“Jaded Julie, in a symphony orchestra, how does one make sure that all of the bass fiddles play the same notes?”
“I don’t know much about orchestras, Curmudge, but I suspect that each bass player reads from an identical musical score.”
“Closer to home, Julie, if a sample is sent to the hospital’s lab for a multi-step analysis, should the result depend on who the analyst was?”
“Absolutely not! The lab has a standard process and procedure for every step in the analysis that each analyst must follow. Even a non-clinical old geezer like you should know that.”
“And finally, in a medical home with several patient service representatives, should a patient’s phone call to renew a prescription be handled differently depending on the PSR that she speaks with?”
“Of course not. I get it, Curmudge. In the medical home we have workflows just like an orchestra has scores and the lab has standard methods. It’s like you taught me, ‘You can’t improve a process until you can control it; you can’t control it until you understand it; and you can’t prove you understand it until you document it.’ The workflows get everyone on the same page. You can’t have people running around willy-nilly ‘doing their own thing.’”
“You are mighty quick on the uptake, Julie. Can you think of ways in which Lean is used in developing workflows?”
“You know I can. Where do you think I’ve been for the past three years? To begin with, you assemble a team from gemba who know best the processes and procedures in present use. They use sticky notes that are color-coded to differentiate patient service reps, health care associates, and providers. Then they make a process diagram on the conference room wall for each of the clinic’s main processes. Sometimes ‘just do it’ improvements are introduced as the workflow is being constructed.”
“That’s the idea, Julie. What happens next?”
“Then the workflow is copied from the wall with Visio software for printing, discussion, and further improvements. Later the team looks into the individual sticky-note boxes to identify procedures that need to be documented. It looks to me, Curmudge, as if workflows are standard work for clinic-wide processes and individual procedures.”
“The drivers for this effort are the forthcoming implementation of the electronic health record (EHR) and ultimate recognition by the National Committee for Quality Assurance (NCQA). As we said last week, one must not try to overlay a good technology on a bad process. Workflows represent the medical homes’ development of effective paper-based process and procedure descriptions for incorporation into the EHR.”
“It’s pretty obvious, Curmudge, that one must know where she is ‘at’ before finding her way to someplace better. By the way, do you realize that the next generation might not even know what a paper-based process description is?”
“That’s likely, Julie, but if there still are bass fiddles, I’ll bet that bass players will still be reading Beethoven from paper scores.”
Affinity’s Kaizen Curmudgeon
Thursday, August 26, 2010
Thursday, August 19, 2010
The World Health Congress
“I’ll bet, Curmudge, that during your professional career you attended a lot of meetings and conferences.”
“I sure did, Jaded Julie. Although I found the short courses associated with the conferences to be most valuable, I also tried to observe some of the local culture when the meeting was held in an exotic location. Let me tell you about what I saw as I walked down Bourbon St. in New Orleans one Halloween night.”
“You may, but not in Kaizen Curmudgeon. I understand that several of our newer colleagues recently attended the World Congress on Excellence in Health Care.”
“They did, and after their return they reported on the high points of the conference. My perception is that they brought home a strengthened conviction that Lean is the right culture for Affinity and that we are progressing well on our Lean journey. In fact, we are among the leaders in Lean health care. When a speaker asked—regarding the focus of his presentation—‘Who is doing this?’, our people could proudly raise their hands to signify, ‘We are.’”
“How about some examples, Old Guy. I presume since this meeting was held in Chicago, their examples will be free of New Orleans-style rowdiness and debauchery.”
“Not a problem, Julie. I believe that the essence of the presentations may be discerned by the following statements and quotations:
‘Philosophy—Patients and families first. Then support our people.’
‘Waste comes cleverly disguised as a lot of work.’
‘Lean is lead from the top down; change from the ground up.’
‘The first day of a kaizen event is usually a food fight, i,e., lots of blaming and finger-pointing.’
‘There is an affinity between Lean and Green.’
‘In their personal behavior, employees must distinguish between being on-stage (in view of patients and visitors) and off-stage (out of view).’
‘Lean is a part of the strategic plan (sounds like hoshin-kanri).’
‘Report-outs must be attended by everyone.’
‘The Joint Commission (TJC) is working to improve their consistency of standards interpretation (anyone who has been audited by anyone should appreciate that).’
