delivery. System protocols, order sets, and evidence-based medicine outperform individual physician decision making in nearly all clinical circumstances.”
“Improving patient satisfaction and physician communication is the most common goal of a physician champion.” “Historically, physicians significantly underestimate the true impact of their own behavior on a nurse’s work experience.”
Training Physicians
“Leveraging the influence of the engaged physician who leads by example is perhaps the greatest catalyst of change in the behaviors of the healthcare workforce.”
“A physician’s technical ability to diagnose and treat a medical condition did not rank in the top six physician attributes that patients ranked as most important.” “In order for physicians to be successful, to grow business, to expand revenue, and to establish a reputation in the community, physicians must deliver the patient’s definition of a great physician.”
“Physicians are the smartest and best students in the world.”
“The reality is that trained, consistently executed communication behaviors will drive every measure of performance that physicians consider to be important—patient loyalty, malpractice risk, patient compliance, clinical outcomes, patient safety …and the quality of a physician’s work life.”
Physician Measurement and Balanced Scorecards
“If there is distrust, animosity, or significant ‘issues’ between leadership and physicians, then measuring and reporting physician performance will come under intense heat, protest, and rejection from physicians.”
Recognizing Physicians
“Recognition changes people, changes physicians, replicates behaviors, creates physician loyalty, and builds partnership and trust with a system and its leaders.”
“Curmudge, you didn’t include anything from Beeson’s discussion of AIDET* for physicians.” (*Acknowledge, Introduce, Duration, Explanation, Thank you.)
“I just assumed that everyone had read about AIDET in Studer’s book, Hardwiring Excellence (2). Which brings me to my final word about Engaging Physicians: READ THE BOOK.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Studer, Quint. Hardwiring Excellence. (Fire Starter Publishing, 2005)
Thursday, September 17, 2009
Engaging Physicians--a Great Book
“Over the weekend, Jaded Julie, I read a great book. It’s called Engaging Physicians by Stephen C. Beeson (1). Remember when we talked about Physicians and Lean back on June 25, and I said that a hospital-wide Lean transformation must involve the physicians? Well, Beeson’s book goes into the subject much more deeply than the IHI white paper that I cited. This book was written principally for hospital administrators, while Beeson’s earlier book, Practicing Excellence: A Physician’s Manual to Exceptional Health Care (2), was written for the physicians themselves.”
“But Curmudge, how can you even comment about physicians? Without an MD after your name, your credibility with physicians is zilch.”
“I was an undergraduate with premeds, I later taught chemistry to premeds, and now I see doctors every day. All of that plus the fact that Beeson is a physician ought to raise my credibility to at least zilch-and-one-half.”
“Good luck, Curmudge. So if we acknowledge that physicians must be involved in a Lean transformation, why must so much ink be devoted to how we can make it happen?”
“Consider premeds and engineering students, Julie. The engineers’ grades can be B’s and they can be successful. The premeds must be sufficiently intense to earn A’s in order to get into medical school. In addition, the engineers learn about systems, collaborating with teams, and eventually working for an organization. In contrast, all the way through college, med school, and residency, physicians focus on developing their individual autonomy and personal responsibility for their patients. Systems and organizational issues—so critical in a Lean transformation—are rarely considered.”
“Curmudge, you sound as if you’ve known a few engineers over the years. Are there other ways that they differ from physicians?”
“It seems to me, Julie, that physicians are a bit more outgoing than engineers. The story goes that when you meet an engineer when walking down a hallway, he is always looking at his shoes. When you meet a doctor in the hallway, he is looking at your shoes.”
“You can’t say that, Curmudge! Somebody might be offended.”
“Okay. Sorry about that, physicians. How about this? Sometimes when you meet a physician in the hallway, he seems to have a ‘thousand-yard stare.’ I once met a guy with that appearance who was hiking down from the summit of Mount Rainier. He looked as if he had really been through the wringer.”
“That’s better, Curmudge. A physician might be thinking intently about his most recent or next patient. So what is your explanation…er, conjecture, Professor?”
“I once read that people can be changed by a significant emotional event—like marriage, motherhood, or in the present case, medical school and residency. My speculation is that med school transforms serious undergraduates into extremely intense practicing physicians.”
“Now I understand, Curmudge. That’s why Beeson wrote a whole book about how one should proceed to engage physicians in a hospital-wide renewal.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Beeson, Stephen C. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. (Fire Starter Publishing, 2006)
“But Curmudge, how can you even comment about physicians? Without an MD after your name, your credibility with physicians is zilch.”
“I was an undergraduate with premeds, I later taught chemistry to premeds, and now I see doctors every day. All of that plus the fact that Beeson is a physician ought to raise my credibility to at least zilch-and-one-half.”
“Good luck, Curmudge. So if we acknowledge that physicians must be involved in a Lean transformation, why must so much ink be devoted to how we can make it happen?”
“Consider premeds and engineering students, Julie. The engineers’ grades can be B’s and they can be successful. The premeds must be sufficiently intense to earn A’s in order to get into medical school. In addition, the engineers learn about systems, collaborating with teams, and eventually working for an organization. In contrast, all the way through college, med school, and residency, physicians focus on developing their individual autonomy and personal responsibility for their patients. Systems and organizational issues—so critical in a Lean transformation—are rarely considered.”
“Curmudge, you sound as if you’ve known a few engineers over the years. Are there other ways that they differ from physicians?”
“It seems to me, Julie, that physicians are a bit more outgoing than engineers. The story goes that when you meet an engineer when walking down a hallway, he is always looking at his shoes. When you meet a doctor in the hallway, he is looking at your shoes.”
“You can’t say that, Curmudge! Somebody might be offended.”
“Okay. Sorry about that, physicians. How about this? Sometimes when you meet a physician in the hallway, he seems to have a ‘thousand-yard stare.’ I once met a guy with that appearance who was hiking down from the summit of Mount Rainier. He looked as if he had really been through the wringer.”
“That’s better, Curmudge. A physician might be thinking intently about his most recent or next patient. So what is your explanation…er, conjecture, Professor?”
“I once read that people can be changed by a significant emotional event—like marriage, motherhood, or in the present case, medical school and residency. My speculation is that med school transforms serious undergraduates into extremely intense practicing physicians.”
“Now I understand, Curmudge. That’s why Beeson wrote a whole book about how one should proceed to engage physicians in a hospital-wide renewal.”
Affinity’s Kaizen Curmudgeon
(1) Beeson, Stephen C. Engaging Physicians: A Manual to Physician Partnership. (Fire Starter Publishing, 2009)
(2) Beeson, Stephen C. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. (Fire Starter Publishing, 2006)
Thursday, September 10, 2009
The Medical Home--Introduction
“Hey, Jaded Julie, let’s invent a model for personalized primary care.”
“We’re too late, Curmudge. It’s already been invented.”
“Let’s do it anyway. With your innate chutzpah and my propensity to pilfer paragraphs from publications (with proper citations), we can’t lose.”
“I’m with you Curmudge, and I’ll bring along my inborn audacity. Presumably, we’ll start by considering the patient’s needs, as the folks at the Mayo Clinic say, ‘The needs of the patient come first.’”
“That’s it, Julie. And one of the patient’s biggest needs is to be able to get into the office at a time that reflects the patient’s condition. If she is acutely ill, she wants to hear, ‘Come on over right now.’ If she is scheduling an annual physical, ‘sometime next month’ should be acceptable.”
“And just like when you were a child, Curmudge, you were certainly more at ease knowing everyone in the office and being able to spend whatever time was necessary with the doctor. I bet that’s still true, even for a senior citizen (actually, an old relic) like you.”
“Time with the doctor is a difficult issue, Julie, especially if the goal of our model clinic is personalized care. Fortunately, not every patient needs to see the doctor at every encounter with the clinic. We’ll discuss that more after we complete our list of basic criteria.”
“Coordination of care is another requirement to build into our model. It seemed to me that traditionally, after the primary care doc made a referral to a specialist, the patient-doctor relationship went from patient-primary care to patient-specialist. Sometimes the primary care doc might find himself/herself left out of the loop. The specialist might neglect to send a report; and if he did, the overworked primary care doc might not find time to read it.”
“Patient involvement in her own care is important, but she shouldn’t have to deal with the whole health care delivery system all by herself. That’s where our model clinic’s coordination of care capabilities can really help the patient.”
“Curmudge, a person with a chronic health condition cannot help but be involved in his/her own care. The newspapers remind us almost every day of the expense of these conditions and of the importance of controlling them by doing the right things at the right times. Our model clinic can help these people by monitoring their condition and reminding them when it is time for a specific test or exam.”
“Here’s another personalized care issue, Julie. In a big clinic or one connected to a hospital, a patient might have to go to different locations for different tests and procedures. It’s easy for the patient to feel ‘herded,’ and that’s what we want to avoid. Some place that I read about—perhaps Geisinger—assigns a guide to each patient. This would be a perfect duty for a volunteer with an outgoing personality.”
“Great idea, as long as the volunteer isn’t a curmudgeon. It would be better if everything could be done in the clinic exam room. This would include patient registration, nurse time, time with the physician, and scheduling the next appointment. Of course, this would require careful coordination.”
“I would call it choreography; but under any name, it’s a great idea. We’re already doing this in our pulmonary area. So Julie, we’ve put together our list of basic requirements, and we’ll talk in more detail about these in subsequent weeks. Do you think we should give our model clinic a name?”
“Of course. Let’s call it The Jaded Julie Primary Care Clinic.”
“(Now you know what I meant when I spoke of chutzpah.) Even though the name is not new, I think we should call it The Medical Home.”
Affinity’s Kaizen Curmudgeon
“We’re too late, Curmudge. It’s already been invented.”
“Let’s do it anyway. With your innate chutzpah and my propensity to pilfer paragraphs from publications (with proper citations), we can’t lose.”
