Post on 24-Jun-2020
12/2/2015
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Joy in Practice:Innovations in Patient Centered Care
Association of Chiefs and Leaders of GIMChristine A Sinsky, MD, FACP
Feb 17, 20163:40-4:40
Agenda
• Introduction: Framing thoughts burnout
• Studies– AMA Rand: Physician Career Satisfaction
– ABIMF: In Search of Joy in Practice
• Discussion
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Two Doctors and a Patient
Program Director GeriatricsUConn
“Working in clinic has become so painful that I have decided to leave my beloved patients—unbearable to think about.”
Gail M Sullivan, MD
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General InternistMGH
Speaking of performance measures: The little things have become the big things—I fear our roles as healers, comforters, and listeners are being lost.”
2008
Ben Crocker, MD
On a recent visit to a new doctor I believe we made eye contact twice—upon her arriving and leaving.
And yet, I am much more able to receive advice
From people I feel are thinking of me
as a person
rather than just
the next patient. http://www.npr.org/blogs/health/2013/08/13/211698062/doctors-look-for-a-way-off-the-medical-hamster-wheel?live=1 and AndieDominick in Patient Listening: A Doctor’s Guide, Loreen Herwaldt
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Nearly ½ of MDs Burned Out
General Internal Medicine
Family Medicine
Arch Intern Med 2012; E1-9
http://www.medscape.com/features/slideshow/compensation/2013/public
Burnout affects Patients
Physician burnout is associated with…o ↑ Mistakeso ↓ Adherenceo Less empathyo ↓ Patient satisfaction
Sources: Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.;
Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.
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Burnout Costs Organizations
Physician burnout is associated with…o ↑ Malpractice risk o ↑ MD and staff turnovero $250,000 to replace PCP (1999)
Sources: Shanafelt Ann Surg. 2010;251(6):995-1000; Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.; http://www.ncbi.nlm.nih.gov/pubmed/10672116
Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.; http://psnet.ahrq.gov/resource.aspx?resourceID=1909
http://journals.lww.com/academicmedicine/Fulltext/2011/03000/Physicians__Empathy_and_Clinical_Outcomes_for.26.aspx
Burnout Costs Physicians
Physician burnout is associated with…o ↑ Disruptive behavioro ↑ Divorceo ↑ CADo ↑ Substance abuse/addictiono ↑ Suicide
Sources: Shanafelt Ann Surg. 2010;251(6):995-1000; Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.; http://www.ncbi.nlm.nih.gov/pubmed/10672116
Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.; http://psnet.ahrq.gov/resource.aspx?resourceID=1909
http://journals.lww.com/academicmedicine/Fulltext/2011/03000/Physicians__Empathy_and_Clinical_Outcomes_for.26.aspx
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Burnout May Cost US Healthcare
Physician burnout is associated with…o ↑ Referralso Fewer PCPs
Social Science and Medicine 1999; (48):547-557 Family Practice doi:10.1093/fampra/cmt060. Arch Intern Med. 2011;171(17):1582-1585http://content.healthaffairs.org/content/29/5/835.full
http://well.blogs.nytimes.com/2012/08/23/the-widespread-problem-of-doctor-burnout/
1 in 2 US physicians burned out implies origins are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals.
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Physician Career Satisfaction
• Quality: Major Driver of Satisfaction– Some control over work environment
– Dissatisfaction: Early warning sign of dysfn
http://www.rand.org/news/press/2013/10/09.html
Physician Career Satisfaction
• EHR: Major Driver of Dissatisfaction– Too much time per task, clerical
– ↓ Face-to-face time
– ↓ Quality of visit note
http://www.rand.org/news/press/2013/10/09.html
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In Search of Joy in PracticeCo-Investigators
• Christine Sinsky- PI
• Tom Bodenheimer-PI
• Rachel Willard
• Tom Sinsky
• Andrew Schutzbank
• David Margolius
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Places Where PC Physicians & Staff are Thriving?
• Where the work of primary care is do-able
• Enjoyable as a life’s vocation
Clinica Family Health Services
Group Health Olympia
Multnomah County Health
Dept
South Central Foundation
Univ of Utah-Redstone Newport News
Family Practice
Cleveland Clinic-Strongsville
Quincy, Office of the Future
West Los Angeles-VA
La Clinica de la Raza
Clinic Ole
Sebastopol Community
Health
Martin’s Point-Evergreen Woods
Harvard Vanguard Medford Brigham and
Women’s Hospital
North Shore Physicians Group
Medical Associates Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont Clinic
Mayo Red Cedar
Medical Center
Allina
Site visits to 23 high-performing practices(most PCMHs)
Mass. General Hospital
Joy in Practice
WorkflowTask distributionPhysical space Technology
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Challenges
Chaotic visits
Teams function poorly
Inadequate support
Time documentation
EHR →work to MD
• Pre-visit planning
• Pre-appt labs
• Systematic Prescriptions
Challenges Innovations
1. Chaotic visits with overfull agendas
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MA pre-visit call
Agenda, Med review Depression screen Advanced directive
Fairview: Care Model Redesign
Mayo-Red Cedar arranges for pre-visit lab
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Same day pre-visit lab (15 min) ThedaCare
Pre-visit Labs
• 89% ↓ phone calls (p<0.001)
• 85% ↓ letters (p<0.0001)
• 61% ↓ additional visits (p<0.001)
• ↑ patient satisfaction
• Save $24 per visit
Crocker B, Lewandrowski E, Lewandrowski N, Gregory K, Lewandrowski K. Patient Satisfaction With Point-of-Care Laboratory Testing: Report of a Quality Improvement Program in an Ambulatory Practice of an Academic Medical Center. Clin Chem Acta 2013; 424:8-12.; and personal communication/poster 3.4.14;
also http://ajcp.ascpjournals.org/content/142/5/640.abstract
http://ajcp.ascpjournals.org/content/142/5/640.full
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Annual Prescription Renewals
• “90 + 4”
• Physician time– 0.5 hr/d
• Nursing time– 1 hr/d per physician
• 40 million PC visits/yr200,000 PCPs x 220d/yr x1 visit/d
Challenges Innovations
1. Chaotic visits with overfull agendas
Insurers
• Single co-pay lab/visit
Institutions
• Hold future orders
Regulatory
• Prescription 15 mo
Action Steps
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Challenges Innovations
2. Inadequate support to meet the patient demand for care
Sharing the care among the team
• 2:1 or 3:1
• Rooming protocol
• Between visit– Health coaching
– Care coordination
– Panel mgm’t
Mayo Red Cedar : New Model of Nursing (2:1)
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Challenges Innovations
2. Inadequate support to meet the patient demand for care
Action Steps
Educators
• MA, nurse: MI, SMS
Institutions/Regulators
• Staffing
• Scope of practice ↑
Payers
• Fund non-MD services
Challenges Innovations
3. Vast amounts of time spent documenting care
• Scribing
• Assistant order entry
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I used to be a doctor. Now I am a typist.