‘The middle manager is no longer a problem solver but a facilitator of problem solving.’
‘Overlaying a new technology on a bad process is like shrink-wrapping a cactus.’”
“I think I understand, Curmudge. These statements are all familiar or obvious to us. They represent problems that we have solved, or are working on, or that we are aware of and need to work on. To someone totally new to Lean, they might be confusing. To an experienced ‘Leaner,’ they are an inspiration. Come to think of it, that’s what a conference is supposed to be—an inspiration.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
“I sure did, Jaded Julie. Although I found the short courses associated with the conferences to be most valuable, I also tried to observe some of the local culture when the meeting was held in an exotic location. Let me tell you about what I saw as I walked down Bourbon St. in New Orleans one Halloween night.”
“You may, but not in Kaizen Curmudgeon. I understand that several of our newer colleagues recently attended the World Congress on Excellence in Health Care.”
“They did, and after their return they reported on the high points of the conference. My perception is that they brought home a strengthened conviction that Lean is the right culture for Affinity and that we are progressing well on our Lean journey. In fact, we are among the leaders in Lean health care. When a speaker asked—regarding the focus of his presentation—‘Who is doing this?’, our people could proudly raise their hands to signify, ‘We are.’”
“How about some examples, Old Guy. I presume since this meeting was held in Chicago, their examples will be free of New Orleans-style rowdiness and debauchery.”
“Not a problem, Julie. I believe that the essence of the presentations may be discerned by the following statements and quotations:
‘Philosophy—Patients and families first. Then support our people.’
‘Waste comes cleverly disguised as a lot of work.’
‘Lean is lead from the top down; change from the ground up.’
‘The first day of a kaizen event is usually a food fight, i,e., lots of blaming and finger-pointing.’
‘There is an affinity between Lean and Green.’
‘In their personal behavior, employees must distinguish between being on-stage (in view of patients and visitors) and off-stage (out of view).’
‘Lean is a part of the strategic plan (sounds like hoshin-kanri).’
‘Report-outs must be attended by everyone.’
‘The Joint Commission (TJC) is working to improve their consistency of standards interpretation (anyone who has been audited by anyone should appreciate that).’
‘The middle manager is no longer a problem solver but a facilitator of problem solving.’
‘Overlaying a new technology on a bad process is like shrink-wrapping a cactus.’”
“I think I understand, Curmudge. These statements are all familiar or obvious to us. They represent problems that we have solved, or are working on, or that we are aware of and need to work on. To someone totally new to Lean, they might be confusing. To an experienced ‘Leaner,’ they are an inspiration. Come to think of it, that’s what a conference is supposed to be—an inspiration.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, August 12, 2010
Amazing Devices 2
“Curmudge, I trust that you read Affinity’s electronic newspaper, The Weekly, every week.”
“I do, Jaded Julie, and there was recently an interesting Library Services’ note on Mobile Devices: Health Care Resources in the June 7 Weekly.”
“I guess you are saying that the note demands a careful reading, which you did. My second guess is that your ancient but orderly mind wants to put the info from the Library note into some sort of historical context. Okay, Curmudge, have at it.”
“In our posting on August 6, 2009, Information at Your Fingertips, I envisioned a provider turning to his/her exam room desktop computer to access information via the Affinity intranet. During the past year, laptop computers have become more common throughout our hospitals and clinics. With these, the provider can use the computer while facing the patient and create a more personalized experience.”
“That’s an interesting observation, Curmudge. With the provider facing the patient I’m sure patients would feel like they are in a much more collaborative conversation.”
“Fortunately, now many providers use handheld devices, and those are what Library Services’ note in the Weekly tells us about. It references their PDA Road Map: its title is Mobile Computing for Healthcare: Smart Phones, PDAs, Pocket PCs, etc. Main headings include: Resources for Affinity Library Users, Free Starter Apps, Calculators (free), Clinical POC, Internet Gateways, and PubMed & Evidence-based Practice. In addition, here’s another resource for handheld users: How the iPad Can Change Emergency Medicine.”
“Very impressive! Perhaps this should be called Information at the Fingertips of Only One Hand.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
“I do, Jaded Julie, and there was recently an interesting Library Services’ note on Mobile Devices: Health Care Resources in the June 7 Weekly.”
