It’s Not About The Box Improving Care at Group Health with People, Process and Technology

December 11, 2009

Practice Management Musings

Filed under: Optimization — David Kauff @ 10:45 am

I have been impressed with the general success of the Practice Management go-live. While not silky smooth and with major issues still remaining, the pure enormity of the undertaking and its is worth a moment of reflection.

What actually do the words Practice Management mean? – It completely depends on who you ask. It is a confusing name. In fact, it is unclear if at its core it is a noun or a verb. It embodies new Epic functionality, major new applications for patient care, billing, scheduling, reporting, lab and pharmacy work. Practice Management is both a Noun and a Verb, it is both a thing and an action. And that is why it is hard to understand. In our clinical work, it has made transparent our schedules, it allows for more flexibility for providers in the exam room. The scheduling is cleaner. I also know that the inpatient and specialty world has had a much more rocky go of it – and attention and resources are being refocused to improve there workflows

CIS Consultants have needed learn and teach a whole new world of applications. Often taken for granted, their role and expertise in this work over the last year cannot be overstated. They are an anchor at the clinical level and we appreciate there new expanded roles.

The Informatics Docs also were tasked with new work. As of today, the doc group provided chair side Epic training for 60 new providers in 15 different clinics in our system. This represented hundred of hours of training and retraining, driving for efficiency and quality.In this time of transition, the medical group added many new outstanding providers. Working in the medical centers is vital and we hope to carry this forward in 2010. We need to continue to optimize our knowledge and comfort in our Information systems, both for Specialty and Primary care.

Time to move the conversation forward and this is happening at many levels in the organization – how can CIS best serve? What are the ‘burning platforms’ to use a hackneyed phase? I have been thinking about this now that PM is mostly up. What are the next nouns and verbs?

December 9, 2009

Transparency, Quality and Safety

Filed under: Uncategorized — Matt Handley @ 7:21 am

I am in an engaging session with Paul Levy, CEO of Beth Israel Deaconess Medical Center, and author of Running a Hospital, a great blog that he uses to amplify efforts to improve performance.  He is a real advocate for using social media to improve transparency and drive performance.  He believes that there is a healthy tension that is created when the world can see performance data.

Their goals as a hospital are to eliminate preventable harm in the hospital, and to be in the top 2% in the country in patient satisfaction.  Some difficult discussions at the Board about transparency – can we use % instead of the number of cases?  Can we use a term other than “Harm”?  Some great clinical leadership and unanimous endorsement, including a commitment to show the numbers publicly.  You can see them on the website.  The clinical leadership at the hospital believes that their improvements in safety have been accelerated significantly by the blog.

Paul’s blog is one that I follow regularly – others include Ted’s blog, Molly Magar’s Healthbeat, The Healthcare Blog, Center for Healthcare Value, and Life as a Healthcare CIO.  Would love to get your ideas for blogs that provide value to you.

December 8, 2009

Healthcare’s Tragedy of the Commons – “Ruin is the destination toward which all men rush”

Filed under: Content of care,Quality / Affordability — Matt Handley @ 7:01 am

Don Berwick’s keynote for the IHI national forum this year invited us all to look at the challenges to US healthcare through the lens of the tragedy of the commons.   Scholar that Don is, he went to the source:  “The Tragedy of the Commons,” Garrett Hardin, Science, 162(1968):1243-1248 In that provocative paper Hardin lays out the tensions that inevitably arise when individuals with their own interests utilize a shared resource.  The key element of the paper:

“a scenario first sketched in a little-known Pamphlet in 1833 by a mathematical amateur named William Forster Lloyd (1794-1852). [6] We may well call it “the tragedy of the commons,” using the word “tragedy” as the philosopher Whitehead used it [7]: “The essence of dramatic tragedy is not unhappiness. It resides in the solemnity of the remorseless working of things.” He then goes on to say, “This inevitableness of destiny can only be illustrated in terms of human life by incidents which in fact involve unhappiness. For it is only by them that the futility of escape can be made evident in the drama.”

The tragedy of the commons develops in this way. Picture a pasture open to all. It is to be expected that each herdsman will try to keep as many cattle as possible on the commons. Such an arrangement may work reasonably satisfactorily for centuries because tribal wars, poaching, and disease keep the numbers of both man and beast well below the carrying capacity of the land. Finally, however, comes the day of reckoning, that is, the day when the long-desired goal of social stability becomes a reality. At this point, the inherent logic of the commons remorselessly generates tragedy.

