Chronic disease prevention and management in central coastal CA

You know soda is not good for you, but are artificial sweeteners better

This article by a nutritionist out of the Washington Post gives advice on getting back to plain old H20

Recent article from the Journal of the AHA speaks to artificial sweeteners relationship to stroke and dementia



HCC Adolescent Wellness Interns’ Week 3

Our Health Care Connections Adolescent Wellness interns just finished their third week, and the service learning continues. The highlights this week included a chance to reach and educate in the berry fields of Reiter Farms off of River Road. The interns also participated in a Population Health webinar about modern management of community data. Remember you can still donate, tax-deductibly, to this great cause at https://www.gofundme.com/hccadolescent-wellness-intern As well, The Natividad Medical Foundation is also recipient at Amazon Smile – https://smile.amazon.com where online purchases at Amazon Smile can help fund this and many other important projects. Thanks so much Juan ChavezStephanie SalesWayne MartinNicholas SassonJusto Minerva Perez LopezTerrill Jane Keeler LMFTDeb Fredell-GonzalezMary DuanKatharine RichmanSteve Blough and Walter MillsEric ParsonsEric SanfordAna Abril AriasWendell HarryEloy RomeroVictoria L. P-WilliamsVictor Hugo DelgadoJeanette CisnerosAntonio VelascoJames LewEdward CastroJay W. LeePenelope VelazquezCraig A. WallsJaime GonzálezJennifer KellyGretchen StoneChristina ZaroMichelle QuiogueMichael Sepúlveda and all other and future donors! If you make it all the way to the end here, please share this post on Facebook, twitter, etc…  #healthequity

Depression’s role in Chronic Pain:Economic perspective

Nice summary with an attached blog you can follow about pain management.
Our community health center (CHC) office has been screening patients for depression for several months.


Medical Assistant Boot Camp on Office Blood Pressure “vitalizing”

Today I’m putting the finishing touches on a Medical Assistant (MA) Boot Camp presentation. Our family practice offers is attempting to make more consistent our MA practices to suit provider expectations and improve flow and patient experience                                       BP Boot Camp 03.12.12

BP Boot Camp

BP definitions, terms and significance

Over 135/85 is true High Blood pressure, best monitored on home BP devices

130-135/80-85  pre-hypertension

nl BP 120/80 or less

Primary reason to treat HTN is to lower risk of stroke, heart failure and kidney disease

No single blood pressure reading diagnoses hypertension, instead one needs home BP monitoring over several days with protocol or we use three clinic elevations over a month long period. Lovibond K et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: A modelling study. Lancet 2011 Aug 24;

The commonest confounding dx is “white coat hypertension”, 796.2- typically non hypertensive, non diabetic, non smokers, and younger Hypertension. 2011;57:898-902

Technique points

BP is routine but errors abound because of faulty technique

  1. Size of arm/cuff

-bets BP is with patient supine, and arm at level of heart

-second best is seated with arm resting at level of heart

-cuff size must be correct

-the width should be approximately 40% of the circumference of the limb

-there are often recommendations on the cuff

-and the bladder must completely encircle the arm

-higher in right arm, can be as high as 15mmHg, so be sure to mention which

-for very large arms, can use arm cuff on the forearm and scope over radial pulse

2. Speed of deflation

-too slow deflation can decrease the systolic BP, and raise the diastolic B


-muscle activity like walking and talking can raise BP

-at least 1 minute between BP’s

-ideal time in between in clinic  is still not known, yet averaging 4-5 BP is acceptable

Ann Intern Med June 21, 2011 154:781-788;

Goal: To design Workflow for BP’s >140/90, needs repeating, but logistically how for our office

I see “wasteful” people, how am I changed?

This little blog entry shows how to be buoyed up by the little things and improvement changes you notice in the Gemba (workspace)


Work relationship survey December 2011

Spent the end of last work completing a Workplace Relationship Survey, looking at preliminary self-awareness of how our team is working. Preliminary in the sense that I am preparing a Medical Assisstant Boot Camp and I want to see where we’re at before starting the training. The survey is based on this work by Tallia, MD et al http://www.aafp.org/fpm/20060100/47seve.html, first published in Family Practice Management. The suvery studies the dimensions: Trust, Respect, Mindfullness, Interelatedness, Diversity, Varied Interaction and Effective Communication. The authors report that successful practices score highly on these dimensions. I had also used this tool in another practice a few years ago.