“I guess you are saying that the note demands a careful reading, which you did. My second guess is that your ancient but orderly mind wants to put the info from the Library note into some sort of historical context. Okay, Curmudge, have at it.”
“In our posting on August 6, 2009, Information at Your Fingertips, I envisioned a provider turning to his/her exam room desktop computer to access information via the Affinity intranet. During the past year, laptop computers have become more common throughout our hospitals and clinics. With these, the provider can use the computer while facing the patient and create a more personalized experience.”
“That’s an interesting observation, Curmudge. With the provider facing the patient I’m sure patients would feel like they are in a much more collaborative conversation.”
“Fortunately, now many providers use handheld devices, and those are what Library Services’ note in the Weekly tells us about. It references their PDA Road Map: its title is Mobile Computing for Healthcare: Smart Phones, PDAs, Pocket PCs, etc. Main headings include: Resources for Affinity Library Users, Free Starter Apps, Calculators (free), Clinical POC, Internet Gateways, and PubMed & Evidence-based Practice. In addition, here’s another resource for handheld users: How the iPad Can Change Emergency Medicine.”
“Very impressive! Perhaps this should be called Information at the Fingertips of Only One Hand.”
Affinity’s Kaizen Curmudgeon
Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.
Thursday, August 5, 2010
Amazing Devices
“Curmudge, nothing documents your antiquity more convincingly than when you talk about the devices you used early in your career.”
“I recall that before the days of photocopiers I had to make 12 copies of an exam by dragging each page plus a so-called ‘master’ through some sort of magic bath. Then the copies were spread out on the counter to dry. I was grateful there weren’t more than a dozen people in the class.”
“That must have been when you had a moonlight job teaching chemistry in the early 1960’s. Since then, advances in all sorts of devices and instruments have really been dramatic. In health care even the simplest of measurement tools, like the glass rectal thermometer, have been replaced. There can’t have been many things that have remained the same. Can you think of one?”
“I sure can, Jaded Julie. What about the stethoscope? It’s not even a scope; it’s a hearing device and should be called a stethophone. It’s still used to listen to the heart and lungs and for measurements of blood pressure. There are anecdotal reports that replacing the stethoscope and manometer with electronic sphygmomanometers yields higher bp’s. However, studies reported in the literature suggest that the methods give comparable results (1, 2). When my wife was in a Czech hospital a year ago, the electronic sphygmomanometer in her room appeared to be the only modern device in the facility.”
“What about pulse oximeters, Curmudge, for measuring the oxygen saturation of blood? The devices clipped onto the end of one’s finger have been in use for a long time, but on your time scale you’d probably consider them a modern invention.”
“You’ve got that right, Julie. When I was studying the use of near-infrared spectroscopy for analysis of wood pulp in the late 1980’s, I met a woman in a short course who was studying near-infrared for clinical applications. Among her interests was pulse oximetry. It seems like only yesterday. Prior to that time, the test of O2 saturation was invasive and labor intensive.”
“I understand that you had in your lab a predecessor of today’s magnetic resonance imaging (MRI) device. That must have been at least 30 years ago.”
“It was a nuclear magnetic resonance (NMR) spectrometer. A solution of the sample was put in a small tube and spun at high speed for the measurement. Someone put a lot of work into scaling up the system to the point where the ‘sample’ is a human lying quietly (not spinning) in the magnetic field. I think they changed the name from NMR to MRI because the term ‘nuclear’ alarmed patients.”
“Speaking of laboratories, Curmudge, clinical labs have undergone great changes over time, haven’t they?”
“I never worked in clinical chemistry, Julie, but I was in a research group with people who did. Leonard Skeggs’ development of the AutoAnalyzer revolutionized clinical chemistry (he was in Cleveland; we were in Madison). He found that samples could be separated from one another by air bubbles as they were pumped sequentially through plastic tubing into as many as 12 concurrent analysis modules. By now, modern lab instruments have undoubtedly displaced the old AutoAnalyzers.”
“While Skeggs and others were automating the clinical laboratory back in the 1960’s, what were you doing?”
“As a research associate in biochemistry, I was developing an instrument for the continuous determination of cyanide in grass. And I’ll answer your question before you ask it; it was not the kind of grass that lots of people were smoking back then. Despite the student riots, Madison was a pretty stimulating place in the late 60’s.”
