Transcript Dr. Stenger - Montana Medical Association

MMA:
Launching High
Impact Health
Care Teams
Rob Stenger, MD, MPH
Faculty Physician
Family Medicine Residency of Western Montana
Why Teams?
Demographics
Changing Health Care Environment
Opportunity for Improvement
Limited Performance on Quality
Adult patients get about 55% of guideline-recommended
care
27% of patients with HTN adequately controlled
54% of diabetics have Hgb A1c > 7.0
14% of patients with CHD have LDL levels in targeted range
Half of smokers counseled about smoking cessation by their
physician
Continued growth in health care costs…
Source: Kaiser Family Foundation, State Health Facts. www.kff.org
f current payment systems, particularly the uncoordinated fee-for-service payment system for
nt payment systems, physicians or hospitals or both will lose revenues if they pursue the kinds of
in Section II; for example, doctors will lose money if they keep patients well, since their income
The “Old” incentive model in health care.
Healthy
Consumer
Continued
Health
Preventable
Condition
$
No
Hospitalization
Acute Care
Episode
High-Cost
Successful
Outcome
Fee-for-Service Pays More
For Bad Outcomes and Less
When People Stay Healthy
ce visit with a doctor.
Efficient
Successful
Outcome
Complications,
Infections,
Readmissions
Payment for Health Care ≠ Value
FIGURE 5
Miller H. How to Create Accountable Care Organizations. Center for Healthcare Quality and
Payment Reform. September 2009.
Emerging Alternate Payment Models - Medicare
Source: The Medicare Access & CHIP Reauthorization Act of 2015, Path to Value. www.cms.gov
What
solutions
are
needed
to
deliver
“value”?
OPPORTUNITIES FOR HEALTHCARE COST REDUCTION
Improved
Inpatient Care
Efficiency Use of
Lower-Cost
Treatments Reduction in
Adverse
Events Reduction in
Preventable Improved
Use of
Readmissions Management Lower-Cost Lower
of Complex Settings &
Total
Patients
Providers
Health
All Providers
Care
Reduction in
Cost
Preventable
Reduction in ER Visits &
Improved Unnecessary Admissions
Testing &
Practice
Improved Efficiency Referrals
Prevention
& Early
FIGURE 1
Diagnosis
Miller H. How to Create Accountable Care Organizations. Center for Healthcare Quality and
Payment Reform. September 2009.
Can our current model deliver???
25
Physician Time
(in hours)
20
15
Prevention
Chronic Disease
10
Acute Care
5
0
Current State
Ideal State
Source: Yarnall, Osteby, et al. Family Physicians as Team Leaders: “Time” to Share the Care.
Preventing Chronic Disease; 6(2): 2009.
Potential Outcomes of Care Teams
 Increased provider and staff satisfaction, less
burnout
 Improved quality and outcomes
 Improved patient experience
 Reduction in medical errors
 Greater standardization of care
 Improved efficiency and value
 Reduced cost
 Etc…
Evidence on Care Teams for
“Complex Patients”
• Most interventions focused on “case management and coordination
of care or the enhancement of skill mix in multidisciplinary teams.”
• Studies used a variety of team members (NP, RN, PT, OT,
Pharmacist, Social Worker, Health Coach, Peer support)
• Mixed results. Some studies found significant improvement across
a variety of domains (physical and mental health outcomes,
psychosocial wellbeing, medication adherence and resource
utilization).
• “Overall the results indicate that it is difficult to improve outcomes
in this population, but that focusing on particular risk factors or
functional difficulties in patients with co-morbid conditions or
multimorbidity may be more effective.”
Source: Smith, Soubhi, et al. Interventions for improving outcomes in patients with
multimorbidity in primary care and community settings. The Cochrane Library.
What is the physician
role on the health care
team?
Basic Team Tools
Team Formation
How do we work together?
Who does what?
Teamwork Basics
Communication and structure
Measurement
Common goals and shared
accountability
Improvement
Creating capacity for adaptive
change
Trying harder will not work.
Changing systems will.
- Crossing the Quality Chasm, Institute of Medicine, 2004
Groups vs Teams
“A team is a group with a specific task or tasks, the
accomplishment of which requires the interdependent and
collaborative efforts of its members.”
“It is naive to bring together a highly diverse group of people
and expect that, by calling them a team, they will in fact behave
as a team. It is ironic indeed to realize that a football team
spends 40 hours a week practicing teamwork for the two hours
on Sunday afternoon when their teamwork really counts. Teams
in organizations seldom spend two hours per year practicing
when their ability to function as a team counts 40 hours per
week.”
Wise H, Beckhard R, Rubin I, Kyte AL. Making Health Teams Work. 1974
How do we work together?
Creating an engaged team.
Ground Rules
team agreements, physician compacts,
etc.
Relational Dynamics understanding the interpersonal
strengths and weaknesses of team members
and how they fit together.
Myers Briggs
Strengths Finder
Six Thinking Hats
Who does what? Skill-task alignment.