Methods: Surveyed 26 staff including physicians, medical assistants and front office receptionist in a Community Health Center in a CA rural agricultural community.  I preceded the survey with a discussion of the various practice characteristics, answered any questions, then distributed the survey.  I scored the Always present, Sometimes present and Never present answers on a linear 0-5 scale and calculated the mean on each characteristic.

Results: Scale 0-5

Characteristic                Mean Score

Respect                                  3.60

Trust                                       3.32

Diversity                                3.32

Mindfulness                         3.17

Interelatedness                    2.93

Effective Communication  2.79

Varied Interaction               2.15

The results were surprisingly similar to results from another CHC office 3 years earlier, where again the lowest scoring parameter being Varied Interaction. The high scores speak for themselves and I will focus on the challenging one.  This characteristic of varied Interaction rates the ability for both task related and social interaction to be fostered.  Clearly, our practices need to work on this. I believe the reasons are both structural, the nature and socialization of a hierarchical field like medicine.  More opportunities for empathy are needed ironically, in a field historically known for compassion.  In terms of team building I mentioned to support staff that we cannot offer true customer service until we realize “internal” customer service, the behind the counter service we need to offer each other.  In our particular case, it needs to start with more opportunities for staff to interact socially.  Our office, by way of no prior planning, has no local break room.  Support staff and professional staff pragmatically break surreptitiously at their desks (we are hoping tom  move into a self-designed clinic within the next two years), in two different locations.  In terms of midway solutions, we did begin recently with a colocation PDSA where, we place a physician and their medical assistant in the same space during clinic, sitting across from each other in the middle of the Gemba, we call this “the fishbowl”.  So far, so good. The experience is getting positive reviews from the participants, yet too early to see improvements in cycle times.  We’re just beginning to look at which metrics to follow.  We are also trying an improved communication tool around uncompleted forms waiting around the office too long, a problem that surfaced when we discussed the characteristics of mindfulness and interrelatedness.

In any case I believe we are beginning to see changes in office relationship as a spin-off of the survey, an early Hawthorne effect that we’ll try to keep building upon.  And I recommend you review this article out of Family Practice management and consider surveying your own workgroup

See in my blogroll or find at below link


From the Daily Kaizen,what can be gained by “trust” in your gemba/workspace

Solve Your Own Problems

by Lee Fried

Last week I had a chance to catch up in the hallway with a Medical Leader I had not seen in over a year.  This conversation made me proud, because it showed me how powerful Lean Management can be if you stick with it over time.

I always liked working with this leader, because while he was always a little skeptical, but he also always showed up as a good student and would immediately take the learning and apply it in his practice.  We had some good debates.

One of the areas I often gave this leader feedback (usually during gemba walks) was his tendency to take problems away from frontline teams and managers too luickly.  He grew up in a management system that was based the premise that managements job was to solve problems so that frontline teams could do the work.  Thus, once he started to gemba he got a lot of feedback and ended up taking a lot of “to dos” many of which were missed opportunities to turn the request into a coaching opportunity.

During one of my training opportunities a Toyota Sensei once told me that the highest form of “respect for people” was allowing people to solve their own problems.  This statement stuck with me and I have often used this during training/coaching sessions.  Apparently, this statement also stuck with my friend.  In the hallway last week he said after a year of gemba he finally understood his role as a leader and what I meant when I talked about “respect for people.”   He said at first he loved the Lean approach, because he loved being in gemba, but after a while the follow-up became overwhelming to him and frustrating to the teams he worked with.  He said each time he went to gemba he felt guilty about the increasing number of problems he was not having the time to solve.

Finally, he said he had a really rough week and realized he needed to do something differently.  He asked for help from his boss.  He started to ask more
questions.  He started to trust that others can take the ownership for problems.
He told me it is fun again and he is amazed at how many people are
stepping up to the challenge.  He also told me it is really hard work to not step back into the problem solving mode and that he is only just getting a knack for it. I give this leader a lot of credit, because it would have been an easier path to go back to the traditional management approach.   I share this story, because I believe that most leaders follow a similar path.



Where we are and need to be in healthcare today. I think!

This article discusses the transition from fee for service, or the system where care is evaluated/charged for, by procedures accomplished to care based on documentation of outcomes.



