“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)
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)
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