“Curmudge, other than ‘Gee Whiz,’ what’s the lesson from today’s discussion?”
“Lessons plural, Julie. Most importantly, one should embrace change, both technological and organizational as in Lean. Both kinds of change will make our lives more productive and enjoyable. The second lesson is that one should take a moment to look around and appreciate the astounding developments that have occurred in science and health care in a few short years. Everyone should be inspired to shout an emphatic ‘Wow!’ We’ll talk more about this in later postings.”
Affinity’s Kaizen Curmudgeon
(1) McManus, R.J. et al. Does changing from mercury to electronic blood pressure measurement influence recorded blood pressure?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314749/pdf/14960220.pdf
(2) Elliott, W. J. et al. A comparison of two sphygmomanometers that may replace the traditional mercury column…
http://www.ncbi.nlm.nih.gov/pubmed/17303984
“I recall that before the days of photocopiers I had to make 12 copies of an exam by dragging each page plus a so-called ‘master’ through some sort of magic bath. Then the copies were spread out on the counter to dry. I was grateful there weren’t more than a dozen people in the class.”
“That must have been when you had a moonlight job teaching chemistry in the early 1960’s. Since then, advances in all sorts of devices and instruments have really been dramatic. In health care even the simplest of measurement tools, like the glass rectal thermometer, have been replaced. There can’t have been many things that have remained the same. Can you think of one?”
“I sure can, Jaded Julie. What about the stethoscope? It’s not even a scope; it’s a hearing device and should be called a stethophone. It’s still used to listen to the heart and lungs and for measurements of blood pressure. There are anecdotal reports that replacing the stethoscope and manometer with electronic sphygmomanometers yields higher bp’s. However, studies reported in the literature suggest that the methods give comparable results (1, 2). When my wife was in a Czech hospital a year ago, the electronic sphygmomanometer in her room appeared to be the only modern device in the facility.”
“What about pulse oximeters, Curmudge, for measuring the oxygen saturation of blood? The devices clipped onto the end of one’s finger have been in use for a long time, but on your time scale you’d probably consider them a modern invention.”
“You’ve got that right, Julie. When I was studying the use of near-infrared spectroscopy for analysis of wood pulp in the late 1980’s, I met a woman in a short course who was studying near-infrared for clinical applications. Among her interests was pulse oximetry. It seems like only yesterday. Prior to that time, the test of O2 saturation was invasive and labor intensive.”
“I understand that you had in your lab a predecessor of today’s magnetic resonance imaging (MRI) device. That must have been at least 30 years ago.”
“It was a nuclear magnetic resonance (NMR) spectrometer. A solution of the sample was put in a small tube and spun at high speed for the measurement. Someone put a lot of work into scaling up the system to the point where the ‘sample’ is a human lying quietly (not spinning) in the magnetic field. I think they changed the name from NMR to MRI because the term ‘nuclear’ alarmed patients.”
“Speaking of laboratories, Curmudge, clinical labs have undergone great changes over time, haven’t they?”
“I never worked in clinical chemistry, Julie, but I was in a research group with people who did. Leonard Skeggs’ development of the AutoAnalyzer revolutionized clinical chemistry (he was in Cleveland; we were in Madison). He found that samples could be separated from one another by air bubbles as they were pumped sequentially through plastic tubing into as many as 12 concurrent analysis modules. By now, modern lab instruments have undoubtedly displaced the old AutoAnalyzers.”
“While Skeggs and others were automating the clinical laboratory back in the 1960’s, what were you doing?”
“As a research associate in biochemistry, I was developing an instrument for the continuous determination of cyanide in grass. And I’ll answer your question before you ask it; it was not the kind of grass that lots of people were smoking back then. Despite the student riots, Madison was a pretty stimulating place in the late 60’s.”
“Curmudge, other than ‘Gee Whiz,’ what’s the lesson from today’s discussion?”
“Lessons plural, Julie. Most importantly, one should embrace change, both technological and organizational as in Lean. Both kinds of change will make our lives more productive and enjoyable. The second lesson is that one should take a moment to look around and appreciate the astounding developments that have occurred in science and health care in a few short years. Everyone should be inspired to shout an emphatic ‘Wow!’ We’ll talk more about this in later postings.”