A Day in the Life of a Medical Director – Monday Pulse 03.24.08, and perspectives from a few years later

     This blog entry retro is from a newsletter of three years ago when I was directing a group of Community Health Center physicians through the strife in diminishing resources resulting from the annual California budget crisis and its ramifications on patient care.

      The first part of this newsletter to staff deals with a process to get the point-of-(billable)service staff to coordinate PTO or Planned Time Off for the health center.  All employees deserve benefits but in a way time-off benefits for providers can serve as a “double whammy” for the center, as revenue will drop when the provider is off the floor; unless the time-off is coordinated.  I was encouraged by my administrative colleagues to encourage the docs to plan vacation and educational time-off earlier and in a more coordinated manner.  Without that planning, time away authorized often felt capricious and even worse as favoritism, which can be very destabilizing to morale.  The PTO Survey represented an attempt to bring some order or better, predictable process to provider time away from clinic.  The process began with a survey and actually became very complicated and perhaps too formulaic as the spring went on.

     The second topic in the newsletter deals with the State’s ratcheting down of the Extended Access to Primary Care (EAPC) program.  this no longer existent program was a way to support cost for the health center’s uninsured patients.  The program allowed some flexibility to spend, and in our site paid for ancillary services, like lab studies and xrays, that the center then purchased, ideally by contract to mollify risk.  In terms of an idea of magnitude, we received ~ $500,00o to help support ancillary care at eight different sites of varying size and percentage uninsured population.  The program had a history of exhausting itself ~8 months into the fiscal year.  EAPC was a program in dire need of clinical management, specifically utilization management. In short, getting physicians to become efficient caretakers of expenses they control.  Ethical issues could abound, …”equal care for all patients”, “standards of care”, “CYA defensive medicine”, and the “no margin-no mission” ideology.  In any case, in order to change physician behavior you have to begin with data.  And in general, they are a very savvy group, leery of administrative data.  Never-the-less, I thought we had two good data sets to go forward with, one internal (lab charges)and one external (insurance carrier data), and this newsletter edition served to begin that discussion with my colleagues.  Post script, by the summer of 2009, one year later, the EAPC program was de-funded, end of story.  Interesting lesson, we probably ted too late with our utilization planning.   Please enjoy and comment!

Monday Pulse


“You can’t always get what you want,… But if you try sometime…you just might find you get what you need!” – M. Jagger

Clinicians’ PTO Request Survey.    

            Attached to this edition of the Pulse you’ll find a survey querying clinician about their August and December PTO desires for 2008.  This information will be used when considering PTO request for the historical short staffing months.  This was a recommendation coming forth from the Working Group of providers that met in February.  Certainly other factors will also be involved like history of prior recent PTO Holiday-time use and date of requests already received (very few if any have already come in for these months).  I will also interoffice a copy to all providers.  If possible return these to me or Jon Y. as soon as possible.  Again the intent here is for fairness in planning.  Reminder will be brought up at our next Clinicians’ meeting.

EAPC Lab Follow-up.

            I have had a chance to review the lab utilization data that was presented at the last Clinicians meeting.  Additionally, I reviewed the Central Coast Alliance for Health (CCAH) lab utilization data from 2006.  The idea was to check trends of note.  Terry Gomez and Jimmy Lew also did some investigation involving Quest lab and presented it in their Monthly Kaizen Provider meeting. Here is some pertinent info. From their presentation.  The commonest Quest ordered labs, during one four month period in 2007,  were in descending order with their EAPC prices: lipid panels ($7.00), TSH (11.00), Comprehensive metabolic panel (1.90), CBC/Hemogram(2.00), HgbA1c(7.00), PAP (21.00), hepatic panel(5.00), GC/CT(17.00), Urine microalbumin (26.00), Basic metabolic (1.58), UA(?), ESR (3.00), H.Pylori breath (25.00), Urine culture (18.00), PSA (5.86), HIV AB (14.00), Stool O&P (5.99 per),CPK (3.74), Hep C (7.60), ALT (4.00), Fecal Globin (9.99).  The most interesting note is the variation at each site, but this data contained no denominator, so exact interpretation is lacking.  But even in similarly sized clinics the variation is really remarkable and really unacceptable.  For example one smaller clinic ordered 25 ALT, AST during the study period, and another ordered 0.  Interesting since clearly the cost efficiency would have been to order the CMP instead.  I think understanding the price breakdown will in itself begin to educate about lab selection choices.  My practice about -statin liver test monitoring will now change now that I know the pricings. 