Personal communication. Beth Kohnen, MD, internist Fairbanks, AK 8.3.11
The Doctor 1891 Fildes
Undivided attention
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The Doctor 2015
Continuous partial attention
Challenges Innovations
3. Vast amounts of time spent documenting care
• Team documentation
• Assistant order entry
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Team documentation at Cleveland Clinic
Kevin Hopkins M.D.
Team DocumentationCleveland Clinic
• Pre-visit (nurse)
– Med Rec
– Agenda, HPI
• Visit (nurse + MD)
– med,lab, x-ray orders
– followup
• Post-visit (nurse)
– Reviews visit summary
– Health coaching
• MD next patient
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Team DocumentationCleveland Clinic
• New Model– 2 MA: 1 MD
– 2 pt/d cover cost
– 21 → 28 visits/d
– 30% ↑ revenue
– Spread to others
– We’re having FUN
The MA’s are more fully engaged in patient care than they have ever been and they enjoy their work…They have increased knowledge about medical care in general and about their individual patients in particular.
Kevin Hopkins M.D.
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Team DocumentationUniversity of Utah: Redstone
• 2.5 MA: 1 MD
I get to look at my patients and talk with them again. We’re reconnecting…. Our patient satisfaction numbers are up, our quality metrics have improved, our nurses are contributing more, and I am going home an hour earlier to be with my family..
Amy Haupert MD, family physician, Allina-Cambridge 11.29.11 personal communication
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Team Documentation
• Six sites
• Similar results– Access 20-30% ↑
– Costs covered
– Satisfaction ↑
– Quality metrics ↑
– Physician• home hour earlier
• no work at home
David ReubenUCLA
• “Physician Partners”– Scripts/COE
– Charting/Charge
• JAMA IM 5.14– Pt satisfaction
w/MD time ↑
– Save 1.5 hr/4hr
• Training Academy
Innovation
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Challenges Innovations
3. Vast amounts of time spent documenting care
Action Steps
Regulatory
• Team log-in
• Meaningful Use Stage 2
Institutions
• Staffing ratios
• Assistant order entry
Technology
• Seamless transitions between users
Challenges Innovations
4. Computerized technology that pushes more work to the clinician
• Verbal messages
• Inbox management
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Fairview: Filtering Inbox
Reduce “backpack” 90min/d to few min
Fairview: Filtering Inbox
Reduce “backpack” 90min/d to few min
Line of Sight
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Verbal messaging at Fairview rather than series e-messages going round and round the office
Semi-circular desk, APF
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Iora Health, Dartmouth-Hitchcock
Challenges Innovations
4. Computerized technology that pushes more work to the clinician
Action Steps
Institutions
• ↓ message generation
• Nurses filter inbox
Regulators
• Modifications to accommodate teamwork
Technology
• Improved usability
• Team-based design
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Challenges Innovations
5. Teams that function poorly and complicate rather than simplify the work
• Co-location
• Huddles
• Team meetings
Flow station at North Shore Physicians Group
HP: Saves 30 min/day/physician
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Printer in every room University of Utah Redstone
HP: Saves 20 min/day/physician
Co-location at South Central Foundation, Alaska
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Team MeetingsDo Work + Make Work Better
Challenges Innovations
5. Teams that function poorly and complicate rather than simplify the work
Action Steps
Institutions
• Co-location
• Line of sight
• Space for huddles
• Time for meetings
• Improvement specialists
• Aligned reporting (MA/nursing to clinical lead)
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• Pre-visit planning• Expanded rooming• Team documentation• Prescription management• Pre-visit lab• Team meetings• Lean• Culture change• Telemedicine
Transformation Toolkits
• Panel mgm’t• Burnout• Huddles• EHR implementation• Inbox mgm’t
www.stepsforward.org
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QI Metrics
Making the business case
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Team Documentation
Checkback 2011
APF: pt centered, team-based and mindful of care team well being.
The biggest difference -- is team, culture and time. Time with patients to better understand who they are, their story
I wouldn't trade that for anything. I'm loving it.
Ben Crocker, MDInternistMGH
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Our Work Going ForwardHow can we contribute to transformation
“Working in clinic is unbearable”
“I’m loving it”Entrusted and empowered by tech, team, policy
What patients want is that deep relationship with a healer;
this is the foundation upon which we need to build healthcare.
Paul Grundy, MDIBM, PCPCCpersonal communication 1.30.09
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Sir William Osler, 1893
“Medical care must be provided with utmost efficiency. To do
less is a disservice to those we treat, and an injustice to those
we might have treated.”
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