Affinity’s Kaizen Curmudgeon
(1) McManus, R.J. et al. Does changing from mercury to electronic blood pressure measurement influence recorded blood pressure?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314749/pdf/14960220.pdf
(2) Elliott, W. J. et al. A comparison of two sphygmomanometers that may replace the traditional mercury column…
http://www.ncbi.nlm.nih.gov/pubmed/17303984
Thursday, July 22, 2010
Mistakes 3
“We’re writing about mistakes again, Curmudge? I thought that our discussions on April 1 and April 8 wrapped up this topic for good.”
“It’s got to stay on our radar screen, Jaded Julie. Those of us in health care require periodic reinforcement that the proper response to an error is not name, blame, and shame. So here’s a reminder, coming at you.”
“I seems so natural to blame someone who commits an error, and then we compound their embarrassment by calling them stupid. It’s as if that attitude is hardwired in everyone at birth. And then the blamed person feels so badly that they will do everything possible to hide any error that they make in the future. But none of this is new information. My guess is that your wanderings on the Web yielded some new insights about errors that you’d like to share with our readers.”
“You’re right, Julie. They are in a book by Kathryn Schulz called, Being Wrong: Adventures in the Margin of Error. She feels that we make errors because, as humans, we are capable of using a guessing strategy known as inductive reasoning. We make decisions based on what we think will happen in the future, i.e., by inductive reasoning, and some of our guesses regarding the future are wrong.”
“I think I understand, Curmudge. Humans have always used inductive reasoning to guide their trial-and-error development of tools, and in the modern age, their professional talents. If we couldn’t do that, we’d still be living in caves, or maybe in trees. So now, people like concert musicians—after extensive training and hours of practice—can play thousands of notes with few if any errors. But mistakes can and do occur because the performer is human. Hey, this sounds a lot like necessary fallibility that we talked about way back on February 19, 2009.”
“Although several kinds of mistakes can occur in health care, such as shortcuts that have gone awry, let’s focus on those that are purely unintentional. To quote Kathryn Schulz, ‘Embracing our fallibility is the only way to build effective backup systems to prevent or mitigate mistakes.’ ‘Understanding the origins of our mistakes is the only way we can learn to deal with them.’ And so we must ferret out and defuse the booby traps in our systems. Our search for the systemic root cause begins when a mistake or a near miss has been reported. We treasure near misses because they reveal potential problems without anyone’s having been harmed.”
“I suspect that near misses are more like buried treasure because they are so often hidden and not reported. So what’s the bottom line, Curmudge, as if I can’t already guess?”
“You know it as well as your own name, Jaded Julie. Get rid of the old name, blame, and shame culture and replace it with a just culture. That will allow us to find and replace those potentially error-causing aspects of our systems with checklists, standardized work, or decision-support software.”
Affinity’s Kaizen Curmudgeon
Another excellent article on patient safety: The Wrong Stuff: What it Means to Make Mistakes. http://www.slate.com/blogs/blogs/thewrongstuff/archive/2010/06/28/risky-business-james-bagian-nasa-astronaut-turned-patient-safety-expert-on-being-wrong.aspx
“It’s got to stay on our radar screen, Jaded Julie. Those of us in health care require periodic reinforcement that the proper response to an error is not name, blame, and shame. So here’s a reminder, coming at you.”
“I seems so natural to blame someone who commits an error, and then we compound their embarrassment by calling them stupid. It’s as if that attitude is hardwired in everyone at birth. And then the blamed person feels so badly that they will do everything possible to hide any error that they make in the future. But none of this is new information. My guess is that your wanderings on the Web yielded some new insights about errors that you’d like to share with our readers.”
“You’re right, Julie. They are in a book by Kathryn Schulz called, Being Wrong: Adventures in the Margin of Error. She feels that we make errors because, as humans, we are capable of using a guessing strategy known as inductive reasoning. We make decisions based on what we think will happen in the future, i.e., by inductive reasoning, and some of our guesses regarding the future are wrong.”
“I think I understand, Curmudge. Humans have always used inductive reasoning to guide their trial-and-error development of tools, and in the modern age, their professional talents. If we couldn’t do that, we’d still be living in caves, or maybe in trees. So now, people like concert musicians—after extensive training and hours of practice—can play thousands of notes with few if any errors. But mistakes can and do occur because the performer is human. Hey, this sounds a lot like necessary fallibility that we talked about way back on February 19, 2009.”