As a rational being, each herdsman seeks to maximize his gain. Explicitly or implicitly, more or less consciously, he asks, “What is the utility to me of adding one more animal to my herd?” This utility has one negative and one positive component.

1. The positive component is a function of the increment of one animal. Since the herdsman receives all the proceeds from the sale of the additional animal, the positive utility is nearly + 1.

2. The negative component is a function of the additional overgrazing created by one more animal. Since, however, the effects of overgrazing are shared by all the herdsmen, the negative utility for any particular decision­making herdsman is only a fraction of – 1.

Adding together the component partial utilities, the rational herdsman concludes that the only sensible course for him to pursue is to add another animal to his herd. And another…. But this is the conclusion reached by each and every rational herdsman sharing a commons. Therein is the tragedy. Each man is locked into a system that compels him to increase his herd without limit — in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.”

The challenge presented today is to have each community approach their issues with explicit recognition of this challenge.  The value of healthcare must be improved – spending must be constrained, and working through communities (rather than free markets) may be the best approach to get there.  That will require healthcare stakeholders (ideally with patients – the ultimate stakeholder) working together in difference ways.  Don used two great examples – health care in Cedar Rapids (where there is an effort to have one cancer treatment center shared by the two major hospitals, and my favorite – the fishermen of Alyana, Turkey.  their story:

The inshore fishery of Alanya in Turkey is a relatively small operation. Fikret Berkes (1985c), a human ecologist at Brock University in Ontario, Canada, has provided an excellent description of the fishery and its institutional arrangements. Many of the 100 local fishermen operate in 2- or 3‑man boats using various types of nets. Half the fishermen belong to a local producers cooperative and half do not. The economic viability of the fishery in Alanya was threatened in the early 1970s by two factors. First, unrestrained use of the fishery created conflict among the users. Secondly, competition among fishermen for the better fishing spots greatly increased production costs and uncertainty regarding the harvest potential for any particular team of fishermen.

Fifteen years ago, members of the local cooperative began to discuss and implement a rather ingenious system for allotting fishing sites to the local fishermen. Fikret Berkes has described the system in the following words:

a.         Each September, a list of eligible fishermen is prepared, consisting of all licensed fishermen  Alanya, regardless of co‑op membership.

b.         Within the area normally used by Alanya fishermen, all usable fishing locations are named and listed. These spots are spaced so that the net set in one does not block the fish that should be available at the adjacent spot.

c.         These named fishing locations are in effect from September to May…

d.         In September, the eligible fishermen draw lots and are assigned to named fishing locations.

e.         From September to January, each day, each fisherman moves to the new location to the east. After January, the fishermen move west. This gives each fisherman an equal opportunity at the stocks which migrate east to west between September and January, and reverse their migration from January to May through the area (Berkes, 1985c: 14‑15).

Each year the list of fishing sites is endorsed by each fisherman and deposited with the mayor and local gendarme. The few infractions which incur are “‘dealt with by the fishing community at large, in the coffee house. Violators may come under social pressure and, on occasion, threats of violence” (Berkes, 1985c: 15). If needed, the local gendarme is prepared to help in the enforcement of the agreement. Enforcement has, however, not been a major problem because the system is supported by most of the fishermen themselves. The system helps to allocate the best fishing sites to all fishermen on an equitable basis and has severely reduced conflict as well as production costs.

I am fascinated by the model of addressing the challenges through broader community efforts.  I know how hard change is within an aligned organization – it is going to be harder to do it more broadly.  It will require models of clinical integration and using the existing community institutions (for us, the Puget Sound Health Alliance).  Here are Don Berwick’s recommendation

1. Understand your health care Commons. Understand its limits and boundaries. Understand who can and does draw upon the common pool of resource, and who it serves.
2. Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters….

3. Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself. One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.

4. Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them.

5. And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.

6. Identify and address conflicts early, often, and with confidence. Conflicts will be frequent and legitimate, and they will demand wisdom. The social capital – the commitment to protect the Commons – has got to trump these conflicts.

7. Expect and offer civility. This is the foundational transactional rule for effective, collaborative management of what we hold in trust…. Respect is a precondition.

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