building teams and changing culture in the medical home

4/14/2011

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Building Teams and Changing Culture in the Medical Home

Iowa Healthcare Collaborative Webinar

Thomas Sinsky, MD

[email protected] Medical Associates Clinic and Health Plans

Dubuque, Iowa

Disclosure of Financial Relationships

Thomas A. Sinsky, MD No relationships with any entity producing,

marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients

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Agenda

The need for teamwork in primary care Primary care team structure and function: examples Teamwork for Medical Home and Meaningful Use certification Sustaining teamwork and culture change with effective team meetings

Who am I?

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115 physicians, owners Health Plan: 1/3 of pt pop. EHR: 2003 Level 3 PCMH: 2008; 2010

Staff Turnover: < 5% PCP Satisfaction: 3x national norm PCP Productivity and Compensation: 85%’ile MGMA

Satisfaction

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Snapshot of Practice

Staffing Primary nurse Help nurse 1.5 nurse: MD (no MAs)

Space 3 exam rooms

Scheduling 1 Receptionist: 2 MDs

Snapshot of Practice

Typical Schedule 6-8 Annual 10-12 Planned Care 4-6 Rapid Access

Panel Size 1800-2000

Outpatient/Inpatient

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Practices We Have Visited

New York City Dept of Public Health small primary care practices project New York City Unite Now garment workers union clinic Maine-Primary care coalition Vermont – Blueprint for Health primary care coalition Massachusetts - Boston – Massachusetts General Internal Medicine Associates Massachusetts - Boston – Brigham and Woman’s Hospital outpatient clinics Minnesota - Minneapolis – Health Partners Minnesota - Mayo Clinic – Primary care internal medicine Iowa - University of Iowa – Internal medicine outpatient clinics Iowa - Des Moines - group practice Iowa - Iowa City – Mercy Medical Group Wisconsin – Red Cedar Clinic Wisconsin – Theda Care Appleton Wisconsin - Affinity Health Systems California– Palo Alto Medical Foundation California – Sutter Medical group Washington - Seattle – VA Washington - Seattle - Virginia Mason Medical Center New Mexico - Santa Fe – Community heath center South Carolina – Medical College of South Carolina Tennessee – Memphis Georgia - Atlanta- Wellstar Health Systems Alabama – FQHC practice coalition Canada – Toronto Primary Care coalition Canada - Edmonton Primary Care coalition

Group discussion Who are you? What are you hoping to accomplish today?

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The Need for Teamwork in Primary Care

Take Home Messages

It’s all about Planning ahead Sharing the load Enjoying the work!

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At the center of PCMH are face-to-face healing relationships.

Patient: Nurse Nurse: Physician

Nurse: Nurse Physician: Patient

Mrs. Janes

65 year old annual exam DM2 HTN Depression

Prevention New c/o

Heartburn Sleep disturbance Fatigue

# of Quality measures?

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There is a lot to be done!

65 year old annual exam DM2 (9) HTN (17) Depression (10)

Prevention (27)

New c/o Heartburn (3) Sleep disturbance Fatigue

# of Quality measures? 56

*McGlynn EA, N Engl J Med 2003. 348;26:2535-2645

There is a lot to be done!

Too much to be done by just one person Too important to be left to chance

# of Quality measures? 56

*McGlynn EA, N Engl J Med 2003. 348;26:2535-2645

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Physicians as Clerical Staff

Work within the skill-set of others is now displaced to physician:

Transcription Documentation Proofreading Paper work Data gathering Data entry Order entry Medication reconciliation Processing prescriptions

I spend two hours at home each night typing my notes and clearing my inbox. I’m not sure how long I can keep this up. Internist, Santa Fe

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I work part-time, and would be willing to increase my clinic hours, but am reluctant to because of all the additional documentation and follow-up work I’d have to take home every night. Family physician, Maine 6.08

For me the final straw came in

2007, we now had to type our

progress notes. This added one to

two hours a day to an already too

long work day for the grunts on

the clinical front....I quit.

Jim Du Busc, PCP, San Rafael, California

http://www.nejm.org/perspective/primary-care-video/

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Episodic Care

Check-in

receptionist

Room pt MA

MD Check-out

Vital signs Medication reconciliation History Exam Data Gathering Data entry Decision making Relationship building Prescription writing Documentation Paperwork Behavior Modification Results reporting Order entry

Insurance verification Collect co-pay Verify contact info

¼ MA: MD

?

