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

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

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

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)