“I’m with you Curmudge, and I’ll bring along my inborn audacity. Presumably, we’ll start by considering the patient’s needs, as the folks at the Mayo Clinic say, ‘The needs of the patient come first.’”
“That’s it, Julie. And one of the patient’s biggest needs is to be able to get into the office at a time that reflects the patient’s condition. If she is acutely ill, she wants to hear, ‘Come on over right now.’ If she is scheduling an annual physical, ‘sometime next month’ should be acceptable.”
“And just like when you were a child, Curmudge, you were certainly more at ease knowing everyone in the office and being able to spend whatever time was necessary with the doctor. I bet that’s still true, even for a senior citizen (actually, an old relic) like you.”
“Time with the doctor is a difficult issue, Julie, especially if the goal of our model clinic is personalized care. Fortunately, not every patient needs to see the doctor at every encounter with the clinic. We’ll discuss that more after we complete our list of basic criteria.”
“Coordination of care is another requirement to build into our model. It seemed to me that traditionally, after the primary care doc made a referral to a specialist, the patient-doctor relationship went from patient-primary care to patient-specialist. Sometimes the primary care doc might find himself/herself left out of the loop. The specialist might neglect to send a report; and if he did, the overworked primary care doc might not find time to read it.”
“Patient involvement in her own care is important, but she shouldn’t have to deal with the whole health care delivery system all by herself. That’s where our model clinic’s coordination of care capabilities can really help the patient.”
“Curmudge, a person with a chronic health condition cannot help but be involved in his/her own care. The newspapers remind us almost every day of the expense of these conditions and of the importance of controlling them by doing the right things at the right times. Our model clinic can help these people by monitoring their condition and reminding them when it is time for a specific test or exam.”
“Here’s another personalized care issue, Julie. In a big clinic or one connected to a hospital, a patient might have to go to different locations for different tests and procedures. It’s easy for the patient to feel ‘herded,’ and that’s what we want to avoid. Some place that I read about—perhaps Geisinger—assigns a guide to each patient. This would be a perfect duty for a volunteer with an outgoing personality.”
“Great idea, as long as the volunteer isn’t a curmudgeon. It would be better if everything could be done in the clinic exam room. This would include patient registration, nurse time, time with the physician, and scheduling the next appointment. Of course, this would require careful coordination.”
“I would call it choreography; but under any name, it’s a great idea. We’re already doing this in our pulmonary area. So Julie, we’ve put together our list of basic requirements, and we’ll talk in more detail about these in subsequent weeks. Do you think we should give our model clinic a name?”
“Of course. Let’s call it The Jaded Julie Primary Care Clinic.”
“(Now you know what I meant when I spoke of chutzpah.) Even though the name is not new, I think we should call it The Medical Home.”
Affinity’s Kaizen Curmudgeon
Thursday, September 3, 2009
The Evolution of Personalized Care
“In earlier conversations, Curmudge, you described family medicine in 1940 based on your personal experience. Back then, personalized care was the norm. Most docs were in solo practice with little or no supporting staff, they knew their patients well because they had delivered many of them, and they were willing to make house calls—sometimes in the middle of the night.”
“Seventy years ago, Jaded Julie, the financial side of solo practice was also pretty straightforward. Our family doctor’s patient load (panel) was kept low by the village’s low population. He charged what he felt was reasonable, my parents paid the bills, Dr. Arnold had a successful medical practice, and we enjoyed personalized care.”
“But now, Curmudge, a solo-practice doc is likely to be a preferred provider for an insurance company and he/she also has Medicare patients. Because of the level of reimbursements, his panel must expand to keep the practice viable. If the all-by-himself doc can’t expand his time to fit his panel and still get even a little sleep, there goes personalized care out the window.”
“That would seem be the case, Julie. In addition, think about how much more technically complex primary care has become. The advances in medicine itself are mind-boggling. Even small clinics have lab and radiology facilities, and the primary care docs have seemingly become the gateways to specialists for every disease, organ, and appendage. Then there are all of the externalities of health care delivery—insurance, Medicare, and regulations that change almost daily.”
“(Externality? I’m not sure what this is, but it sounds like more work.) You have described a rather unenviable plight for today’s primary care docs. So what, Ancient Oracle, do you suggest to get them out of it?”
“Suggest? No way! That’s beyond my salary grade. We must classify any statement that sounds like my judgment as pure conjecture. All I do is report what I find in the literature. Here’s an example, a Dr. Iliff, who sounded in 2003 as if he had done everything right in his solo practice (1). Seemingly everyone on his staff is a long-term employee: ‘My nurses have worked with me so long they know what I am going to say without my saying it.’ He has a long-time friend, a physician’s assistant, who also operates a solo practice; he helps smooth out the peaks in the doctor’s daily workload. Thus it would appear that the doctor has surrounded himself with surrogates who contribute greatly to his patients’ satisfaction. Perhaps we can call his practice ‘augmented solo.’”
“Curmudge, most docs that I know are, by nature, inclined to provide all of the personalized care that their patients desire. Their biggest constraint is lack of time. Dr. Iliff’s professional staff—because of their high quality and long service—make up for the doctor’s time limitation. But how does the doctor handle those externalities that you mentioned? Things like insurance, lab reports, reports from specialists, and Medicare?”
“He didn’t address many of these in his article, but he did emphasize that he limits his practice and keeps his office as simple as possible, with all records stored on site almost at arm’s reach. One might suspect that he has adequate—but minimal—clerical help who match the quality of the rest of his staff.”
“Well that’s one way to achieve personalized care. Are there others?”
“Sure thing, Julie. One is called ‘Concierge Medicine’ (Wikipedia calls this ‘Direct Care’). ‘Here are the basics: The patient pays an annual fee, ranging anywhere from $1500 to $10,000 a year for 24/7 access to her doctor. That means calls in the middle of the night, immediate, hour-long appointments, hospital visits, even house calls in some cases. Sometimes the fee includes appointment charges, but sometimes those are added on. Tests cost extra. Referrals get paid for separately’ (2). By significantly limiting his panel (100 to 1,000 patients), the physician is able to spend more time with each patient as needed. Typically, the concierge medicine practice does not become involved with insurance externalities; a patient with insurance handles that on his own.”
“I understand, Curmudge, that there are several business models for direct care.”
“One, apparently attractive to the uninsured, gets away from the pretentious connotation of ‘concierge’ by using the more descriptive term, ‘retainer practice.’ They charge $99 to join and then a flat monthly rate of $39 to $119 (3). Apparently however, retainer physicians are facing legal obstacles in some states (4). Primary care is certainly dynamic, Julie. Stay tuned for the latest news.”
“At your torpid tempo, Speedy, we could spend all year talking about primary care. When are we going to get to the medical home concept?”
“Never fear, Julie. The next time we talk about primary care, the medical home will be center stage.”
Affinity’s Kaizen Curmudgeon
(1)Iliff, D. Solo practice: the way of the future. http://www.aafp.org/fpm/20031000/23solo.html
(2)Trisha Torrey. Patient empowerment blog. http://patients.about.com/b/2008/03/21/your-doctor-on-call-247-for-a-price.htm
(3)Seattle doctors try flat-rate, no-limit primary care. (July 7, 2009)
http://www.medscape.com/viewarticle/705446
(4)Retainer physicians help uninsured but face legal obstacles. (June 4, 2009).
http://www.medscape.com/viewarticle/703900
“Seventy years ago, Jaded Julie, the financial side of solo practice was also pretty straightforward. Our family doctor’s patient load (panel) was kept low by the village’s low population. He charged what he felt was reasonable, my parents paid the bills, Dr. Arnold had a successful medical practice, and we enjoyed personalized care.”
“But now, Curmudge, a solo-practice doc is likely to be a preferred provider for an insurance company and he/she also has Medicare patients. Because of the level of reimbursements, his panel must expand to keep the practice viable. If the all-by-himself doc can’t expand his time to fit his panel and still get even a little sleep, there goes personalized care out the window.”
“That would seem be the case, Julie. In addition, think about how much more technically complex primary care has become. The advances in medicine itself are mind-boggling. Even small clinics have lab and radiology facilities, and the primary care docs have seemingly become the gateways to specialists for every disease, organ, and appendage. Then there are all of the externalities of health care delivery—insurance, Medicare, and regulations that change almost daily.”
“(Externality? I’m not sure what this is, but it sounds like more work.) You have described a rather unenviable plight for today’s primary care docs. So what, Ancient Oracle, do you suggest to get them out of it?”
“Suggest? No way! That’s beyond my salary grade. We must classify any statement that sounds like my judgment as pure conjecture. All I do is report what I find in the literature. Here’s an example, a Dr. Iliff, who sounded in 2003 as if he had done everything right in his solo practice (1). Seemingly everyone on his staff is a long-term employee: ‘My nurses have worked with me so long they know what I am going to say without my saying it.’ He has a long-time friend, a physician’s assistant, who also operates a solo practice; he helps smooth out the peaks in the doctor’s daily workload. Thus it would appear that the doctor has surrounded himself with surrogates who contribute greatly to his patients’ satisfaction. Perhaps we can call his practice ‘augmented solo.’”
“Curmudge, most docs that I know are, by nature, inclined to provide all of the personalized care that their patients desire. Their biggest constraint is lack of time. Dr. Iliff’s professional staff—because of their high quality and long service—make up for the doctor’s time limitation. But how does the doctor handle those externalities that you mentioned? Things like insurance, lab reports, reports from specialists, and Medicare?”
“He didn’t address many of these in his article, but he did emphasize that he limits his practice and keeps his office as simple as possible, with all records stored on site almost at arm’s reach. One might suspect that he has adequate—but minimal—clerical help who match the quality of the rest of his staff.”
“Well that’s one way to achieve personalized care. Are there others?”
