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Systems Based Practice American Society of Hematology Atlanta, GA December 7, 2012 http://www.screencast.com/t/CuChNEvh04 Objectives • Teach Systems Based Practice by having learners work in the specialty’s various microsystems • Teach the anatomy and physiology of clinical microsystems for quality, safety, and joy in work • Use coordination of care across microsystems to teach the importance of competence SBP • Structure teaching and evaluation to assure learners can do the EPAs for an SBP Milestone ACGME Systems-Based Practice Demonstrate awareness & responsiveness to system of health care. 1. Work in various health care settings 2. Coordinate patient care 3. Use cost/benefit analysis in patient and population-based care 4. Advocate for quality patient care 5. Work in interprofessional teams to improve safety and quality 6. Identify system errors & implement systems solutions Internal Medicine adds: 7. Transmit clinical information in transitions of care Pediatrics adds: 8. Show how systems control cost, assure quality, & allocate resources 9. Advocate for population health promotion & disease prevention Health Care Systems Patient Self-Care PatientPhysician Clinical Microsystem MacroOrganization Policy, Finances, Market, Community ACGME Competencies and Systems Medical Knowledge Patient Self-Care Communication & Interpersonal Skills PatientPhysician Professionalism Clinical Microsystem Patient Care MacroOrganization System Based Practice Policy, Finances, Market, Community Practice-Based Learning & Improvement Milestones for SBP System Based Practice Patient Self-Care PatientPhysician Clinical Microsystem MacroOrganization Policy, Finances, Market, Community 6 MO- Describe the specialty’s microsystems 12 MO- Perform physician role in microsystem’s team 30 MO- Assures quality & safety of care provided by microsystems Entrustable Professional Activities System Based Practice Patient Self-Care PatientPhysician Clinical Microsystem MacroOrganization Policy, Finances, Market, Community 6 MO- Describe the specialty’s Microsystems Perform orientation to microsystem Explain “metrics-thatmatter” for microsystem Diagram the work flow processes for microsystem Entrustable Professional Activities System Based Practice Patient Self-Care PatientPhysician Clinical Microsystem MacroOrganization Policy, Finances, Market, Community 12 MO- Performs physician jobs in microsystems Performs consults, comanagement, procedures, & team-based care for specialty patients Adjusts team’s work flow to finish schedule of patient care on time Systems-Based Practice • Competence To… – Perform physician role in the healthcare team – Perform microsystem processes , including improvement • Learned By… – Working in multiple real microsystems – Faculty observing and giving feedback on SBP to deliver and improve healthcare Paradigm Shift in Medical Work One Professional to One Patient From Doctor to Practice System Social Work Specialist Consultant One Doctor One Patient Drug Store Lab or X-ray Hospital From Doctor to Practice System Social Work Specialist Consultant PSR MA One Doctor Nurse One Patient Drug Store Business Office Medical Information & Records Lab or X-ray Hospital Health Insurance From Doctor to Practice System Social Work Specialist Consultant PSR MA One Doctor Nurse One Patient We have failed to design roles & accountabilities that assure safe, high value care and joy in work Drug Store Business Office Medical Information & Records Lab or X-ray Hospital Health Insurance This is Systems-Based Practice What makes Human Systems Work? Frequent Communication Timely Communication Accurate Communication Blameless Problem Solving Shared Goals Shared Knowledge Mutual Respect Jody Hoffer-Gittell – Relational Coordination Brandeis University Promises Glue Systems Together • Make promises to one another – Truth about the performance of the system – Know our role in the interdependent processes that produce the work • Seek forgiveness when our promises are not kept and patients are misled or harmed by – Inaccurate understanding of how the system performs, – Failing to do our part in the interdependent work Baltadin & Leach, 2009 JGME Clinical Microsystem Purpose www.clinicalmicrosystem.org Clinical Microsystem Purpose The promises that hold the microsystem together Quality Quality Sustainable Care Education Business Joy in Work www.clinicalmicrosystem.org Clinical Microsystem Purpose Needs Patients www.clinicalmicrosystem.org Clinical Microsystem Purpose Needs Met Patients www.clinicalmicrosystem.org Clinical