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

June 29, 2010

Shadowing Colleagues

Filed under: Uncategorized — Matt Handley @ 9:06 am

Today I am spending the day shadowing a colleague, Dr Kate Brostoff.   Kate is the “Medical Director of Everything Else”, leading our clinicians who are not in Primary Care or Specialty Care – so her team includes Hospitalists, ED/UC, Lab, pharmacy, home health, nursing homes and a few other areas.  While I have shadowed clinicians for many years, I have only recently begun to invest the time to shadow colleagues with administrative roles.

Shadowing in clinic is always fascinating.  For most of us, we are isolated with our patients from the time we finish residency or fellowship – we close the exam room door and do our best to care for and work with our patients.  We each develop our way of working with patients and evolve that over time.  Shadowing allows us back in to watch the interaction and learn from each other – I don’t think that there is a time shadowing clinically where I did not pick up something that made me a better clinician.   The effectiveness of shadowing seems directly related to how small a space I can occupy in the room.  Dr Andy Lum transformed shadowing for me when he showed me his method.  His way of doing it was very different – instead of working to acknowledge the patient and provide cues that demonstrate listening, he just vanished.  After I introduced him he moved to a part of the room least visible to the patient, and seemed to vanish.  It was the first time that a patient and I had a completely normal interaction, unaffected by the idea that we were being observed.  I have used his technique ever since, to much better effect.

Some reflections on the value of shadowing.  For me, it is a great opportunity to gain a better understanding of two things – both the experience of their day (although for my colleagues in leadership roles every day is quite different), and more importantly a glimpse of how they are in the world.  The view I see from shadowing is often quite different than the view I see in meetings where we are both active participants, and for clinicians very different than the view of them I get in our team meetings of one on one conversations.  Shadowing provides the opportunity for me to stay quiet and focus on them, how they navigate the agenda or visit, draw out their colleagues/patients and help move ahead.   It gives me a better understanding of how they think and helps me understand how I can better support them.

I encourage everyone to take the time to shadow someone for at least a bit.  We are each other’s greatest asset – lets take advantage of that.

June 2, 2010

The Birnbaum Lecture – Brent James MD on Organized Care

Filed under: Uncategorized — Matt Handley @ 8:04 am

Once a year the Birnbaum lecture brings together our clinical, research and leadership communities to meet and learn together.  The speaker is chosen to challenge us to stay true to the Group Health mission – to transform healthcare.   Today we are having breakfast in the Westin hotel in Seattle, and the person challenging us is Brent James MD from Intermountain Health.  Dr James’ was featured in an excellent New York Times Magazine article during the recent health care reform debate.

Intermountain is quite an operation – they supply about 60% of the health care in the geographic area where they serve.  And they use data like nobody else, in the quest to improve the safety and value of the care that they deliver to their patients.

The basics of the presentation:

The opportunity – We are all finally aligned around the facts – both that we have better healthcare outcomes (life expectancy) than every before, and that there is considerable waste and harm in our system (such as it is).  There is massive variation, high rates of inappropriate care, lots of harm ( rates of preventable care-associated patient injury and death , inability to reliably do what we know works, and huge amounts of waste (up to 50% of spend does not provide value to patients)

So why does this still happen? The collision between the craft of medicine (the art of medicine, know to all of us as “in my experience….), clinical uncertainty (limitations of evidence base, exponentially expanding new medical knowledge, continued reliance in subjective judgment, and limitation s of the expert mind when making complex decisions).  This leads to “enthusiasm for unproven methods” (Mark Chassin MD),  The maxim “If it might work, try it” (David Eddy MD), and Quality means “spare no expense” (Bent James MD)    Practicing medicine is tough.

So how do we get the available evidence into practice.  To improve processes that drive outcomes, they use a model of “shared baselines”.  they select a high priority care process, generate an evidence based guidelines, blend the guideline into the flow of work, use that as a shared baseline and then allow for variation based on individual patient circumstances and patient preference, and then measure what happens.  They key is having a standard process that everyone shares, and limiting variation from that process.

They have a great panel support tool (identifying populations and care gaps) and reporting of outcomes that includes peer comparison and performance over time.

Organized care – the real hope for reform – requires:

  • Tools to change culture (training that teaches methods, identifies and supports early adopters, improves front line work)
  • Tools for quality control (Design, manage and improve using integrated clinical and operations management structure – requires infrastructure – and allows for data to support improvement)
  • Knowledge management
  • Administrative follow through on clinical savings

It all rests on the idea of profession based practice – where we use evidence instead of anecdotes, work in teams, and put the caring professions back in control of care delivery.  It is the foundation for useful sharing of electronic data and the ability to use data to provide safer care of greater value to patients.

Dr James’ slides are available here

The challenge is before all of us.  Lets make sure that every day we work to get closer to that ideal

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