“Sure thing, Julie. One is called ‘Concierge Medicine’ (Wikipedia calls this ‘Direct Care’). ‘Here are the basics: The patient pays an annual fee, ranging anywhere from $1500 to $10,000 a year for 24/7 access to her doctor. That means calls in the middle of the night, immediate, hour-long appointments, hospital visits, even house calls in some cases. Sometimes the fee includes appointment charges, but sometimes those are added on. Tests cost extra. Referrals get paid for separately’ (2). By significantly limiting his panel (100 to 1,000 patients), the physician is able to spend more time with each patient as needed. Typically, the concierge medicine practice does not become involved with insurance externalities; a patient with insurance handles that on his own.”
“I understand, Curmudge, that there are several business models for direct care.”
“One, apparently attractive to the uninsured, gets away from the pretentious connotation of ‘concierge’ by using the more descriptive term, ‘retainer practice.’ They charge $99 to join and then a flat monthly rate of $39 to $119 (3). Apparently however, retainer physicians are facing legal obstacles in some states (4). Primary care is certainly dynamic, Julie. Stay tuned for the latest news.”
“At your torpid tempo, Speedy, we could spend all year talking about primary care. When are we going to get to the medical home concept?”
“Never fear, Julie. The next time we talk about primary care, the medical home will be center stage.”
Affinity’s Kaizen Curmudgeon
(1)Iliff, D. Solo practice: the way of the future. http://www.aafp.org/fpm/20031000/23solo.html
(2)Trisha Torrey. Patient empowerment blog. http://patients.about.com/b/2008/03/21/your-doctor-on-call-247-for-a-price.htm
(3)Seattle doctors try flat-rate, no-limit primary care. (July 7, 2009)
http://www.medscape.com/viewarticle/705446
(4)Retainer physicians help uninsured but face legal obstacles. (June 4, 2009).
http://www.medscape.com/viewarticle/703900
Thursday, August 27, 2009
More about Primary Care in 1940
“Curmudge, what’s this more 1940 stuff? We talked about that last week. Didn’t you get it all out of your system?”
“Actually, Jaded Julie, I didn’t. I simply remembered more. My mind runs rather slowly in reverse.”
“Sure. About the same as your top forward speed. Okay, so what’s your story? Was everything better or worse back then?”
“Some of each, Julie. Remember my telling about our family doctor cutting out my ingrown toenail? Well, it got infected. It hurt like mad, and when Dr. Arnold took off the bandage, it looked ghastly. I was afraid we’d have to use gentian violet or whatever the purple stuff was that he used to treat my impetigo a couple years before. Instead, he sprinkled something called ‘sulfa powder’ on it, and it cleared right up. It was a miracle!”
“I bet it was. There were fewer antibacterial medications then; and because they were so new, the infection-causing bacteria had not yet developed resistance to them. It was good news in 1940, but now fighting many infections has become more difficult. So what else was going on then other than World War II in Europe and Jack Benny (who was that?) on the radio?”
“I recall Mrs. Arnold telling about traveling with her three children. They all became ill and needed medical attention. She told the physician that her husband was a doctor, and the physician felt obligated to treat the family without charge. It was called ‘professional courtesy,’ and then it was offered routinely. It is not as straightforward now because of legal (Stark anti-kickback laws) and insurance issues.”
“You are still making things sound pretty good in 1940, Curmudge. Other than the physicians’ limited armamentarium (see, Curmudge, I finally learned that word), there must have been some things that weren’t so great about primary care during your childhood.”
“When I was much younger, it was common for a person to become ill and die while under the care of just his primary care physician. Now in the U.S., except for extremely isolated locations, a seriously ill person is promptly referred to the appropriate specialist. The patient often studies his illness and becomes involved with more than a single caregiver in developing his plan of care.”
“I guess medical care was not always as transparent as it is now.”
“Right, Julie, and that could have been a problem in the past when medicine was often practiced in patient-one-doctor isolation. If your primary care physician had the knowledge and personality of a Marcus Welby, you experienced positive, personalized care. In the hypothetical case of a physician who was so confident of his abilities that he would not entertain discussion with anyone about alternate approaches or a second opinion, the patient would be at risk. That would certainly be the case when the physician made the statistically almost-inevitable error in diagnosis or treatment.”
“That sounds scary, Curmudge, especially when you consider that nobody is perfect.”
“The problem is compounded, Julie, when the patient as well as the physician carry the old-time image of the infallible doc. The patient says, ‘It’s okay if the doctor says so,’ and then abdicates all decisions to the physician.”
“So what do you do if the patient in this situation is your aged parent?”
“You intervene, if possible. But that’s a different story.”
“I have the feeling, Curmudge, that this is one of those very rare occasions when you know what you are talking about.”
“In this blog even the hypothetical cases are true. The only things fictional are you, Jaded Julie, and I, Kaizen Curmudgeon.”
Affinity’s Kaizen Curmudgeon
“Actually, Jaded Julie, I didn’t. I simply remembered more. My mind runs rather slowly in reverse.”
“Sure. About the same as your top forward speed. Okay, so what’s your story? Was everything better or worse back then?”
“Some of each, Julie. Remember my telling about our family doctor cutting out my ingrown toenail? Well, it got infected. It hurt like mad, and when Dr. Arnold took off the bandage, it looked ghastly. I was afraid we’d have to use gentian violet or whatever the purple stuff was that he used to treat my impetigo a couple years before. Instead, he sprinkled something called ‘sulfa powder’ on it, and it cleared right up. It was a miracle!”
“I bet it was. There were fewer antibacterial medications then; and because they were so new, the infection-causing bacteria had not yet developed resistance to them. It was good news in 1940, but now fighting many infections has become more difficult. So what else was going on then other than World War II in Europe and Jack Benny (who was that?) on the radio?”
“I recall Mrs. Arnold telling about traveling with her three children. They all became ill and needed medical attention. She told the physician that her husband was a doctor, and the physician felt obligated to treat the family without charge. It was called ‘professional courtesy,’ and then it was offered routinely. It is not as straightforward now because of legal (Stark anti-kickback laws) and insurance issues.”
“You are still making things sound pretty good in 1940, Curmudge. Other than the physicians’ limited armamentarium (see, Curmudge, I finally learned that word), there must have been some things that weren’t so great about primary care during your childhood.”
“When I was much younger, it was common for a person to become ill and die while under the care of just his primary care physician. Now in the U.S., except for extremely isolated locations, a seriously ill person is promptly referred to the appropriate specialist. The patient often studies his illness and becomes involved with more than a single caregiver in developing his plan of care.”
“I guess medical care was not always as transparent as it is now.”
“Right, Julie, and that could have been a problem in the past when medicine was often practiced in patient-one-doctor isolation. If your primary care physician had the knowledge and personality of a Marcus Welby, you experienced positive, personalized care. In the hypothetical case of a physician who was so confident of his abilities that he would not entertain discussion with anyone about alternate approaches or a second opinion, the patient would be at risk. That would certainly be the case when the physician made the statistically almost-inevitable error in diagnosis or treatment.”
“That sounds scary, Curmudge, especially when you consider that nobody is perfect.”
“The problem is compounded, Julie, when the patient as well as the physician carry the old-time image of the infallible doc. The patient says, ‘It’s okay if the doctor says so,’ and then abdicates all decisions to the physician.”
“So what do you do if the patient in this situation is your aged parent?”
“You intervene, if possible. But that’s a different story.”
“I have the feeling, Curmudge, that this is one of those very rare occasions when you know what you are talking about.”
“In this blog even the hypothetical cases are true. The only things fictional are you, Jaded Julie, and I, Kaizen Curmudgeon.”
Affinity’s Kaizen Curmudgeon
Thursday, August 20, 2009
Primary Care in 1940
“Okay, Curmudge, who cares about health care in 1940, and what does it have to do with Lean?”
“In 1940, Jaded Julie, I cared a lot. And the Toyota Production System had not yet been invented, so we won’t talk about Lean until later.”
“Proceed with your ancient history, Curmudge. I’ll just sit here in wide-eyed amazement.”
“I grew up in a small town with a population of about 2,500. We had one law enforcement officer, Marshal Bill Arnold, and one physician, Dr. Russell Arnold (no relation). Bill Arnold was the first responder for everything. When one had a minor illness or injury, they would call Bill; he would jump on his motorcycle and ride over to apply first aid. If the patient had to be transported to the hospital 10 miles away, he would summon the local undertaker with his hearse. Bill also responded to all fire calls. If the fire were serious, Bill would call Ted Kekic, who would get the town’s fire truck out of his barn.”
“It sounds as if your town lived life in the slow lane.”
“Regrettably that’s true Julie, even if your house was burning down. Dr. Arnold’s medical practice was also typical of the age. His office was in the basement of his home, his wife was his nurse and bookkeeper, and office hours were from 2:00 to 4:00 every afternoon. He did not have appointments; everyone had to sit and wait their turn. The wait was not usually very long, because he asked people requiring minor surgery, like me with an ingrown toenail, to arrive around 4:00. Dr. Arnold had only one exam room; and as a kid, I always wondered what the stirrups were for at the end of the examination table.”
“It seems that in those days primary care medicine wasn’t very complex, Curmudge. No receptionist, no laboratory, no radiology, no Medicare, no insurance, almost no referrals to specialists, and one nurse who was rarely needed.”
“That’s it, Julie. I never saw Dr. Arnold write anything, so he must have kept everyone’s records in his head. I guess he knew everybody in town, literally outside and inside. His bills would show only two items, numbers of house calls and numbers of office visits. Years later in 1978, my mother died suddenly. It was Dr. Arnold who called at 2:00 a.m. to tell me. He had arrived at my parents’ house only moments after the 911 EMTs. That was the ultimate in personalized care.”
“It sounds as if Dr. Arnold was exceptional…an early model for Marcus Welby, MD.”
“Well sort of, but back then most doctors were family physicians in a solo practice and on call 24/7. It took an exceptional person to live that way. In 1940 primary care was, by far, the major part of the health care delivery system. If your physician was clinically competent and had a good so-called ‘bedside manner,’ you had a favorable patient experience. That was especially true if you were lucky enough to get well. As I recall, personalized care was the norm.”