“Although several kinds of mistakes can occur in health care, such as shortcuts that have gone awry, let’s focus on those that are purely unintentional. To quote Kathryn Schulz, ‘Embracing our fallibility is the only way to build effective backup systems to prevent or mitigate mistakes.’ ‘Understanding the origins of our mistakes is the only way we can learn to deal with them.’ And so we must ferret out and defuse the booby traps in our systems. Our search for the systemic root cause begins when a mistake or a near miss has been reported. We treasure near misses because they reveal potential problems without anyone’s having been harmed.”
“I suspect that near misses are more like buried treasure because they are so often hidden and not reported. So what’s the bottom line, Curmudge, as if I can’t already guess?”
“You know it as well as your own name, Jaded Julie. Get rid of the old name, blame, and shame culture and replace it with a just culture. That will allow us to find and replace those potentially error-causing aspects of our systems with checklists, standardized work, or decision-support software.”
Affinity’s Kaizen Curmudgeon
Another excellent article on patient safety: The Wrong Stuff: What it Means to Make Mistakes. http://www.slate.com/blogs/blogs/thewrongstuff/archive/2010/06/28/risky-business-james-bagian-nasa-astronaut-turned-patient-safety-expert-on-being-wrong.aspx
Thursday, July 15, 2010
Docs on a Treadmill
“Jaded Julie, there’s something wrong with our title. What is it?”
“It’s not the physicians who are on the treadmill, Curmudge. It’s hamsters or gerbils serving as a metaphor (how do you like that word, Old Guy?) for physicians who are caught up in the excessive demands of their practice.”
“You are correct as usual, Julie. But the thing that really bothers me about the title is that it depicts physicians in an inescapable situation. These people are resourceful and highly intelligent. When I was teaching them as undergrad premeds, they got the A’s in the class.”
“As I see it, anyone—not just a physician—in a difficult job situation has three options: stay and endure it, change the system to relieve their discomfort, or leave. Back on September 3, 2009 in The Evolution of Personalized Care we talked about several things individual physicians and groups have done to reduce the stress and increase the efficiency of their practice. In subsequent postings we described how these innovations were brought together to become the Patient Centered Medical Home.”
“Note, Julie, that most innovations came from physicians in a small group practice (Dr. Burger, the Sinskys, etc.). And in addition, there are many individual improvements in efficiency that are never published. A small group that includes a friend of mine has hired nurse practitioners and implemented an electronic health record. A recently retired pediatrician wrote a book and gave it to all of his patients; this resulted in his having fewer calls from distraught mothers in the middle of the night.”
“Sounds like he was a modern day Dr. Spock. But what about those solo-practice docs who don’t have time to read the literature or the resources to try anything new?”
“They are indeed out there, Julie. The Kane Scrutiny blog recently summarized the findings of a survey of small practices regarding the Patient Centered Medical Home. The respondents’ reservations about operating as a medical home were (in order): lack of money, lack of time, and lack of information about the process involved.”
“The small practices’ responses are a real concern, Curmudge. I’m grateful that the medical home concept is spreading through Affinity’s clinics. Physicians and staff that I have talked with in our pilot clinics are enthusiastic about it, and it will help us bring personalized care to more and more of our patients.”
“Have you thought about the physicians in other large organizations, Julie? If they feel that they are stuck on a treadmill, there’s not a lot they can do to change the process. It’s pretty hard to initiate changes from the middle of any organization, and it’s especially difficult if the organization is very large and extremely hierarchical. The options there would seem to be either stay or leave.”
“The military is about the largest and most hierarchical outfit that I can think of, Curmudge. All too often physicians leave when they have fulfilled the active duty obligation they incurred when they accepted a scholarship to medical school. One career Army doc that I know transferred from a hospital to an infantry battalion. So, Rambling Writer, what’s the bottom line of this discussion?”
