“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
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