Work Within Skill-set of Others

Check-in

receptionist

Room pt MA

MD Check-out

Vital signs Medication reconciliation History/History Exam Data Gathering Data entry Decision making Relationship building Prescription writing Documentation Paperwork Behavior Modification Results reporting Order entry

Insurance verification Collect co-pay Verify contact info

¼ MA: MD

?

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Integrated, Continuous Care

Office Visit

Between

Visit Care Efficiencies and care coordination

Nurse-MD Team

Pre-visit

planning Build-in

rather than Carve-out

MA-MD Team

Primary Care teams: Structure and Function Med

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Teamwork: Empowered Nursing

•Nexus of organization of our practice

Between Visit

•Extension of me when dealing with patients; patients recognize this.

•Coordinates transitions (hospital, NH, Hospice)

•Manages & returns most phone calls

•Processes prescriptions

•Updates EHR

•Visit

•Med. Reconcil.

•Initial review of lab

•Pt education

•Immunizations

•Colonoscopy

•Sx driven tests

•Diabetic foot exam/eye exam

Post- Visit

•Med list

•Summary

•Reinforce plan

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Mini-huddle

Give report ↓ info drop off

Staff deeply engaged Mentor nurses Stronger handoff

Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Annual Exam Rapid Access Intentional Behaviors

Core Team: Mini-huddle

47 yo “Rapid Access”

new patient CC: dysphagia

Nurse Mini-huddle “She seems depressed” “Is anyone hurting

you?” Physician better prepared

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Pre-clinic Huddle

Plan relentlessly RN-MD 10 min day before Identify planning needs

Abnormal CT: review

Central Role of Nurses

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Welcome to Our Practice “Start here first”

Teamwork at the Office Visit

Check-in Vital Signs Med reconciliation Update PFSH

Operationalize Decisions Documentation

Order Entry Scripts Prior Authorization Referrals Pt education

Mini-huddle

Follow-up

Visit note Coding

Letters Calls Between visit care

MD-Patient Bonding/History/Exam/Plan

0.5 nurse: MD

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Time for Tasks



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

40 min

The Doctor Does it All

0.5 nurse: MD

Unload the Constraint



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

40 min

1.5 nurse: MD

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Mini-huddle

Follow-up


1 min

15 min 1 min

5 min 6 min 10 min

37 min

3 min

1.5 nurse: MD




Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

36 min

TIME SAVED 4 min/patient

X

18 patients/day

=

1 hour/day

Reclaim an hour per day

1.5 nurse: MD

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Unload the Constraint II



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

36 min

1.5 nurse: MD

Unload the Constraint II



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

31 min

1.5 nurse: MD

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Do Today’s Work Today



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

31 min

Pre-appt lab

1.5 nurse: MD

Do Today’s Work Today



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

21 min

Pre-appt lab

1.5 nurse: MD

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Value Case



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

Work Patients and MDs most value

1.5 nurse: MD

Value Case



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

Squeezed out when insufficient support

1.5 nurse: MD

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Value Case



Mini-huddle

Follow-up


3 min 1 min

15 min 1 min

5 min 6 min 10 min

More time when more staff support 1.5 nurse: MD

Access Case


Operationalize Decisions Documentation Follow-up

3 min 1 min

5 min 10 min

Improved Access and Capacity

6 min

Mini-huddle 1 min


1.5 nurse: MD

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Satisfaction Case: Staff



3 min 1 min

5 min 10 min

Deeper level of engagement

6 min

Mini-huddle 1 min


1.5 nurse: MD

Satisfaction Case: Physician



2 min 1 min

4 min 6 min

Continuity Less clerical work ↓ After hours work

6 min

Mini-huddle 1 min


1.5 nurse: MD

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Teamwork: Post Appointment work Empowered Receptionists

MD completes post-appointment order sheet

Teamwork: Empowered Receptionists

Pt to receptionist Appt scheduled Order entry Reminder call

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Sharing the Load: Creating efficiencies

Order sheet 3 sec/pt 100 pt/week x 3 sec/pt = 5 min MD time/wk

CPOE 2 min/pt 100 pt/wk x 2 min/pt = 3.3 hr MD time/wk

Teamwork: Empowered Patients Pre-appointment Questionnaire

Identifies patient’s agenda Patient part of the team

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Pre-appointment Questionnaire