“In most situations, primary care is not binary, Jaded Julie. It’s not simply good in a medical home and bad if it is delivered by a doc on a treadmill. There are lots of variations in between provided by physicians who have devised ways to make their practice more efficient. Of course, in my opinion the medical home concept is the best. Here it is, summarized in the Kane Scrutiny:
‘The PCMH concept calls for physician practices to develop a team approach for caring for patients; use evidence-based practices; coordinate patient care; utilize performance measurement and quality improvement; adopt health information technology, and track patients and results.’
As the automobile salesman used to say, ‘You can’t do better than that, now can you?’”
Affinity’s Kaizen Curmudgeon
“It’s not the physicians who are on the treadmill, Curmudge. It’s hamsters or gerbils serving as a metaphor (how do you like that word, Old Guy?) for physicians who are caught up in the excessive demands of their practice.”
“You are correct as usual, Julie. But the thing that really bothers me about the title is that it depicts physicians in an inescapable situation. These people are resourceful and highly intelligent. When I was teaching them as undergrad premeds, they got the A’s in the class.”
“As I see it, anyone—not just a physician—in a difficult job situation has three options: stay and endure it, change the system to relieve their discomfort, or leave. Back on September 3, 2009 in The Evolution of Personalized Care we talked about several things individual physicians and groups have done to reduce the stress and increase the efficiency of their practice. In subsequent postings we described how these innovations were brought together to become the Patient Centered Medical Home.”
“Note, Julie, that most innovations came from physicians in a small group practice (Dr. Burger, the Sinskys, etc.). And in addition, there are many individual improvements in efficiency that are never published. A small group that includes a friend of mine has hired nurse practitioners and implemented an electronic health record. A recently retired pediatrician wrote a book and gave it to all of his patients; this resulted in his having fewer calls from distraught mothers in the middle of the night.”
“Sounds like he was a modern day Dr. Spock. But what about those solo-practice docs who don’t have time to read the literature or the resources to try anything new?”
“They are indeed out there, Julie. The Kane Scrutiny blog recently summarized the findings of a survey of small practices regarding the Patient Centered Medical Home. The respondents’ reservations about operating as a medical home were (in order): lack of money, lack of time, and lack of information about the process involved.”
“The small practices’ responses are a real concern, Curmudge. I’m grateful that the medical home concept is spreading through Affinity’s clinics. Physicians and staff that I have talked with in our pilot clinics are enthusiastic about it, and it will help us bring personalized care to more and more of our patients.”
“Have you thought about the physicians in other large organizations, Julie? If they feel that they are stuck on a treadmill, there’s not a lot they can do to change the process. It’s pretty hard to initiate changes from the middle of any organization, and it’s especially difficult if the organization is very large and extremely hierarchical. The options there would seem to be either stay or leave.”
“The military is about the largest and most hierarchical outfit that I can think of, Curmudge. All too often physicians leave when they have fulfilled the active duty obligation they incurred when they accepted a scholarship to medical school. One career Army doc that I know transferred from a hospital to an infantry battalion. So, Rambling Writer, what’s the bottom line of this discussion?”
“In most situations, primary care is not binary, Jaded Julie. It’s not simply good in a medical home and bad if it is delivered by a doc on a treadmill. There are lots of variations in between provided by physicians who have devised ways to make their practice more efficient. Of course, in my opinion the medical home concept is the best. Here it is, summarized in the Kane Scrutiny:
‘The PCMH concept calls for physician practices to develop a team approach for caring for patients; use evidence-based practices; coordinate patient care; utilize performance measurement and quality improvement; adopt health information technology, and track patients and results.’
As the automobile salesman used to say, ‘You can’t do better than that, now can you?’”
Affinity’s Kaizen Curmudgeon
Thursday, July 1, 2010
AIDET Redux
“I guess what you are talking about, Curmudge, is AIDET all over again. Back on October 1, 2009 we discussed AIDET for Physicians. Of course everyone at Affinity should know about using AIDET (Acknowledge-Introduce-Duration-Explanation-Thank you) in communications with patients.”
“At Affinity, yes, but not everywhere. In Twice Blessed on May 13, I mentioned that many older patients use providers all over the area for various aspects of their health care. I’m one of them, and I had a rather simple procedure performed outside of Affinity a few weeks ago. Probably most Affinity employees and volunteers observe their health care encounters in other organizations with a critical eye, as I did.”
“And, Mr. Secret Shopper, what did you see?”