Physician
care plan development, office visits, urgent care, telephone
and e-mail care
NP/PA
urgent care, patient education, routine visits
RN
complex case management, patient education,
care coordination, registry management
LPN/MA
pre-appointment planning, schedule scrubbing, protocoldriven prevention and chronic disease management
Pharmacist
medication therapy management, protocol-driven
management of chronic diseases, medication reconciliation
Behavioral Health
brief intervention and counseling, behavioral change support,
crisis management
Social Work
housing, social programs, eligibility
JCAHO: Importance of Communication
Ineffective communication is a
root cause for nearly 66 percent
of all sentinel events reported*
* (JCAHO Root Causes and Percentages for Sentinel Events (All
Categories) January 1995−December 2005)
Is it surprising that communication in
health care is often a problem?
In an average office practice:
> 3000 patient visits per year
> 250 primary diagnoses
> 900 comorbidities
? Medications
? Procedures
? Referrals
? Medical Decisions
Examples of basic communication skills
Closed loop communication
SBAR (Situation, Background, Assessment,
Recommendation)
Critical language
Assertiveness training
Others
Systems solutions to facilitate team
communication
Patient charts
Huddles
Worksheets and other workflow organizers
Co-location
Surgical Pause/Checklist
ACLS - summary
Multidisciplinary rounds in the ICU or Hospital
Critical event debriefings
What is a Huddle?
Brief
Prior to starting work
Involves the entire care team
Consistent agenda:
•
Follow up of previous
day’s work
•
Identification of
potential problems
•
Preparation for work to
be done
Checklists
Checklists Are
Prompts to conduct
key tasks
Selective
Effective for simple
and complex
problems
Checklists Aren’t
✘Cookbook medicine
✘All-inclusive
✘Only for “routine”
situations
Example – Safe Surgery Checklist
Co-location
• Bringing the “front” and “back” office together
• Clerical and clinical staff in the same physical
space





Real-time clinical input into patient phone calls
Better skill-task alignment and sharing of work
One touch flow
Reduced phone volumes
Improved response times
Source: Fisher, ES and
Shortell SM. JAMA.
2010;304(15):p1715.c
The limitations of current approaches to
performance measurement are well
recognized. Measures too often assess
individual clinicians and silos of care, focus
largely on processes of questionable
importance, are imposed as an add-on to
current work, and require burdensome chart
reviews and auditing or reliance on out-of-date
administrative claims data. Poor performance
is seen as a consequence of individual failure,
rather than flawed systems. The result is a
performance measurement system that often
provides little useful information to patients or
clinicians, reinforces the fragmentation that
pervades the US health care system, and
reinforces physicians’ perception that
measurement is a threat.
Where the women are strong,
the men are good looking,
and all the doctors are above average.
- Garrison Keillor (adapted)
What gets measured gets done.
What gets measured and fed back gets done well.
What gets rewarded gets repeated.
- John Jones
Group Participation
What do you currently measure?
RVUs/Productivity?
Financial Performance?
Service volumes (patient visits, daily census, # of cases)
Patient satisfaction/experience?
Quality?
Cost of care?
How are measures shared?
Only with providers?
All team members?
Posted publically?
Patients?
How successful teams use measurement:
 Clear articulation and agreement on common goals
(shared goals if possible)
 Consistency, predictability and accuracy of
measurement
 Transparency (across providers and health care teams)
 Meetings and dedicated time to discuss measures and
improve
 Shared accountability for performance
Improvement – creating capacity for
adaptive (and technical) change
Process Improvement Methodologies
 PDSA/PDCA
 LEAN/A3
 6 Sigma
 Value Streams
What are the most effective strategies
for training your team?
“Moderate-to-high-quality evidence suggests team-training can
positively impact healthcare team processes and patient outcomes…
Evidence suggests bundled team-training interventions and
implementation strategies that embed effective teamwork as a
foundation for other improvement efforts may offer greatest impact
on patient outcomes.”
Team training “bundle:”
 Readiness, preparation
 Muti-disciplinary training
 Tools to support active transfer and sustained use of effective
teamwork practices into daily care
 Post-training support and re-training
Weaver SJ, et al. Team Training in Healthcare: A Narrative Synthesis of the Literature. BMJ
Qual Saf 2014;23:359–372.
Recommended Reading
AHRQ – Team STEPPS Curriculum - teamstepps.ahrq.gov
VA Clinical Team Training (CTT) - www.patientsafety.va.gov
Institute for Healthcare Improvement, Open School - www.ihi.org/
Huddles: Improve Office Efficiency in Mere Minutes (Family Practice
Management 6/07) www.aafp.org/fpm/20070600/27hudd.html
UW – Institute for Translational Sciences Blog https://www.iths.org/i2p-blog/
The Checklist Manifesto. Atul Gawande
HRSA Quality Improvement Resources http://www.hrsa.gov/quality/toolsresources.html
Grumbach K, and Bodenheimer T. "Can health care teams improve
primary care practice?." JAMA 291.10 (2004):1246-51.