Systems approach Update PFSH Complete ROS Behavior issues:

exercise, smoking, alcohol

Future Kiosk Web portal

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Teamwork Elsewhere

Mayo Clinic Satellite New Model of Nursing

Geisinger Embedded nurse case managers

Vermont

Behavioralists

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Mayo Clinic—Red Cedar Medical Center

New Model of Nursing Care

2 nurses per MD Chart Prep Pre-visit planning per protocol Patient Education Preventive Care

Smoking cessation, immunizations, mammo, colon screening

n http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2008/Sep/Continuous-Innovation-in-Health-Care--Implications-of-the-Geisinger-Experience.aspx

Geisinger: Embedded Nurse Case Managers

Intervention RN case mgr in office

+3 case mgr: 6 MDs Results

250% ROI 20% ↓ hospital adm 50% ↓ readmissions 7% ↓ total costs

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http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2008/Sep/Continuous-Innovation-in-Health-Care--Implications-of-the-Geisinger-Experience.aspx
























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Vermont Blueprint for Health: Community Care Teams

Behavioralist in practice (3 visits max)

Smoking Weight Sleep Substance Abuse

Community Connection “Easy button” Insurance Housing Self-management class

VA

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Discusssion: What do your teams look like? MA? Social worker? Pharmacist? Nurse? Patients?

Questions

or Comments?

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Achieving Medical Home and Meaningful Use Certification

A Daunting Task?

Maybe Not!

Patient Centered Medical Home

•40 pages •146 criteria

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Empowered Teamwork

NCQA PCMH 1: Access and Continuity A2 Provide clinical advice by phone A3 Provide clinical advice by e-mail E1 Coordinate across multiple settings E2 Instruct pts on care during/after hours (brochure) E3 Collect information care other settings E4 Provide care and self-management advice

Empowered Teamwork

NCQA PCMH 3: Plan and Manage Care C Gives pt/family written care plan

NCQA PCMH 4: Self-Care A1 Provides education A5 Provides self-management tools A6 Counsels healthy lifestyles

NCQA PCMH 5: Track and Coordinate B Coordinates referrals C Coordinates care transitions

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PCMH 1 Access Continuity

PCMH 2 Population Manage

PCMH 3 Care Manage

PCMH 4 Self-care

PCMH 5 Coordinate

PCMH6 Measure Improve

Teams A1-3,4 E1-4 G1-8

A1-12 B1-9 C1-9 D1-4

A1-3 B1,2 C1-7 D1-6

A1-6 B1-4

A1-5 B1-3,5 C1-6

A1-3 B1-4 C1-3 D1-4 F1-3

Empowered Teamwork

Empowered teamwork fulfills or facilitates

109 of 146 NCQA Medical Home Criteria

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Utilizing Clinical Strategies to Fulfill Meaningful Use Criteria

15 “core” criteria 10 “menu” criteria (choose five) Most are dependent on EHR software. Many can be facilitated using teamwork.

Utilizing Strategies to Fulfill Meaningful Use Criteria

Empowered Teamwork: Core 1 CPOE for meds Core 3 e-Transmit prescriptions Core 4 Record demographics Core 5 Maintain problem list Core 6 Maintain active medication list Core 7 Maintain active allergy list Core 8 Record vital signs and BMI Core 9 Record smoking status Menu 19 Send reminders for follow-up care Menu 22 Perform medication reconciliation

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Sustaining Teamwork and Culture Change with Effective

Team Meetings

Creating a Culture of Teamwork

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Go to a meeting…

And come home to

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What Does it Feel Like to be Asked to Change?

Aren’t I doing

a good job already? Does this mean I’ll have

to stay late?

I just want to get through my day and get home. I’m already doing as much as I possibly can. Don’t ask me to do any thing more. Internist, Boston

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How to Effect Change

Move from culture of “good enough”

to “best we can be.” The message cannot simply be “do more.”

Team Meetings

Re-engineering during the work day is like trying to repair the airplane while it is flying at 20,000 feet.

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In marriage… it’s the little things that will get you.

