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
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
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.
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.
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!
“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
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
This 3 year old edition of my former weekly staff newsletter dealt with cuts to then upcoming cuts to a CA state funded program called EAPC, Extended Access to Primary Care. As the budget problems in CA became more severe, many cuts were enacted to various health and human service program. This was one program that allowed reimbursement for services to the uninsured. As of today it is completely gone. Additionally, I reported from the final Health Disparities Collaborrative Western Cluster, which included disparities work partners as far west as Hawai’i and Guam. The HDC is a HRSA project unifying efforts to coordinate governmental healthcare agency work throughout the nation to address the inequities, or its euphemism, disparities in health outcomes. These meetings ended up being a last chance for health center staffs to meet, socially network and plan ongoing collaborations as the HDC efforts were whittling down. Despite the disappearance or the HDC’s support, important lessons about process were learned at the convenings. Most useful to my practice, in an ongoing sense, has been the exposure to the Chronic (Planned) Care Model by Ed Wagner and the importance of its constituent pieces. Particularly the necessities of self management of illness and data base registry to track experience and monitor for better outcomes. Enjoy!
Monday Pulse 03.10.08
“The only certain thing in today’s world is change”-a wise man
“Catch the Latest Wave in Healthcare!” California Primary Care Assn. Health Disparities Collaborative Conference Recap.
I attended this conference in Anaheim at the end of February. It is scheduled as the Region’s Final HD Collaborative meeting, which I found rather sad. One has to wonder what is the future of organized efforts to eliminate disparities in healthcare. Surely, any efforts at cost reform must consider the effects of poverty on access to care, and the consequences of denied access. In any case, many creative and resourceful responses to several concerns troubling our population base were presented as possible solutions. I was most impressed by the spark stimulating these folks, especially in the worrisome environment of Community Health Center theses days. Many examples were presented to solve the problems of increasing quantity demand of visits, of understanding options for best documenting quality with the specter of Pay for Performance (P4P) lurking, and most interestingly addressing obesity through community collaboration models.
The Chronic Care Collaborative Model (see http//:www.healthdisparities.net) offers a schema to address the clinical collaborations. I was amazed by the enthusiasm and organization of the presenters who were guided by the Model. But mostly, at the end of the weekend I was wondering about motivation, how is the spark of creativity awakened. In working with my patients, I particularly am familiar with the Hierarchy of Needs model because of its developmental nature. That being, one can work to set a strong foundation at the base of the hierarchy then build upon those strengths. Contrary to many of our patients, we are functioning at a much higher level within the Hierarchy. As we begin our careers here we’re probably already at the mid-level of belongingness, hopefully, with support, mentoring and experience we can quickly vault to satisfy our esteem needs. We do understand mastery of all the clinical and administrative skills needed for mastery, at large healthcare institutions, can delay this vault. I feel that part of the answer here is prioritization, not losing sight of the forest for the trees. I also admit a tension exists, especially amongst us perfectionists. There is a lot of external and internal pressure to scale each tree correctly. To get to the highest level within the Hierarchy, self-actualization, where the much needed creativity resides, requires that bigger picture perspective, as well as practice (dreaming with action). Why did I go into medicine in the first place? Why primary care? Isn’t a Community Health Center an ideal resource to improve healthcare options for a community or population? If not, what’s needed? I do not think these are musings of a Medical Director alone.
One of the most interesting examples of a community approach toward remedying childhood obesity in San Marcos, CA, that began with a lunch table discussion (dream to goal) between the staff pediatrician, an FNP, and some WIC/CPSP staff. The initial funding for their projects came from recognizing they could recoup more from CPSP nutrition counseling visits and leverage that for services and efforts off-site, collaborations. The conference highlighted story after story like these.
Extended Access to Primary Care Program. As we heard about last week the EAPC program is out of funds for FY 2007-08. As it exists now, this under funded state program is clearly in need of management or re-evaluation. The management changes involve more eligibility screenings, collections etc., but clearly there is a pressure for case management as well. As we found out at the meeting last week, some data does exist, mostly coming from Quest and Medical Manager, yet Central Coast Alliance forHealth did send us some lab utilization data from last year. Unfortunately, Quest data for our EAPC patients does not include diagnosis codes. So to stratify cost per patient per provider cannot be further examined by diagnosis codes. I admit this is a frustration, but I do see some useful recommendations forthcoming, regarding limiting certain high cost laboratory studies.
For example recommending the Comp. panel over the individual tests, requiring prior authorizations for HPV, H. Pylori testing and urine microalbumin, may be initial recommendations, although no process has been developed yet on how to effect these changes. Be assured that any of my individual discussion with providers will be with the intention of education/clarification not punitive.
On a related note, I have submitted a list of combination antihypertensive drugs, to our consultant pharmacist for consideration. Additionally remember to continue using the Walmart, Costco, Target formulary programs as much as possible. Keep in touch with your PSM’s about any changes in these programs and remember that EAPC meds are now subject to a $5 copay.
Call providers. Pedro Moreno is working with CSVS and others to try to get help with his call obligations for next year. For a while he is looking to step away from call, that would leave a large number of calls open for the rest of this year. Reimbursement is available for those call for any substitutes. The drawback at this moment is investigating our malpractice coverage for those calls as they involve covering the Internal Medicine service as well. I will keep informed as things reveal.
Diabetes Collaborative Health Fair Reminder. Once again CSVS will be offering a Diabetes Collaborative Health Fair on March 27th, 2008 at El Sausal Middle School, beginning at 6:30PM. Committed participants so far are, Dr. Alan Smith, Jeanette Cisneros M.D., Chesney Hoagland-Fuchs, Lupe Covarrubias from WIC, Ruth Ramirez and more. We plan on an organizational meeting Tuesday night 3/11/08, so contact me prior with any ideas, desires to volunteer, etc. It’s exciting and hopefully foundational for future community collaborations around obesity prevention and chronic disease.