Microsystem Purpose Patients Patients Professionals MD PA RN PSR Social Technician Pharm DO NP LPN MA Work Call/Web D www.clinicalmicrosystem.org Clinical Microsystem Purpose Processes Patients Patients Professionals www.clinicalmicrosystem.org Clinical Microsystem Purpose Processes Patients Patients Professionals Registration & Orientation to Practice Rooming, Screening & Reconciliation Diagnosis & Treatment Plan www.clinicalmicrosystem.org Clinical Microsystem Purpose Prevention Care Processes Acute New Illness Care Patients Patients Professionals Chronic Care Management High Risk Coordination Registration & Orientation to Practice Rooming, Screening & Reconciliation Diagnosis & Treatment Plan www.clinicalmicrosystem.org Clinical Microsystem Purpose Processes Patients Patients Professionals Measures That Matter Patterns www.clinicalmicrosystem.org The Medical Home • • • • • • • Superb 24/7 Access to Care Patient Engagement in Care Clinical Information Systems Care Coordination Team Care Patient Feedback and Input to Care Publically Available Quality Information PCPCC March 2011 www.pcpcc.org Medical Neighborhood Purpose-Urology Purpose-Cardiology Purpose-Gynecology Processes Processes Processes Patients Patients Patients Patients Professionals Patients Patients Professionals Professionals Patterns Patterns Patterns www.clinicalmicrosystem.org www.clinicalmicrosystem.org www.clinicalmicrosystem.org Purpose- Clinical Laboratory Processes Patients Patients Purpose-Oncology Professionals Purpose-Surgery Purpose-GI Processes Patterns Processes Processes www.clinicalmicrosystem.org Patients Patients Patients Patients Patients Professionals Patients Professionals Professionals Patterns Purpose-Primary Care Patterns Patterns www.clinicalmicrosystem.org www.clinicalmicrosystem.org www.clinicalmicrosystem.org Processes Patients Patients Professionals Purpose-Orthopedics Patterns Processes Patients Purpose-Pulmonary Purpose-Hematology www.clinicalmicrosystem.org Patients Professionals Processes Processes Patients Patients Patients Patients Professionals Professionals Purpose-Pharmacy Processes Patients Patterns Patients www.clinicalmicrosystem.org Professionals Patterns Patterns www.clinicalmicrosystem.org www.clinicalmicrosystem.org Patterns www.clinicalmicrosystem.org Purpose-Emergency Medicine Purpose-Hospital Care Processes Processes Patients Patients Patients Purpose-Psychiatry Professionals Processes Patients Patients Professionals Patients Professionals Patterns www.clinicalmicrosystem.org Patterns www.clinicalmicrosystem.org Patterns www.clinicalmicrosystem.org Medical Neighborhood Purpose-Urology Purpose-Cardiology Purpose-Gynecology Processes Processes Processes Patients Patients Patients Patients Professionals Patients Patients Professionals Professionals Each provider acts as if he or she has a 1:1 relationship with each patient Patterns Patterns Patterns www.clinicalmicrosystem.org www.clinicalmicrosystem.org www.clinicalmicrosystem.org Purpose- Clinical Laboratory Processes Patients Patients Purpose-Oncology Professionals Purpose-Surgery Purpose-GI Patterns Processes Processes Processes www.clinicalmicrosystem.org Patients Patients Patients Patients Patients Professionals Patients Professionals Professionals Patterns Purpose-Primary Care Patterns Patients must sort out conflicting priorities and the meaning of all the tests and recommendations Patterns www.clinicalmicrosystem.org www.clinicalmicrosystem.org www.clinicalmicrosystem.org Processes Patients Patients Professionals Purpose-Orthopedics Patterns www.clinicalmicrosystem.org Processes Patients Purpose-Pulmonary Purpose-Hematology Patients Professionals Processes Processes Patients Patients Patients Patients Professionals Professionals Purpose-Pharmacy Processes Patients Patterns Patients www.clinicalmicrosystem.org Professionals Patterns Patterns Physicians cling to autonomy & professional identity – Payment is for 1:1 fee-for service, not for coordination of care www.clinicalmicrosystem.org www.clinicalmicrosystem.org Patterns www.clinicalmicrosystem.org Purpose-Emergency Medicine Patients Purpose-Hospital Care Purpose-Psychiatry Processes Processes Patients Patients Professionals Processes Patients Patients Professionals Patients Professionals Patterns www.clinicalmicrosystem.org Patterns www.clinicalmicrosystem.org Patterns www.clinicalmicrosystem.org Accountable Care Organization Community of Individuals & Families Adapted from Premier Healthcare Alliance PCPCC 3/11 Accountable Care Organization Health Information Exchange PCMH PCHM PCMH Community of Individuals & Families Health Access Network Adapted from Premier Healthcare Alliance PCPCC 3/11 Accountable Care Organization Participation Agreements Social Agencies Health Information Exchange Mental Health DME Specialist Pharmacy $ Public Health PCMH Hospice Long term care PCMH Home Health PCHM Labs & Path Community of Individuals & Families Imaging EMS Health Access Network Emergency Care Rehab Q Hospital Adapted from Premier Healthcare Alliance PCPCC 3/11 Pediatrics Purpose-Primary Care Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org Primary Care Purpose-Hematology Specialty Care Processes Patients Patients Professionals Consultation Referral Co-Management Transfer of Care Patterns www.clinicalmicrosystem.org Purpose-Hemophelia Center Tertiary Care Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org Our Promises Pediatrics Purpose-Primary Care Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org Purpose-Hematology PCMH-N Agreement Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org PCMH-N Agreement Purpose-Hemophelia Center Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org Coordination of Care Agreement PCMH Name: Phone Specialty Name: E-mail Phone Address: E-mail Address: Specialty Services Requested by PCMH Pre-consultation (online) X Ongoing principal care of a disease/condition Formal Consultation/Procedure Principal care of patient for time of treatment Ongoing follow-up & advice Transfer all patient care to Specialty PCMH Responsibility? PCMH PCMH-N We Mutually Agree To… X Prevention services X Send transition record X First Contact for patient X Send notes of all visits X Prescription refills X Disease Avoid secondary referrals X Manage new problems X Disease Avoid patient self-referrals X Unrelated conditions X Notify of admissions X May act in emergency X Review agreement yearly X X Adapted from American College of Physicians Policy PCMH-N 2010 Coordination of Care Agreement PCMH Name: Phone Specialty Name: E-mail Phone Address: E-mail Address: Specialty Services Requested by PCMH Pre-consultation (online) X Ongoing principal care of a disease/condition Formal Consultation/Procedure Principal care of patient for time of treatment Ongoing follow-up & advice Transfer all patient care to Specialty PCMH Responsibility? PCMH PCMH-N We Mutually Agree To… X Prevention services X Send transition record X First Contact for patient X Send notes of all visits X Prescription refills X Disease Avoid secondary referrals X Manage new problems X Disease Avoid patient self-referrals X Unrelated conditions X Notify of admissions X May act in emergency X Review agreement yearly X X Adapted from American College of Physicians Policy PCMH-N 2010 Pediatrics Purpose-Primary Care Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org Adult Care Purpose-Primary Care Processes Transition of Care Record Patients Patients Professionals Patterns www.clinicalmicrosystem.org Purpose-Hematology Purpose-Hematology Processes Patients Patients Professionals Transition of Care Record Patterns Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org www.clinicalmicrosystem.org Purpose-Hemophelia Center Processes Patients Patients Professionals Patterns www.clinicalmicrosystem.org PCMH-N Agreement Transition of Care Record Patient: Sender Phone # E-mail DOB: Address: Phone: Insurance Patient Goals Self-Care Capacity Problems Medications Prognosis Goals of Care Receiver Phone # E-mail Emergency Contact Phone # E-mail Diagnostic Tests or Treatment to be Done Next Care Giver Name Phone # Capacity Recent Tests Directives Power of Attorney: Phone # Consultants/Co-Manager/Equipment Results Pending? Appointment Transition of Care Record Patient: Sender Phone # E-mail DOB: Address: Phone: Insurance Patient Goals Self-Care Capacity Problems Medications Prognosis Goals of Care Receiver Phone # E-mail Emergency Contact Phone # E-mail Diagnostic Tests or Treatment to be Done Next Care Giver Name Phone # Capacity Recent Tests Directives Power of Attorney: Phone # Consultants/Co-Manager/Equipment Results Pending? Appointment Take Home Message • SBP transforms profession-based practice – The microsystem is the source of all care – Each microsystem is defined by its purpose, patients, professionals, processes, and patterns • We teach SBP to residents and fellows by: – Orienting to microsystem’s 5 Ps on each rotation – Assigning residents to perform the physician role and work on improvement in each microsystem – Observing and giving corrective feedback about learner performance as a team member and the quality of their work in the processes of care