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.