Recruitment. I hope to have some good recruitment news next Pulse. We have on the line a very experienced clinician relocating from Hawai’i. He’s previously worked with Jimmy there. If he were to sign on, there may be some related CSVS shifting that could benefit all sites, at least during the summertime PTO crunch. I hope to get a provider PTO August and Holiday season survey out this week, which you can return to me by interoffice. This will help plan better for “crunch time recommendations.
Hasta Luego, next Pulse will be 03.24.08, as next week I’ll be celebrating my 23rd anniversary with a day off.
Health Disparities Collaborative http://healthdisparities.net
02.11.08 (Redux 2011)
Random Acts of Kindness Week 2011 begins on 02.14.11 and info can be found at this web url http://www.randomactsofkindness.org/ One of the hospitals I where I work has just begun a team building campaign where employees are encouraged to do an unexpected favor for a workmate, a random act of kindness.
Additionally this edition of my newsletter is from 3 years ago when I was actively medical directing in my previous position. I was involved in a process of seeking and teaching efficiency in our clinic “gembas” or workplaces, to use a Japanese Kaizen term. It’s clear that the transition to highly effective teams is a project and I was trying to teach the elements of teamwork to staff. I had great help, including an intuitive Director of Nursing who got it and a motivated Psych D. who I often collaborated with.
Mostly the three of us were trying to coach up the future team leaders. As we move towards Patient Centered Medical Home models, it’s clear that licensed practitioners will have to learn to share and delegate responsibilities to others of lesser training. Confidence in each other will be a requirement, and this will necessitate a commitment to ongoing training (and remediation) and accountable supervision. Two skills physicians, in my estimations, often lack the patience and a desire for when it comes to unlicensed staff. My Desktop updates below were an effort to breakdown teamwork into its foundational components and encourage staff to develop them.
The focus here is on workplace Kaizen’s initial steps environmental management and that all important piece of teamwork: effective communication.
Greetings! This week marks the 13th annual Random Acts of Kindness Week, sponsored by the Random Acts of Kindness Foundation. This foundation is a non profit, that represents the US at the World Kindness Council. The words “Random Acts of Kindness” are a response to the all-too-commonly heard phrase “random acts of violence”. The other emphasis here is on the word random. Ideally its emphasis will encourage us to look beyond our circle of friend and family, as recipients of kindness. The foundation believes “these completely unexpected gestures to or from total strangers have the most impact on our lives”. Sample ideas: invite someone new to lunch; get to know new hires; leave a treat on the desk of a co-worker you may not get along with; write, draw or make an encouraging card for someone experiencing difficulties; give a compliment. In this vein I am totally inspired by a patient of mine, Deborah Aguilar. I saw her in Saturday’s paper planting a tree in Closter Park to honor victims of violence. After her son was killed in a drive-by shooting in 2002, she started meeting with other families who had lost loved ones to violence, and this effort evolved into the community support group “A Time for Grieving”. The group meets regularly, at Sunrise House in Salinas, and their contact # is 443-0480, in case you know of a family in such need, or if you want to contribute time or funds for a plaque on the site nearby the bench and lighting the city is providing.
February Clinicians’ Meeting Desktop Updates (leftovers). # IV Kaizen/Pursuit of Flow. In tracking the holy grail of flow through Kaizen, it’s clear that there are foundational undergirdings that are necessary before the other disciplines can take hold. I believe two crucial ones are sound communication and management of the workspace (remember the 5S’s, sort, set in order, shine, standardize, start over). A personal goal is to 5S my desk, then with those benefits in place, hopefully export with a 5S office wide initiative. In terms of communication, the staff development here continues. During our meeting Thursday morning, Vicki and Linnea were continuing their effective communication skills building practicum with MA staff. They learned about the relationship between the intended message and how it can be nuanced by tone and other non-verbal cues like body language, emotionality and contexts. The presentation was very similar to the first chapter in my Intro to Org. Communication textbook. This describes the process of communication involving a sender and a receiver, and a properly encoded message being sent through the correct channel. Unfortunately confounders exist and are referred to as noise (interference), either external, physiologic or psychologic. In my experience a major cause of workplace noise is psychologic (stress, emotions). When you get a chance touch base with staff about how the last communication workshop went; consider sharing what you’ve learned over the years about reading patients’ body language.
In terms of our (providers/leaders) own communication my Kaizen guru, Daniel Goleman says “…star teams can use intellectual battle to upgrade the quality of decisions, provided they keep the debates free of the emotionality that might alienate or sabotage commitment to the decision by some team members. The key lies in emotional competencies such as self-awareness, empathy and communication–that is, how well team members argue”… Food for thought. Hasta la proxima vez!
I totally missed this report from the NYT during the fall of 2010. Apparently former Tuskegee Study researchers were in their waning days in the States and they still had many unanswered questions. Some remaining Public Health Service work apparently had to be outsourced. This report must give us insights into what the situation must have been like for the Tuskegee patients, as the cheif investigator, Dr. John Cutler, was a Tuskegee Study researcher. Interestingly as these studies were getting started in Guatemala, the Helsinki Declarations were being honed down in Europe, ultimately recommending the Nuremburg Code of ethics for prisoner and POW (and really human) medical care.
See the whole archived article at: http://www.nytimes.com/2010/10/02/health/research/02infect.html?_r=1&ref=donaldgjrmcneil
In this post, Wendy Harpham, a medical blogger, physician, cancer survivor and mother of three speaks to doctors’ socialization to sometimes be dispassionate. I have wondered often why we physicians are not required to undergo counselling as part of out training, as psychologic counsellors do. If we did, I believe a lot less harm would be done.