‘Speaking of personalized care, did Dr. Arnold meet all of the attributes of personalized care in our Affinity Brand Promise (1)?”
“Some of the attributes would have been different back then, especially for me, a six-year-old child. Dr. Arnold could not have known me better. Except for the surgeon who took out my tonsils, he was my only doctor from the moment I was born until I left home to go to college. In that era, partnering with one’s physician in decision-making was rare because he was the only one with access to health care knowledge. He always spent enough time with me to handle my problems, but frankly, as a kid I couldn’t wait to get out of the office. Thinking back, our doctor’s outstanding attributes were his willingness to make house calls and the depth of our personal friendship. He was always there when we needed him.”
“You seem to be suggesting, Curmudge, that despite the complexity of modern medicine, primary care physicians should try to duplicate the feeling of personalized care that you experienced in 1940.”
“Actually, Julie, I suspect that because of the complexity of modern medicine, what I experienced will rarely be achieved today by a primary care physician in a solo practice with his wife as both nurse and bookkeeper.”
“So, senescent sage, how can physicians today achieve this elusive personalized care?”
“I’ll conjure up a vision, Julie, and share it with you in a week or two.”
Affinity’s Kaizen Curmudgeon
(1) Kaizen Curmudgeon. The 5P Pyramid. Posted April 2, 2009.
“In 1940, Jaded Julie, I cared a lot. And the Toyota Production System had not yet been invented, so we won’t talk about Lean until later.”
“Proceed with your ancient history, Curmudge. I’ll just sit here in wide-eyed amazement.”
“I grew up in a small town with a population of about 2,500. We had one law enforcement officer, Marshal Bill Arnold, and one physician, Dr. Russell Arnold (no relation). Bill Arnold was the first responder for everything. When one had a minor illness or injury, they would call Bill; he would jump on his motorcycle and ride over to apply first aid. If the patient had to be transported to the hospital 10 miles away, he would summon the local undertaker with his hearse. Bill also responded to all fire calls. If the fire were serious, Bill would call Ted Kekic, who would get the town’s fire truck out of his barn.”
“It sounds as if your town lived life in the slow lane.”
“Regrettably that’s true Julie, even if your house was burning down. Dr. Arnold’s medical practice was also typical of the age. His office was in the basement of his home, his wife was his nurse and bookkeeper, and office hours were from 2:00 to 4:00 every afternoon. He did not have appointments; everyone had to sit and wait their turn. The wait was not usually very long, because he asked people requiring minor surgery, like me with an ingrown toenail, to arrive around 4:00. Dr. Arnold had only one exam room; and as a kid, I always wondered what the stirrups were for at the end of the examination table.”
“It seems that in those days primary care medicine wasn’t very complex, Curmudge. No receptionist, no laboratory, no radiology, no Medicare, no insurance, almost no referrals to specialists, and one nurse who was rarely needed.”
“That’s it, Julie. I never saw Dr. Arnold write anything, so he must have kept everyone’s records in his head. I guess he knew everybody in town, literally outside and inside. His bills would show only two items, numbers of house calls and numbers of office visits. Years later in 1978, my mother died suddenly. It was Dr. Arnold who called at 2:00 a.m. to tell me. He had arrived at my parents’ house only moments after the 911 EMTs. That was the ultimate in personalized care.”
“It sounds as if Dr. Arnold was exceptional…an early model for Marcus Welby, MD.”
“Well sort of, but back then most doctors were family physicians in a solo practice and on call 24/7. It took an exceptional person to live that way. In 1940 primary care was, by far, the major part of the health care delivery system. If your physician was clinically competent and had a good so-called ‘bedside manner,’ you had a favorable patient experience. That was especially true if you were lucky enough to get well. As I recall, personalized care was the norm.”
‘Speaking of personalized care, did Dr. Arnold meet all of the attributes of personalized care in our Affinity Brand Promise (1)?”
“Some of the attributes would have been different back then, especially for me, a six-year-old child. Dr. Arnold could not have known me better. Except for the surgeon who took out my tonsils, he was my only doctor from the moment I was born until I left home to go to college. In that era, partnering with one’s physician in decision-making was rare because he was the only one with access to health care knowledge. He always spent enough time with me to handle my problems, but frankly, as a kid I couldn’t wait to get out of the office. Thinking back, our doctor’s outstanding attributes were his willingness to make house calls and the depth of our personal friendship. He was always there when we needed him.”
“You seem to be suggesting, Curmudge, that despite the complexity of modern medicine, primary care physicians should try to duplicate the feeling of personalized care that you experienced in 1940.”
“Actually, Julie, I suspect that because of the complexity of modern medicine, what I experienced will rarely be achieved today by a primary care physician in a solo practice with his wife as both nurse and bookkeeper.”
“So, senescent sage, how can physicians today achieve this elusive personalized care?”
“I’ll conjure up a vision, Julie, and share it with you in a week or two.”
Affinity’s Kaizen Curmudgeon
(1) Kaizen Curmudgeon. The 5P Pyramid. Posted April 2, 2009.
Friday, August 14, 2009
Lean Success Stories--the Charge Capture Project
“Jaded Julie, I think it’s time for us to share some success stories.”
“If these ‘Curmudgeon Chronicles’ really do depict success, I can be certain that they won’t be autobiographical.”
“Don’t be disparaging, Julie. For some senior citizens, just getting out of bed in the morning is a success story. But we want to talk about how implementing the Lean culture and using Lean tools led to process improvements right here at Affinity. These stories will be told by the people who did the work and made things happen, or you and I will tell the story for them. We’ll start with Deb Voyles and her charge capture project.”
“Okay, Curmudge, just what is ‘charge capture,’ anyway? You know that I can’t understand the story unless I learn the language.”
“A person’s hospital bill is the summation of the charges for each treatment or service performed for the patient. This cannot be done correctly unless each service and its duration are recorded on the patient’s chart. These data are then transferred to a charge sheet, given a billing code, and sent to Patient Billing. If any step in this process is overlooked, the bill will be low; and the hospital will not receive its full payment from Medicare, the patient’s insurance, or the patient himself.”
“So what was the problem?”
“The nurses considered the charge capture process to be extra work. Their job was to care for the patients, not collect money. When Deb met with the nurses to plead for their cooperation, they—to use a common phrase—just blew her off.”
“Very frustrating! But we wouldn’t be talking about this if it hadn’t somehow become a success. What—and who—turned the process around?”
“The economy went south, Affinity instituted a margin improvement hoshin, and the hospital president provided the support necessary to put the charge capture project in high gear. Deb Voyles was appointed project leader with Stan Shelver co-leader to aid in communication and provide a director’s ‘inspiration.’ Carol Jansen was Lean facilitator. A ‘charge specialist,’ the unit clerk in each patient care unit, was designated; a new FTE was created in each emergency department to fill that roll.”
“Okay, Curmudge, we’ve got the team. Now what?”
“The first step was to change the prevailing mindset about charge capture. Deb did that by looking at charts from the previous month, computing the ‘forgotten charges,’ and posting the results on each patient care unit in the nurses’ break room.”
“That sounds like visual management. Good move!”
“She followed that up by meeting with the staff of each patient care unit to explain the financial impact of the forgotten charges and to demonstrate the effectiveness of utilizing the Universal Chargesheet. Stan joined Deb at the meetings and ‘encouraged’ the staff to begin using the new chargesheet.”
“Curmudge, as an old chemist like you would say, ‘Management provided an essential catalyst.’”
“Twice weekly, Deb would meet with charge specialist staff, training them on effective charge capture, and addressing charge issues. She made herself available to them 24/7 (via phone and email) to answer charge capture questions. The specialists would track the additional charges they found using the new charge capture process. They posted these results every week in the break room. At the end of the first month, Deb was able to pull the financial data from the monthly finance reports. She created a chart that compared the revenue per patient from the previous month to the current month. These charts illustrated the success of the new charge capture process and were posted on every patient care unit every month. The staff responded with enthusiasm, and the charge capture project gained momentum. Deb’s weekly meetings with the charge specialists became less focused on training and more focused on reviewing new procedures to develop charges. She saw a new culture emerging at the hospitals. It was exciting!”
“There is, of course, more to the story.”
“Deb continued tracking their success on a larger scale in which last year’s charges (with money left on the table) were compared with this year’s (with all charges properly captured). The three-month trial yielded a 40% increase in revenue capture per patient.”
“That undoubtedly attracted people’s attention.”
“It’s like our Flywheel posting on 3/26/08, Julie. One person with enthusiasm and determination was needed to get the project moving and to attract others to the effort. That was Deb Voyles.”
“Curmudge, despite this project’s resounding success, it didn’t seem to require many of the classical Lean tools.”
“You’re correct, Julie. The project was well defined without needing value stream mapping. It had abundant top-level support, extraordinary leadership, a team with accelerating enthusiasm, and a result that should be enduring. One essential Lean tool was visual management. Perhaps we should summarize by saying, ‘All’s well that ends well.’”
“You’ve got that right, Mr. Shakespeare.”
Affinity’s Kaizen Curmudgeon
“If these ‘Curmudgeon Chronicles’ really do depict success, I can be certain that they won’t be autobiographical.”
“Don’t be disparaging, Julie. For some senior citizens, just getting out of bed in the morning is a success story. But we want to talk about how implementing the Lean culture and using Lean tools led to process improvements right here at Affinity. These stories will be told by the people who did the work and made things happen, or you and I will tell the story for them. We’ll start with Deb Voyles and her charge capture project.”
“Okay, Curmudge, just what is ‘charge capture,’ anyway? You know that I can’t understand the story unless I learn the language.”
