Making Room for Process in Relationship-centered Care Kathy McGrail MD, Rochester Regional Health...
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Transcript of Making Room for Process in Relationship-centered Care Kathy McGrail MD, Rochester Regional Health...
Making Room for Process in Relationship-centered CareKathy McGrail MD, Rochester Regional Health SystemKrista Hirschmann PhD, Lehigh Valley Health Network
AACH Winter Course 2015
AgendaTime
• 10 min• 5 min• 5-7 min• 10 min• 5 min• 10 min• 25 min• 10 min
Topic
• Review of goals• Distribute roles • Why cycle time • 8 Wastes • Relational co-ordination mini-didactic • Debrief RCC survey results • Brainstorming and multi-voting• Debrief and Close
Our Objectives & Yours• Describe the impact of process on relationships
in primary care• Explain how standard roles and process are
essential to team based care• Apply cone in the box principles during an
interactive case scenario• List two ways you can promote attention to
process in your clinical setting as an avenue to relationship-centered care
Quadruple Aim
Improve Patient Experience
Decrease per capita cost
Improve Health of Populations
Improve Work Life of Healthcare Workers
Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Ann Fam Med. 12: 573-76, 2014
A Framework for the Quadruple Aim
Relational Coordination
Shared goalsShared knowledge
Mutual respectFrequent
TimelyAccurate
Problem-solving communication
Structural InterventionsShared accountability
Shared costs & rewardsSelection & trainingConflict resolution
Meetings & HuddlesBoundary spanners
Shared protocolsShared info systems
Spatial design
Performance
OutcomesQuality
EfficiencyPatient engagementWorker well being
Work Process Interventions
Goal and Role clarification Process mapping
Structured problem solving
Relational InterventionsCreate psychological safety
Relational diagnosisCoaching & Role Modeling
RELATIONAL COORDINATION
Jody Hoffer-Gittell , Edgar Schein, Amy Edmundson
http://rcrc.brandeis.edu/about-rc/model.html
Nature of the ChallengeTechnical Challenge• Problem is well defined• Solution is known and
can be found• Implementation is clear• You can always go to the
genius bar
Adaptive Challenge• Challenge is complex• To solve requires transforming
long-standing and deeply held assumptions and values
• Involves feelings of loss, sacrifice• Solution requires learning and a
new way of thinking, new relationships
• Those with problem must be those who develop solutions
R Heifetz, A Grashow, M Linsky. Adaptive Leadership, 2009
overall ex-plains
listens in-structs
knows re-spects
time rec-cmnd
access
Burki 87 98 96.3 96.1 88.9 98.1 92.6 88.9 76.6
Huselton
91.5 97.2 97.2 98.5 97.2 98.6 97.2 97.2 76.6
Mc-Grail
92.7 98.2 98.2 96.1 98.2 100 96.4 98.2 67.5
My-ers
90.7 96.1 96.1 93.2 97.4 94.7 96.1 93.3 71.6
Meyer
80 100 100 90.9 73.3 93.8 100 93.3 78.8
1030507090
110
Patient Satisfaction YTD Dec 2014
Patients perception of “knows my history” seems to drive overall score; it would be good to understand what that means to patients; national percentile rank: 50%tile = raw score of 92
Seen within 15 min of appt
Rec of-fice
Access Test re-sults
Office staff
quality
Clerks helpful
Clerks treat w respect
Nurses
Mar-14
100 95.7 75.2 100 95.7 NaN NaN NaN
Jun-14
54 98 72.7 94 96.1 94 98 NaN
Dec-14
51.6 94.2 70.3 92.9 94.9 93.8 96 92.6
1030507090
110
Overall Office Satisfaction Trends
Defects
Overproduction
• Lines, staff waiting for patients, patients waiting on phone or waiting for staff
Waiting
Non-used Talent
Transportation
Inventory
Motion
Extra/over processing Multiple people doing same tasks or parts of tasks
Doing more than is asked, needed, or really possible in a visit
Too much back and forth, walking to find/get reports, AVS etc
Pick up of lab specs, movement of paper through office
8
WASTES
Medications/ immunizations errors, missed screening opportunities/abnormal results
Stocking of rooms, supplies outdate before used
Top of license issues, moving secretarial tasks to support staff; forms processing
Lines, staff waiting for patients, patients waiting on phone or waiting for staff; MDs for POC testing
Current Process
• Total process time overall: 35 - 83 mins• Value added process time: 25 – 49 mins• Wait Time: 10 – 34 mins
Check inNurse visit
Provider visit
Check out
5-10 mins 7-14 mins
Waiting Room Exam Room Front Desk
13-25 mins 0 - ? mins3-12 mins 3-27 mins 0-? mins
Resource for process map & workflow diagram P Scholtes, B Joiner, B Streibel. The Team Handbook Chp 4
Exam roomMD Office
Secretaries
Waiting Room
Exam Room
Exam room
This is the activity pattern for 1 patient who needed spirometry during the visit PatientNurseMD
Rx Printer/scale
Nurses station
AVS printer
Workflow Diagram
Relational Coordination(How we would normally engage you)
1. What is Relational Coordination?• Communicating and relating for the purpose of task
integration2. What is the Relational Coordination Survey?