            The CCAH data is also interesting about variation.  The data is better in that their clinic-by-clinic data is normalized to a rate per 1000 members.  For example, let me show you these numbers:

Disease panel variance from norm range for the 6 sites   (-47% to +36% from specialty average)

Blood counts                “                                          -23% to +30%                  “                 

Urinalysis                                  “                                          -30% to  +82%                 “          

TSH                                         “                                          -34% to +37%                  “

HgbA1c                                   “                                          -22%  to+115%                “

PSA                                         “                                          -35%  to +100%               “

Other Chemistry                       “                                          -27%  to +301%               “

            From a pursuit of uniformity standpoint that Total Quality Management approaches seek, this degree of variation suggests waste is occurring somewhere.  And looking forward, as the IOM pointed out in its “Crossing the Quality Chasm Report”, a 21st Century health care system needs to pursue waste reduction over cost reduction, because the cost of waste is tremendous, and some begins within the clinicians’ sphere of influence.  As we have been discussing here, modern quality experts talk about variation as distance from the mean.  The more of the outcomes that are closer to the mean, the more reliable the procedure.  One could consider the decision to order a lab as the procedure, so the more lumped together the order rate, the fewer outliers several standard deviations away from the mean, the more confidence we can have that we are being efficient in our practices.  The less we are wasting valuable institutional resources.  Quality experts believe all improvements begin with the data.  One final quick but useful point about variation.  Variation can be of two types, special-cause variation, a result of employee error or undertraining, and common-cause variation, that variation that a policy or a technology allows, usually a management decision.   The majority of variation is usually common-cause type. I believe this data truly justifies the need for a lab utilization review policy, which should combine both clinical and cost information as described above.  Until such a policy/tool is in place I’ll be sharing the data I have with you for consideration with your lab ordering.

            To date no feedback is forthcoming from CCAH about our variation in utilization but I do plan on speaking to their Assoc. Med. Director Julio Porro, MD, about his interpretation of acceptable variance from the norm.  I’ll try to have the clinic specific data at the next provider meeting to share for educational purposes.

Tamper-Resistant Rx Pads.

            As of  04.01.08 Medi-Cal, Medicare and CCAH prescriptions will need to be on tamper-resistant forms as we are presently using for our controlled substances.  I have been in communication with Victor Rodriguez from Purchasing and we should be receiving increases numbers of the existing tamper-resistant forms for prescribing.  We understand that these pads allow only one drug at a time and their use will be inefficient, because of the many medications some of our patients require.  We are attempting to obtain larger tamper-resistant forms for betterprescribing efficiency.  Additional options we have for prescribing are for staff to phone in or fax prescriptions on these complicated patients.  Certainly the more discussion we have with our staffs and receiving pharmacies should minimize this transition period, and I’ll keep working with purchasing to get these larger pads as promptly as possible.

                       This will be the final reminder for our Health Disparities Collaborative Diabetes Health Fair on Thursday night at El Sausal School.  The fun begins at 6:30PM, come on down if you get a chance, you’ll find a chance to meet and greet some of our collaborating agencies in town and socialize/network about future joint efforts.


For a lttle more on utilization mangement begin here


and review this more global update on Massachusetts’ three year effort at healthcare delivery/cost reform


New patient friendly medication for anticoagulation described with respect to challenges of patient education

I saw a 60 year old woman in the office this week who told me she had a heart condition since childhood and that she was very leery of taking chronic medications, mostly seeking out holistic, naturopathic ways of self treatment.  And in general her condition was not disabling.

Upon exam I detected atrial fibrillation which may have been treated with anticoagulants in her case in the past, to prevent a stroke, but presently she was on no blood thinners.  Not even aspirin.  As we talked it became more clear that she was very hesitant of many common medical interventions including PAP smears and mammography.  I’m sure I do not have the whole story yet, after only one 15 minute encounter.

I have attached to this post a podcast describing a newly available anticoagulant, dabigatran, which has the potential to really change the current management about anticoagulation, which is very doctor-centric, and could really change the locus of responsibility, to prevent stroke, to the patient.  This podcast points out to me the struggle with releasing that responsibility, and in a bigger sense the challenges our profession will need to overcome with the adoption of  Patient-centered approaches.  The below URL will take you to the article and podcast


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