“A person’s hospital bill is the summation of the charges for each treatment or service performed for the patient. This cannot be done correctly unless each service and its duration are recorded on the patient’s chart. These data are then transferred to a charge sheet, given a billing code, and sent to Patient Billing. If any step in this process is overlooked, the bill will be low; and the hospital will not receive its full payment from Medicare, the patient’s insurance, or the patient himself.”
“So what was the problem?”
“The nurses considered the charge capture process to be extra work. Their job was to care for the patients, not collect money. When Deb met with the nurses to plead for their cooperation, they—to use a common phrase—just blew her off.”
“Very frustrating! But we wouldn’t be talking about this if it hadn’t somehow become a success. What—and who—turned the process around?”
“The economy went south, Affinity instituted a margin improvement hoshin, and the hospital president provided the support necessary to put the charge capture project in high gear. Deb Voyles was appointed project leader with Stan Shelver co-leader to aid in communication and provide a director’s ‘inspiration.’ Carol Jansen was Lean facilitator. A ‘charge specialist,’ the unit clerk in each patient care unit, was designated; a new FTE was created in each emergency department to fill that roll.”
“Okay, Curmudge, we’ve got the team. Now what?”
“The first step was to change the prevailing mindset about charge capture. Deb did that by looking at charts from the previous month, computing the ‘forgotten charges,’ and posting the results on each patient care unit in the nurses’ break room.”
“That sounds like visual management. Good move!”
“She followed that up by meeting with the staff of each patient care unit to explain the financial impact of the forgotten charges and to demonstrate the effectiveness of utilizing the Universal Chargesheet. Stan joined Deb at the meetings and ‘encouraged’ the staff to begin using the new chargesheet.”
“Curmudge, as an old chemist like you would say, ‘Management provided an essential catalyst.’”
“Twice weekly, Deb would meet with charge specialist staff, training them on effective charge capture, and addressing charge issues. She made herself available to them 24/7 (via phone and email) to answer charge capture questions. The specialists would track the additional charges they found using the new charge capture process. They posted these results every week in the break room. At the end of the first month, Deb was able to pull the financial data from the monthly finance reports. She created a chart that compared the revenue per patient from the previous month to the current month. These charts illustrated the success of the new charge capture process and were posted on every patient care unit every month. The staff responded with enthusiasm, and the charge capture project gained momentum. Deb’s weekly meetings with the charge specialists became less focused on training and more focused on reviewing new procedures to develop charges. She saw a new culture emerging at the hospitals. It was exciting!”
“There is, of course, more to the story.”
“Deb continued tracking their success on a larger scale in which last year’s charges (with money left on the table) were compared with this year’s (with all charges properly captured). The three-month trial yielded a 40% increase in revenue capture per patient.”
“That undoubtedly attracted people’s attention.”
“It’s like our Flywheel posting on 3/26/08, Julie. One person with enthusiasm and determination was needed to get the project moving and to attract others to the effort. That was Deb Voyles.”
“Curmudge, despite this project’s resounding success, it didn’t seem to require many of the classical Lean tools.”
“You’re correct, Julie. The project was well defined without needing value stream mapping. It had abundant top-level support, extraordinary leadership, a team with accelerating enthusiasm, and a result that should be enduring. One essential Lean tool was visual management. Perhaps we should summarize by saying, ‘All’s well that ends well.’”
“You’ve got that right, Mr. Shakespeare.”
Affinity’s Kaizen Curmudgeon
Thursday, August 6, 2009
Information at Your Fingertips
“Despite what you read, Jaded Julie, health care is a lot better than it used to be.”
“So, Curmudge, is that your professional opinion?”
“Nope, it’s my conjecture. That’s a better word for a fictional person. Consider this example: When I was a kid 70 years ago, the doc-with-the-black-bag couldn’t drag around a medical library when he made a house call. When he encountered a patient with unfamiliar symptoms—me—he could only rely on his experience, or as we say now, he had to ‘wing it.’”
“Since you are still with us, I congratulate your parents on their choice of family physician.”
“Fast forward to the present. Everyone knows about the power of CT’s and MRI’s for diagnosis, but I was curious about what is available in the readily accessible literature.”
“By ‘readily accessible,’ Curmudge, you mean just a couple of mouse clicks away.”
“Exactly, and I found a ton of stuff for physicians, midlevel (advanced practice) providers, nurses, pharmacists, and people writing about health care. Some of these are available only by purchase, such as the Isabel Diagnosis Reminder System (1) and several from Wolters Kluwer Health [5-Minute Consult Database, Drug Facts and Comparisons®, Evidence Based Guidelines, Lippincott’s Nursing Procedures and Skills, and several others] (2). The Institute for Clinical Systems Improvement has order sets and algorithms for diagnosis and treatments available on their website (3). Closer to home, we have Affinity policies and preprinted or standing orders for hundreds of diagnoses, evidence based treatments, and procedures. To obtain this treasure trove, I just talked with a few people and rummaged around in Google. Just imagine how much more could be obtained with a literature search done by the St. E’s or Mercy library.”
“Now I know why you were huddled with your computer for the past two weeks. So what good is all this?”
“The physician with his handy computer or personal digital assistant will no longer have to ‘wing it.’ If necessary, he can check a diagnosis or medication during the patient encounter or perhaps after the fact to confirm his decisions and monitor the quality of care he provides (4). Nurses and managers can use the evidence based procedures in these resources as the basis for standard work in any of the patient care areas of the hospital.”
“I understand, Curmudge, that we are already using the preprinted orders in our hospitals. Their check-the-boxes feature serves to remind the physicians of the latest evidence based therapies. When a physician overrides a pre-checked box, it must be justified. These forms also minimize variations in provider prescribing practices and critical aspects of patient care.”
“That’s it, Julie. I hope you now agree with me that health care has improved over the years.”
“Curmudge, you were fortunate to have survived old-time medicine, but I suspect that was not always the case.”
“Here’s another personal example: The same doctor who used his vast experience to cure me of gosh-knows-what in the 1940’s also brought my mother into the world in 1899. He was at the bedside of her mother who died of gosh-knows-what in 1902. So my mother, at the age of three, lost her mother and I lost a grandmother that I never knew.”
Affinity’s Kaizen Curmudgeon
(1) http://www.isabel.org.uk/pdf/Product_Release.pdf
(2) http://www.clineguide.com/Common/PDF/ClineguideMobileReleaseFinal.pdf
(3) http://www.icsi.org
(4) http://www.ama-assn.org/amednews/2009/06/29/prsn0629.htm
“So, Curmudge, is that your professional opinion?”
“Nope, it’s my conjecture. That’s a better word for a fictional person. Consider this example: When I was a kid 70 years ago, the doc-with-the-black-bag couldn’t drag around a medical library when he made a house call. When he encountered a patient with unfamiliar symptoms—me—he could only rely on his experience, or as we say now, he had to ‘wing it.’”
“Since you are still with us, I congratulate your parents on their choice of family physician.”
“Fast forward to the present. Everyone knows about the power of CT’s and MRI’s for diagnosis, but I was curious about what is available in the readily accessible literature.”
“By ‘readily accessible,’ Curmudge, you mean just a couple of mouse clicks away.”
“Exactly, and I found a ton of stuff for physicians, midlevel (advanced practice) providers, nurses, pharmacists, and people writing about health care. Some of these are available only by purchase, such as the Isabel Diagnosis Reminder System (1) and several from Wolters Kluwer Health [5-Minute Consult Database, Drug Facts and Comparisons®, Evidence Based Guidelines, Lippincott’s Nursing Procedures and Skills, and several others] (2). The Institute for Clinical Systems Improvement has order sets and algorithms for diagnosis and treatments available on their website (3). Closer to home, we have Affinity policies and preprinted or standing orders for hundreds of diagnoses, evidence based treatments, and procedures. To obtain this treasure trove, I just talked with a few people and rummaged around in Google. Just imagine how much more could be obtained with a literature search done by the St. E’s or Mercy library.”
“Now I know why you were huddled with your computer for the past two weeks. So what good is all this?”
“The physician with his handy computer or personal digital assistant will no longer have to ‘wing it.’ If necessary, he can check a diagnosis or medication during the patient encounter or perhaps after the fact to confirm his decisions and monitor the quality of care he provides (4). Nurses and managers can use the evidence based procedures in these resources as the basis for standard work in any of the patient care areas of the hospital.”
“I understand, Curmudge, that we are already using the preprinted orders in our hospitals. Their check-the-boxes feature serves to remind the physicians of the latest evidence based therapies. When a physician overrides a pre-checked box, it must be justified. These forms also minimize variations in provider prescribing practices and critical aspects of patient care.”
“That’s it, Julie. I hope you now agree with me that health care has improved over the years.”
“Curmudge, you were fortunate to have survived old-time medicine, but I suspect that was not always the case.”
“Here’s another personal example: The same doctor who used his vast experience to cure me of gosh-knows-what in the 1940’s also brought my mother into the world in 1899. He was at the bedside of her mother who died of gosh-knows-what in 1902. So my mother, at the age of three, lost her mother and I lost a grandmother that I never knew.”
Affinity’s Kaizen Curmudgeon
(1) http://www.isabel.org.uk/pdf/Product_Release.pdf
(2) http://www.clineguide.com/Common/PDF/ClineguideMobileReleaseFinal.pdf
(3) http://www.icsi.org
(4) http://www.ama-assn.org/amednews/2009/06/29/prsn0629.htm
Thursday, July 30, 2009
Managing Variability--Countermeasures
“Curmudge, the last time we talked you and some swamp-dwelling possum were telling me that the hills and valleys in hospital routine were man-made. You also said that handling the workload peaks stressed the staff and reduced the patients’ safety and quality of care. Finally, you promised to tell me what can be done to improve this situation. Now’s the time. What’s the word?”
“Lean.”
“Lean? Is that your one-word, one-size-fits-all default answer?”
