“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.
Thursday, November 19, 2009
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)
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