Team Meeting: Components

Meeting q 2 weeks Participants:

2 MDs 4 nurses Receptionist Nurse Manager

Agenda Posted and Pre- planned

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Team Meeting: Agenda

Check in 1:00-1:10

Check-back 1:10-1:20

Refinement of Workflow 1:20-1:45

Education 1:45-2:00

Check-in Relationship Building

“ My daughter’s volleyball team won again last

Night”

“My mom just got out of the hospital and she’s

doing OK.“.

“I have a big test coming up and I’m worried

about it.”

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Check in 1:00-1:10



Education 1:45-2:00 HINI, menopause, diabetes, mammography

Check Back: Positive Re-enforcement Changes working, or not?

Patient S.H. severe back pain, urinary retention

.Nurse found out dose of toradal last ER visit and gave it; Catheterized patient for 700 cc. Pt. improved, ER visit avoided.

Patient H.T. not sure of meds, nurse called his wife, called pharmacy for accurate list. Patient H.E. presented with weight loss complaints. Nurse printed up summary of all weights over past years before I saw the Pt

Patient R.D. spoke with primary nurse while we were gone. Received the reassurance she needed.

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Building Self-Management into Every Aspect of Clinic Care ?

Not every idea is a keeper

Check Back: Positive Re-enforcement Changes working, or not?

Nurses report: Healthy Living handouts not useful ACTION ITEM: Stop, except for new patients Calling in high risk patients for H1N1 vaccine. How is it going? Colonoscopy discussion/scheduling: A great day! Mr. B gets a colonoscopy! Any problems?

Reminder: nurses please circle the pt’s BMI on the graph when discussing , this allows me to know the discussion has been accomplished. STILL NOT BEING DONE CONSISTANTLY.

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Check in 1:00-1:10




Refinement of Workflow Continual Quality Improvement

Goal: Decrease waiting room and in room wait times for patients.

Process Mapping: Sticky notes to identify each step in the

process and sources of delay. Each team member – three sticky notes Physician, nurse, patient factors Uncovered multiple sources of delay

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Refinement of Workflow: Initiative: Improve Timeliness

Goal Decrease wait time

Value Stream Mapping

Map rooming process Identify delays at each step

Refinement of Workflow: Initiative: Improve Timeliness

Sticky notes Uncovered multiple sources of delay

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Refinement of Workflow Problems/Solutions

Nurses scheduling MRI in exam room. Receptionists to schedule MRI Opthalmascope not in room / battery not charged Plug in wall units Nurses need to leave patient to answer phone Nurses chose to wear phone headsets . Nurse/MD leaves room to print patient copy Printers in every room* Physicians not arriving on time Tardy Physician Project

Refinement of Workflow: Problems/Solutions

Nurse tied up on phone

Nurses chose to wear phone headsets

Nurse leaves room to print

Printers in every room*

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Refinement of Workflow: Problems/Solutions

The Tale of Two Tardy Doctors

“Can we make this into a game?” Donny Osmond Dancing with the Stars Champion Fall 2009

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Refinement of Workflow: Two Tardy Doctors


Check in 1:00-1:10




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Education

H1N1 virus. How is it different from usual influenza?

Goals for diabetic patients HgbA1c, Lipid, Blood

Pressure. Why are they important? Which is most important?

Diuretics- Why do we use different ones for

different situations?

Team Meetings

Protected time for communication, mentoring Attention to nitty-gritty details Everyone sets the agenda Staff as problem solvers Feedback from those doing the work Changes discussed/approved then implemented Continually refine the choreography of work day

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Tips on Teams:

How to Solve Problems in Your Practice With a New Meeting Approach.

Chase,Nutting,Crabtree

Family Practice Management March/April 2010

Tips on Teams:

Make contact with every person on the team every day in a positive way. Have a vision. Make a Blueprint.

Proceed until apprehended. Keep expecting more from your team. Everyone likes to grow.

Clarify expectations Don’t become a fire marshal.

The best organizations communicate 200 times more than mediocre organizations. Encourage ideas. When there is a good idea give credit.

Culture eats strategy for breakfast every morning. The most important thing for a team leader to learn is to “shut up”.

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At the center of PCMH are face-to-face healing relationships.

Patient: Nurse Nurse: Physician

Nurse: Nurse Physician: Patient

“It’s not a house…it’s a home.” The Ballad of Frankie Lee and Judas Priest

Bob Dylan

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Discussion

“It’s not a house…it’s a home.” The Ballad of Frankie Lee and Judas Priest

Bob Dylan

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building teams and changing culture in the medical home

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