“Well Jaded Julie, if you must have a second word, it’s heijunka or level loading. But in this case, heijunka is more of a goal than a tool. People in a hospital with high variability need to employ the Lean philosophy and techniques that we have been talking about for the past several months. Kaizen or rapid process improvement events, current- and future-state value stream mapping, go to gemba, A3 reports, the Deming cycle…the whole Lean Geschäft (business).”
“Easy, Curmudge. Please limit your enthusiasm to English words.”
“Getting the right people on the team is most important. If physicians will be impacted, they must become active and engaged team members. Not just any docs; they must be the docs that the others respect. The team should first look at variability and identify that which is man-made. When I say ‘look at,’ that means to go to gemba, gather data, and construct value stream maps. Plan and evaluate trials of changes that might smooth out the variability (plan-do-check-act). Consider any process element where ‘batching’ occurs to be a candidate for smoothing.”
“All of that sounds like Lean with a capital ‘L’, Curmudge. Have any hospitals undertaken this kind of effort?”
“You can read about them in the presentations by Litvak (1) and Paulson (2). They suggest that quality of care can be increased ‘free of charge.’ These are some of the benefits that have been achieved (1):
· Reduced ED diversions
· Greater staff and patient satisfaction
· Reduced mortality and medical errors
· Reduced length of stay
· Increased hospital throughput
· Increased surgical throughput”
“I presume that after a hospital has smoothed out its artificial variability it can better manage its natural variability with queuing theory.”
“That’s the idea, Julie. Characteristics of a system that one must know are the average patient arrival rate and the system’s average service rate. One can then determine staffing and numbers of rooms that will be needed to meet demand. Some of this is shown in the presentations that have been cited (1, 2). Other situations are described in the notes from Litvak’s ‘Queuing Theory’ course offered through IHI. Additional study will be needed to tackle more complex scenarios.”
“It sounds as if you are saying that for tougher situations I’m on my own.”
“Julie, as long as I am here, you’ll never be on your own. And don’t forget my colleagues in the Kaizen Promotion Office.”
Affinity’s Kaizen Curmudgeon
(1)http://www.iom.edu/Object.File/Master/21/207/Litvak_Variability%20in%20Patient%20Flow_updated.pdf
(2)http://www.hospitalcouncil.net/Upload/BEACON_PAULSON_IntrodImprovingInpatientFlow_4-24-07.pdf
“Lean.”
“Lean? Is that your one-word, one-size-fits-all default answer?”
“Well Jaded Julie, if you must have a second word, it’s heijunka or level loading. But in this case, heijunka is more of a goal than a tool. People in a hospital with high variability need to employ the Lean philosophy and techniques that we have been talking about for the past several months. Kaizen or rapid process improvement events, current- and future-state value stream mapping, go to gemba, A3 reports, the Deming cycle…the whole Lean Geschäft (business).”
“Easy, Curmudge. Please limit your enthusiasm to English words.”
“Getting the right people on the team is most important. If physicians will be impacted, they must become active and engaged team members. Not just any docs; they must be the docs that the others respect. The team should first look at variability and identify that which is man-made. When I say ‘look at,’ that means to go to gemba, gather data, and construct value stream maps. Plan and evaluate trials of changes that might smooth out the variability (plan-do-check-act). Consider any process element where ‘batching’ occurs to be a candidate for smoothing.”
“All of that sounds like Lean with a capital ‘L’, Curmudge. Have any hospitals undertaken this kind of effort?”
“You can read about them in the presentations by Litvak (1) and Paulson (2). They suggest that quality of care can be increased ‘free of charge.’ These are some of the benefits that have been achieved (1):
· Reduced ED diversions
· Greater staff and patient satisfaction
· Reduced mortality and medical errors
· Reduced length of stay
· Increased hospital throughput
· Increased surgical throughput”
“I presume that after a hospital has smoothed out its artificial variability it can better manage its natural variability with queuing theory.”
“That’s the idea, Julie. Characteristics of a system that one must know are the average patient arrival rate and the system’s average service rate. One can then determine staffing and numbers of rooms that will be needed to meet demand. Some of this is shown in the presentations that have been cited (1, 2). Other situations are described in the notes from Litvak’s ‘Queuing Theory’ course offered through IHI. Additional study will be needed to tackle more complex scenarios.”
“It sounds as if you are saying that for tougher situations I’m on my own.”
“Julie, as long as I am here, you’ll never be on your own. And don’t forget my colleagues in the Kaizen Promotion Office.”
Affinity’s Kaizen Curmudgeon
(1)http://www.iom.edu/Object.File/Master/21/207/Litvak_Variability%20in%20Patient%20Flow_updated.pdf
(2)http://www.hospitalcouncil.net/Upload/BEACON_PAULSON_IntrodImprovingInpatientFlow_4-24-07.pdf
Thursday, July 16, 2009
Managing Variability--The Problem
“’Managing Variability’ doesn’t look too tough, Curmudge. After your mentioning queuing theory and mathematical models in our last discussion, I was afraid you’d dump a pile of differential equations—whatever they are—on me.”
“Don’t worry, Jaded Julie. Math is too complex for a blog. But to temper your exaltation, I’d better warn you that we have a new Japanese word to learn. The word is heijunka, and it means ‘level loading.’”
“I know it must make sense in your ancient alchemist’s mind, Curmudge, but would you please share with me the connection, however tenuous, between heijunka and queuing theory. My brain is spinning, and we’ve only talked for three short paragraphs.”
“It’s really quite logical. Remember Dr. Deming’s writings about common-cause or natural variation as well as special-cause or artificial, man-made variation. We have both kinds in a hospital, such as the random patient arrivals in the ED and the man-made hills and valleys in people’s workloads caused by block scheduling of elective surgeries, morning rounds, and physician-requested early morning blood draws. Although hospital schedules are largely traditional, we must consider them man-made. As Pogo said, ‘we have met the enemy and he is us.’”
“(Pogo? Who’s Pogo? I’d better google him. Oh, Greybeard is probably just recalling some long-ago cartoon character.) So you and this Pogo-person (Pogo-thing?) are saying that traditional hospital routine is a man-made system designed to give hill-and-valley workloads, and ‘surprise!’ that’s what we get.”
“That’s it, Julie. We can’t begin to use queuing theory on the random variation until we have knocked the peaks off the artificial variation. That’s level loading or heijunka, and the study of the hills and valleys is called variability analysis.”
“But, Curmudge, traditional hospital routine is just the way it is. Don’t we have to live with it?”
“What you’re saying sounds a lot like, ‘We’ve always done it that way.’ That’s a very un-Lean statement that flies in the face of ‘continuous improvement.’”
“Sorry, Curmudge. When I get home I’ll wash my mouth out with soap. But what is so bad about variable workloads?”
“Dr. Eugene Litvak, the guru of queuing theory applied to health care, and his disciples feel that the OR is the driver of artificial variability. (1, 2) High-productivity surgeons tend to perform elective surgery on the same day every week. This impacts the whole hospital: admitting, discharging, the lab, housekeeping, and especially the availability of rooms for admissions from the ED. If a hospital’s midnight census is over 90%, it has very little capacity available for new admissions the next morning. (3) This might also cause internal gridlock, when patients can’t be moved from where they are presently (e.g., the ICU) to where they need to be (e.g., med/surg acute care). ‘Optimal care can only be delivered when the right patient is in the right place with the right provider and the right information at the right time.’ (3)”
“This must also affect the scheduling of nurses.”
“It does. If the hospital schedules nurses to accommodate the peaks, it incurs excessive costs. If nurses are scheduled to meet the average census, they are stretched to the limit in handling the peaks.”
“My guess is that nurses would rather have level loads than hills and valleys.”
“It’s more than just ‘rather,’ Julie. According to the literature (2), ‘overworked nurses and stressed resources raise the risk of error, increases staff dissatisfaction, and staff turnover.’ In addition, JCAHO says that 24% of sentinel events are associated with nurse understaffing.”
“That’s alarming, Curmudge. What can be done about it?”
“Next week we’ll talk about countermeasures. I hope you can wait.”
“I can wait if you will answer one question. Over the past year you have quoted a 19th Century novelist (Alexandre Dumas), several 21st Century professors (John Kotter, Jim Collins, and others), and now a 20th Century swamp-dwelling possum (Pogo). A possum? That doesn’t seem very scholarly.”
“Julie, I’d even go to the Okefenokee for the right kind of insight.”
Affinity’s Kaizen Curmudgeon
(1)http://www.iom.edu/Object.File/Master/21/207/Litvak_Variability%20in%20Patient%20Flow_updated.pdf
(2)http://www.hospitalcouncil.net/Upload/BEACON_PAULSON_IntrodImprovingInpatientFlow_4-24-07.pdf
(3) IHI White Paper, Optimizing Patient Flow, Innovation Series 2003. Institute for Healthcare Improvement.
“Don’t worry, Jaded Julie. Math is too complex for a blog. But to temper your exaltation, I’d better warn you that we have a new Japanese word to learn. The word is heijunka, and it means ‘level loading.’”
“I know it must make sense in your ancient alchemist’s mind, Curmudge, but would you please share with me the connection, however tenuous, between heijunka and queuing theory. My brain is spinning, and we’ve only talked for three short paragraphs.”
“It’s really quite logical. Remember Dr. Deming’s writings about common-cause or natural variation as well as special-cause or artificial, man-made variation. We have both kinds in a hospital, such as the random patient arrivals in the ED and the man-made hills and valleys in people’s workloads caused by block scheduling of elective surgeries, morning rounds, and physician-requested early morning blood draws. Although hospital schedules are largely traditional, we must consider them man-made. As Pogo said, ‘we have met the enemy and he is us.’”
“(Pogo? Who’s Pogo? I’d better google him. Oh, Greybeard is probably just recalling some long-ago cartoon character.) So you and this Pogo-person (Pogo-thing?) are saying that traditional hospital routine is a man-made system designed to give hill-and-valley workloads, and ‘surprise!’ that’s what we get.”
