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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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70

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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