Transcript Slide 1
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