“That’s it, Julie. We can’t begin to use queuing theory on the random variation until we have knocked the peaks off the artificial variation. That’s level loading or heijunka, and the study of the hills and valleys is called variability analysis.”
“But, Curmudge, traditional hospital routine is just the way it is. Don’t we have to live with it?”
“What you’re saying sounds a lot like, ‘We’ve always done it that way.’ That’s a very un-Lean statement that flies in the face of ‘continuous improvement.’”
“Sorry, Curmudge. When I get home I’ll wash my mouth out with soap. But what is so bad about variable workloads?”
“Dr. Eugene Litvak, the guru of queuing theory applied to health care, and his disciples feel that the OR is the driver of artificial variability. (1, 2) High-productivity surgeons tend to perform elective surgery on the same day every week. This impacts the whole hospital: admitting, discharging, the lab, housekeeping, and especially the availability of rooms for admissions from the ED. If a hospital’s midnight census is over 90%, it has very little capacity available for new admissions the next morning. (3) This might also cause internal gridlock, when patients can’t be moved from where they are presently (e.g., the ICU) to where they need to be (e.g., med/surg acute care). ‘Optimal care can only be delivered when the right patient is in the right place with the right provider and the right information at the right time.’ (3)”
“This must also affect the scheduling of nurses.”
“It does. If the hospital schedules nurses to accommodate the peaks, it incurs excessive costs. If nurses are scheduled to meet the average census, they are stretched to the limit in handling the peaks.”
“My guess is that nurses would rather have level loads than hills and valleys.”
“It’s more than just ‘rather,’ Julie. According to the literature (2), ‘overworked nurses and stressed resources raise the risk of error, increases staff dissatisfaction, and staff turnover.’ In addition, JCAHO says that 24% of sentinel events are associated with nurse understaffing.”
“That’s alarming, Curmudge. What can be done about it?”
“Next week we’ll talk about countermeasures. I hope you can wait.”
“I can wait if you will answer one question. Over the past year you have quoted a 19th Century novelist (Alexandre Dumas), several 21st Century professors (John Kotter, Jim Collins, and others), and now a 20th Century swamp-dwelling possum (Pogo). A possum? That doesn’t seem very scholarly.”
“Julie, I’d even go to the Okefenokee for the right kind of insight.”
Affinity’s Kaizen Curmudgeon
(1)http://www.iom.edu/Object.File/Master/21/207/Litvak_Variability%20in%20Patient%20Flow_updated.pdf
(2)http://www.hospitalcouncil.net/Upload/BEACON_PAULSON_IntrodImprovingInpatientFlow_4-24-07.pdf
(3) IHI White Paper, Optimizing Patient Flow, Innovation Series 2003. Institute for Healthcare Improvement.
Thursday, July 9, 2009
An Introduction to Queues
“What’s a ‘cue-you,’ Curmudge?”
“It’s not a ‘cue-you,’ Jaded Julie; it’s pronounced just like the letter ‘Q.’ It comes from the French word for tail, and it means a line of people waiting their turn. So when you walk into McDonald’s, you are at the tail end of the tail.”
“Well that’s something everyone should know. If you can justify this enlightening discussion, now would be an excellent time to do it.”
“Of course, Julie. Today we are going to talk about customer flow management, a part of which is queuing theory; and before you ask me ‘why?’ I’m going to tell you why. An important aspect of the Toyota production system is one-piece flow. They build cars in an essentially continuous process with minimal inventory, work in process, and waste. Wouldn’t our patients be delighted if we could treat them in a similar, efficient process?”
“They definitely would like to be treated efficiently but probably not like a partially-built car. While patients are sitting in a waiting room, it probably wouldn’t make them any happier to think of themselves as ‘work in process.’”
“You’re right as usual, Julie. We certainly must treat our patients with respect, dignity, and compassion. But for today’s discussion, let’s think of patients as people who just want to arrive, receive a service, and depart ASAP.”
“Okay, Curmudge. I’m with you, at least for the moment. But if any of our discussion is going to involve queuing theory, I really need to know what that is.”
“Queuing theory uses mathematical models in analyzing how to match demand (usually variable) with capacity (usually fixed). Unfortunately, there’s a major limitation to elementary queuing theory: it can only be applied when customers arrive in a random manner. It doesn’t apply when service is provided on an appointment basis, which excludes most of the hospital. The ED and walk-in clinics would be examples of where patients arrive randomly.”
“If the use of queuing theory is so limited, why should we even study it?”
“Traditionally, when a patient walks into a clinic or hospital they expect they will have to spend time waiting. If queuing theory might help shorten waiting times, it’s certainly a subject with which we should have an acquaintance.”
“I guess it’s okay to get acquainted, but I don’t want to get too close to any mathematical models. Can you give me a non-mathematical introduction?”
“I’d be delighted, Julie. Linear queuing means that the customer waits physically in a line. (1) The simplest version is Single-Queue-Single-Service-Point, like waiting in line to buy your ticket for a popular movie. Several of these side-by-side make a Multiple-Queue-Multiple-Service-Point system like in a grocery store. This can be made more efficient by adding Segmentation, where certain lines handle only customers with 15 items or less. The most advanced form of linear queuing is Single-Queue-Multiple-Service-Points. A common example is the Post Office, where the line is not held up when one of the clerks is delayed by a customer sending a package to Timbuktu.”
“I must admit that I haven’t given much thought to the type of queue that I’m in. I do know that in the grocery store Erma Bombeck’s Law applies, ‘The other line always moves faster.’” (2)
“There are several variations on these simple systems. One is virtual queuing, where, after registering, a customer is sent to a waiting room rather than a physical line. Because the customer does not know his/her exact position in the queue, the staff is able to exercise some segmentation. An example would be an ED in which more urgent patients are seen first. A variation of this, virtual queuing with buffering, is also used in an ED; the next patient to be seen is taken to an exam room (the buffer) to minimize the service provider’s delay.”
“I know there are more, Curmudge. There always are.”
“Another fairly simple one is the multiple stage system in which the customer is served by more than one facility before leaving. This is termed ‘serial servers.’ I’ve seen this in European fast food restaurants where one decides what he wants, lines up to pay for it, and then lines up again to receive the food in exchange for the receipt. A similar system exists in a hospital where an outpatient must go to the lab and then to radiology.”
“Is there no end to this, Curmudge?”
“There is for us today, Julie, and it’s right now. Let’s go down to the cafeteria and stand in a queue.”
Affinity’s Kaizen Curmudgeon
(1)http://www.q-matic.com White Paper: An Introduction to Customer Flow Management
(2)Maister, David H. Note on the Management of Queues, Harvard Business Review (March 17, 1995): 1-14, Reprint #9-680-053.
“It’s not a ‘cue-you,’ Jaded Julie; it’s pronounced just like the letter ‘Q.’ It comes from the French word for tail, and it means a line of people waiting their turn. So when you walk into McDonald’s, you are at the tail end of the tail.”
“Well that’s something everyone should know. If you can justify this enlightening discussion, now would be an excellent time to do it.”
“Of course, Julie. Today we are going to talk about customer flow management, a part of which is queuing theory; and before you ask me ‘why?’ I’m going to tell you why. An important aspect of the Toyota production system is one-piece flow. They build cars in an essentially continuous process with minimal inventory, work in process, and waste. Wouldn’t our patients be delighted if we could treat them in a similar, efficient process?”
“They definitely would like to be treated efficiently but probably not like a partially-built car. While patients are sitting in a waiting room, it probably wouldn’t make them any happier to think of themselves as ‘work in process.’”
“You’re right as usual, Julie. We certainly must treat our patients with respect, dignity, and compassion. But for today’s discussion, let’s think of patients as people who just want to arrive, receive a service, and depart ASAP.”
“Okay, Curmudge. I’m with you, at least for the moment. But if any of our discussion is going to involve queuing theory, I really need to know what that is.”
“Queuing theory uses mathematical models in analyzing how to match demand (usually variable) with capacity (usually fixed). Unfortunately, there’s a major limitation to elementary queuing theory: it can only be applied when customers arrive in a random manner. It doesn’t apply when service is provided on an appointment basis, which excludes most of the hospital. The ED and walk-in clinics would be examples of where patients arrive randomly.”
“If the use of queuing theory is so limited, why should we even study it?”
“Traditionally, when a patient walks into a clinic or hospital they expect they will have to spend time waiting. If queuing theory might help shorten waiting times, it’s certainly a subject with which we should have an acquaintance.”
“I guess it’s okay to get acquainted, but I don’t want to get too close to any mathematical models. Can you give me a non-mathematical introduction?”
“I’d be delighted, Julie. Linear queuing means that the customer waits physically in a line. (1) The simplest version is Single-Queue-Single-Service-Point, like waiting in line to buy your ticket for a popular movie. Several of these side-by-side make a Multiple-Queue-Multiple-Service-Point system like in a grocery store. This can be made more efficient by adding Segmentation, where certain lines handle only customers with 15 items or less. The most advanced form of linear queuing is Single-Queue-Multiple-Service-Points. A common example is the Post Office, where the line is not held up when one of the clerks is delayed by a customer sending a package to Timbuktu.”
“I must admit that I haven’t given much thought to the type of queue that I’m in. I do know that in the grocery store Erma Bombeck’s Law applies, ‘The other line always moves faster.’” (2)
“There are several variations on these simple systems. One is virtual queuing, where, after registering, a customer is sent to a waiting room rather than a physical line. Because the customer does not know his/her exact position in the queue, the staff is able to exercise some segmentation. An example would be an ED in which more urgent patients are seen first. A variation of this, virtual queuing with buffering, is also used in an ED; the next patient to be seen is taken to an exam room (the buffer) to minimize the service provider’s delay.”
“I know there are more, Curmudge. There always are.”
“Another fairly simple one is the multiple stage system in which the customer is served by more than one facility before leaving. This is termed ‘serial servers.’ I’ve seen this in European fast food restaurants where one decides what he wants, lines up to pay for it, and then lines up again to receive the food in exchange for the receipt. A similar system exists in a hospital where an outpatient must go to the lab and then to radiology.”