“First of all, I must congratulate the technician on her congeniality and professional performance. I’m confident that she did an excellent job. But with one exception, she didn’t use AIDET. She called me from the waiting room by my not-very-common first name, but she made no further effort (last name? date of birth?) to make certain of my identity. She never identified herself nor did she introduce the student who accompanied her. (‘This is Mary Smith, a student from the University of Wherever. Do you mind if she observes?’) I asked the young woman if she were a student, and her only word during the whole encounter was ‘Yes.’”
“Curmudge, you tend to ‘chat up’ nurses and techs; without that it would have been a very quiet encounter.”
“That’s right, Jaded Julie. The technician never explained the procedure, but I already knew how it was done and how long it would take. When it was finished, I’ll give her credit for telling me that I would learn the results in about a week. I thanked her for her good work, and her final words were, ‘Go through that door and turn left.’”
“I’m not impressed. Any other observations?”
“While a few other patients and I sat in the waiting room, a couple of the techs (or whoever) stood around the desk and talked about their weekend. That didn’t appear very professional.”
“So other than using AIDET, what would be your recommendations for that organization?”
“When I was in the same waiting room a few years ago, they had a phlebotomist whose welcoming smile would have melted the heart of the grouchiest curmudgeon. I had to restrain myself from running up to her, holding out my arm, and saying, ‘here, take my blood.’ And I wasn’t even there for a blood draw.”
“Your lesson must be that if one doesn’t practice AIDET, an engaging smile will go a long way.”
“It’s more than that, Julie. A pleasant voice has to accompany the smile. Here’s the complete lesson: Smile and speak with your most reassuring voice, acknowledge the patient by name and with eye contact, introduce yourself as completely as seems appropriate, explain the procedure and its duration, and thank the patient for coming in.”
“That sounds great, Curmudge. Why don’t you do that at the beginning of each of our discussions?”
“Because you already know that I’m just an old grouch.”
Affinity’s Kaizen Curmudgeon
“At Affinity, yes, but not everywhere. In Twice Blessed on May 13, I mentioned that many older patients use providers all over the area for various aspects of their health care. I’m one of them, and I had a rather simple procedure performed outside of Affinity a few weeks ago. Probably most Affinity employees and volunteers observe their health care encounters in other organizations with a critical eye, as I did.”
“And, Mr. Secret Shopper, what did you see?”
“First of all, I must congratulate the technician on her congeniality and professional performance. I’m confident that she did an excellent job. But with one exception, she didn’t use AIDET. She called me from the waiting room by my not-very-common first name, but she made no further effort (last name? date of birth?) to make certain of my identity. She never identified herself nor did she introduce the student who accompanied her. (‘This is Mary Smith, a student from the University of Wherever. Do you mind if she observes?’) I asked the young woman if she were a student, and her only word during the whole encounter was ‘Yes.’”
“Curmudge, you tend to ‘chat up’ nurses and techs; without that it would have been a very quiet encounter.”
“That’s right, Jaded Julie. The technician never explained the procedure, but I already knew how it was done and how long it would take. When it was finished, I’ll give her credit for telling me that I would learn the results in about a week. I thanked her for her good work, and her final words were, ‘Go through that door and turn left.’”
“I’m not impressed. Any other observations?”
“While a few other patients and I sat in the waiting room, a couple of the techs (or whoever) stood around the desk and talked about their weekend. That didn’t appear very professional.”
“So other than using AIDET, what would be your recommendations for that organization?”
“When I was in the same waiting room a few years ago, they had a phlebotomist whose welcoming smile would have melted the heart of the grouchiest curmudgeon. I had to restrain myself from running up to her, holding out my arm, and saying, ‘here, take my blood.’ And I wasn’t even there for a blood draw.”
“Your lesson must be that if one doesn’t practice AIDET, an engaging smile will go a long way.”
“It’s more than that, Julie. A pleasant voice has to accompany the smile. Here’s the complete lesson: Smile and speak with your most reassuring voice, acknowledge the patient by name and with eye contact, introduce yourself as completely as seems appropriate, explain the procedure and its duration, and thank the patient for coming in.”
“That sounds great, Curmudge. Why don’t you do that at the beginning of each of our discussions?”
“Because you already know that I’m just an old grouch.”
Affinity’s Kaizen Curmudgeon
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