“Is there no end to this, Curmudge?”
“There is for us today, Julie, and it’s right now. Let’s go down to the cafeteria and stand in a queue.”
Affinity’s Kaizen Curmudgeon
(1)http://www.q-matic.com White Paper: An Introduction to Customer Flow Management
(2)Maister, David H. Note on the Management of Queues, Harvard Business Review (March 17, 1995): 1-14, Reprint #9-680-053.
Thursday, June 25, 2009
Physicians and Lean
“Tell me again, Curmudge, about the connection between physicians and Lean.”
“It’s pretty simple, Jaded Julie. A hospital-wide Lean transformation must involve the physicians. It would be like trying to produce an opera without the star sopranos and tenors. On one hand, doctors don’t want to be told what to do, but at the same time, most are too busy to serve on the kaizen teams that work on improving hospital processes. That puts all of us—the docs as well as the hospitals—between a rock and a hard place.”
“The IHI White Paper that you gave me to read, Engaging Physicians in a Shared Quality Agenda (1), looks like the definitive work on the topic. (Did I say definitive? That’s a Curmudge word, not a Julie word.) But most people aren’t going to take time to read all of its 49 pages.”
“And that, Julie, is why we are going to use this blog to share some of its more important points. To begin with, throughout their education and training physicians have been taught to think and perform independently. As a result, to use the words of IHI, they have a ‘fierce attachment to individual autonomy’ and a deep sense of personal responsibility for the outcomes of their patients. Thus we need to improve their ‘systems’ thinking.”
“Lots of luck, Curmudge.”
“Physicians have a strong sense of collegiality. In that, we can see good news and bad news. Physicians will be slow to accept a change in procedure devised by ‘some nurse in an office,’ but they will be receptive to ideas presented by another physician whom they respect. To be accepted, one must ‘walk a mile in their moccasins’ almost on a daily basis. When you think about it, that’s pretty consistent with Lean; one must ‘go to gemba’ for meaningful knowledge.”
“I knew—sooner or later—that you would bring Lean into this.”
“Physicians are certainly acquainted with evidence-based treatments. Thus their thinking can be influenced by evidence they consider credible if it is presented properly and by the right person. Here are some other factors that should increase physicians’ acceptance of quality initiatives:
Select physician Project Champions who possess courage and social skills.
Identify respected ‘early adopters’ of the proposed changes.
Base proposed new protocols on medical evidence and test them locally on a small scale.
To the greatest extent possible, involve physicians in contemplated changes from the very beginning.
Couch proposed changes in physician-relevant terms such as better patient outcomes and less wasted physician time.
Make clear that proposed standard work is not ‘cookbook medicine.’ ‘Standardize what is standardizable; no more.’
Implement change incrementally, and make the right thing easy to do.”
“Hey, Curmudge, that sounds pretty straightforward, but I know that it isn’t. What’s the bottom line—the hook that will increase physician engagement?”
“Physician leaders, using incontrovertible data if they have it, must show their colleagues how participation in Lean events will bring about improvements in their patients, their practice, and their personal lives. And remember, Julie, success will breed success.”
“(Incontro…? Sounds like evidence-based.) Thanks for the insight, Old Guy. You may now return to your morning nap.”
Affinity’s Kaizen Curmudgeon
(1) http://www.ihi.org/IHI/Results/WhitePapers/EngagingPhysiciansWhitePaper.htm
Thursday, June 18, 2009
Communicate--Think--Diagnose--Communicate
“Tell me, Curmudge, why we are talking about how physicians think, diagnose, and communicate with patients, some of whom may be disingenuous (hey, I looked up the word).”
“To lead the list, Jaded Julie, it will make us better patients. It will also help us be more effective at enlisting physicians in the hospital’s Lean cultural transformation. We can better collaborate with the docs if we understand them.”
“Okay, let’s get under way. I assume like last week that all quoted material is from Dr. Groopman’s book (1).”
“Let’s begin by acknowledging that not all communication is verbal. At first sight, the patient looks at the physician and thinks to herself, ’Am I going to like and trust this person?’ And the doctor begins his diagnosis before the first word is spoken. If his nose is good, he can immediately sense that the patient is a smoker. Of course, sometimes these first impressions can lead the doctor down the wrong path. It’s hard to believe a person who appears ruggedly healthy is seriously ill (perhaps he is just here to get a flu shot). One might first suspect emphysema in a heavy smoker and cirrhosis in an unkempt boozer. Groopman calls these types of first impressions—when they turn out to be wrong—‘representativeness errors.’ These may also be called ‘attribution errors,’ when the patient fits a negative stereotype.”
“Groopman mentions some other types of ill-advised shortcuts leading to incorrect diagnoses. ‘Availability means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind’ (most of my other patients today have the flu, so this patient must have it too). ‘Anchoring’ occurs when the physician doesn’t consider multiple possibilities but firmly latches onto a single one. In ‘confirmation bias’ one sees only the expected landmarks and neglects the others. Curmudge, all of these errors resulted from docs’ taking shortcuts. Does that mean that they are a no-no?”
“Julie, a chance encounter with The Happy Hospitalist blog (2) convinced me of the multitude of mental data points that must be considered in making an accurate diagnosis. The only way this can be achieved in a reasonable time is to take appropriate shortcuts—each based on sound clinical judgment—among the possibilities. Doctors are taught to be methodical, but they must learn to be efficient. This is what differentiates a physician from a technician with a checklist or an algorithm.”
“Then according to Groopman, ‘The key cues to the patient’s problem—from medical history, physical exam, x-ray or lab tests—coalesce into a pattern that the physician recognizes as a specific disease or condition.’ But, Curmudge, what if they don’t?”
“That may be a situation where the physician should listen to the little voice that says, ‘Don’t just do something; stand there.’ If the doctor senses that missing pieces are leaving blanks in the puzzle, he should work toward filling them. He may have to say to the patient, ‘I believe when you say something is wrong, but I haven’t figured it out.’ Sometimes he just has to wait until the problem ‘declares itself,’ usually by becoming worse.”
“Curmudge, what should the doc tell the patient when the diagnosis indicates a life-threatening or debilitating disease?”
“I recall in my youth when neither the physician nor the patient’s family would share with the patient the seriousness of his diagnosis. That’s when life-threatening almost certainly meant life-ending. Now many of those diseases can be cured or at least arrested. The physician can be upbeat when it is justified, and even in the bleakest situations assure the patient that he will not be abandoned.”
Affinity’s Kaizen Curmudgeon
(1) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(2) The doctor’s doctor: How to be an internist in five minutes. http://thehappyhospitalist.blogspot.com/2008/10/doctors-doctor-how-to-be-internist-in.html
“To lead the list, Jaded Julie, it will make us better patients. It will also help us be more effective at enlisting physicians in the hospital’s Lean cultural transformation. We can better collaborate with the docs if we understand them.”
“Okay, let’s get under way. I assume like last week that all quoted material is from Dr. Groopman’s book (1).”
“Let’s begin by acknowledging that not all communication is verbal. At first sight, the patient looks at the physician and thinks to herself, ’Am I going to like and trust this person?’ And the doctor begins his diagnosis before the first word is spoken. If his nose is good, he can immediately sense that the patient is a smoker. Of course, sometimes these first impressions can lead the doctor down the wrong path. It’s hard to believe a person who appears ruggedly healthy is seriously ill (perhaps he is just here to get a flu shot). One might first suspect emphysema in a heavy smoker and cirrhosis in an unkempt boozer. Groopman calls these types of first impressions—when they turn out to be wrong—‘representativeness errors.’ These may also be called ‘attribution errors,’ when the patient fits a negative stereotype.”
“Groopman mentions some other types of ill-advised shortcuts leading to incorrect diagnoses. ‘Availability means the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind’ (most of my other patients today have the flu, so this patient must have it too). ‘Anchoring’ occurs when the physician doesn’t consider multiple possibilities but firmly latches onto a single one. In ‘confirmation bias’ one sees only the expected landmarks and neglects the others. Curmudge, all of these errors resulted from docs’ taking shortcuts. Does that mean that they are a no-no?”
“Julie, a chance encounter with The Happy Hospitalist blog (2) convinced me of the multitude of mental data points that must be considered in making an accurate diagnosis. The only way this can be achieved in a reasonable time is to take appropriate shortcuts—each based on sound clinical judgment—among the possibilities. Doctors are taught to be methodical, but they must learn to be efficient. This is what differentiates a physician from a technician with a checklist or an algorithm.”
“Then according to Groopman, ‘The key cues to the patient’s problem—from medical history, physical exam, x-ray or lab tests—coalesce into a pattern that the physician recognizes as a specific disease or condition.’ But, Curmudge, what if they don’t?”
“That may be a situation where the physician should listen to the little voice that says, ‘Don’t just do something; stand there.’ If the doctor senses that missing pieces are leaving blanks in the puzzle, he should work toward filling them. He may have to say to the patient, ‘I believe when you say something is wrong, but I haven’t figured it out.’ Sometimes he just has to wait until the problem ‘declares itself,’ usually by becoming worse.”
“Curmudge, what should the doc tell the patient when the diagnosis indicates a life-threatening or debilitating disease?”
“I recall in my youth when neither the physician nor the patient’s family would share with the patient the seriousness of his diagnosis. That’s when life-threatening almost certainly meant life-ending. Now many of those diseases can be cured or at least arrested. The physician can be upbeat when it is justified, and even in the bleakest situations assure the patient that he will not be abandoned.”
Affinity’s Kaizen Curmudgeon
(1) Groopman, Jerome. How Doctors Think. (Mariner, 2008)
(2) The doctor’s doctor: How to be an internist in five minutes. http://thehappyhospitalist.blogspot.com/2008/10/doctors-doctor-how-to-be-internist-in.html
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