• Seven question instrument based on
• Survey participants re a particular work process • Communication and relationships with other
participants in that work process
Frequent Communication Shared Goals
Timely Communication Shared Knowledge
Accurate Communication Mutual Respect
Problem-Solving Communication
Survey Questions1. How frequently do people in each of these groups communicate with you
about addressing patient wait time in the office?
2. Do they communicate with you in a timely way about addressing patient wait time in the office?
3. Do they communicate with you accurately about addressing patient wait time in the office?
4. When there is a problem with patient wait time, do people in each of these groups blame others or work with you to solve the problem?
5. Do people in each of these groups share your goals for addressing patient wait time?
6. Do people in each of these groups know about the work you do with addressing patient wait time?
7. Do people in each of these groups respect the work you do with addressing patient wait time?
Debrief• What’s the story or example you could tell
about these numbers?
• Does anything surprise you?
• What do you think would be the most important dimension for the team to work on?
• Is that something that you’d be willing to do?
Brainstorming
• Used to help brainstorm and focus on the reasons why a problem is occurring• Problem: Long cycle time for patients• Let’s brainstorm root causes:• Process/Policy• Equipment/Supplies• Environment• 8 Wastes Think about what you see in your day to day
work that, if done differently, could improvepatient cycle time. Write down all the ideas on post-its (6 mins)
Resource for brainstorming, multi-voting & nominal group technique:P Scholtes, B Joiner, B Streibel. The Team Handbook Chp 3-13 through 23
Prioritizing: Multi-voting
• Cluster Post it notes in shared categories• Review, name categories• Vote• Identify priorties
Debrief Workshop• How did we set up the team meeting that could
produce a change in the team dynamics and behavior? • How do you do these things within the
constraints of real time limits?• How is similar or different than your home
practice? • What got you excited or curious?
outtakes• Assumption: This is an office with some ground of health; that assessment is
based on either site visit and conversation, observation and/or review of self assessed function/teamwork
• If ground of health is not present at a foundational level, don’t start with something this complex; start with something simple and an easier win; you may not even be able to start with work; you may need to start with relationship repair or basic relationship building
• Without collecting new data, some data is routinely collected by healthcare organizations that can be used to form some initial impressions about the team’s ground of health: existing patient satisfaction scores, existing hedis measures (not as helpful for safety net settings), Culture of safety scores (or equivalent)
• Existing scores provide information about how well the teams are doing under current circumstances, but do not necessarily give an accurate picture of their capacity to be creative, to learn, and to adapt to changing circumstances
• A goal central to improvement work is to do the work , improve it while doing, and to create self sustaining, reflective, learning communities
Continuous Quality Improvement
Multi-method Assessment Process and Reflective Adaptive Proces
Vision Improved components, improved measurement, improved patient outcomes
Reflective, adaptive practices, increased capacity for learning, improved systems, richer connections & relationships, improved pt outcomes
Leadership Goals
Create better run organization, increased efficiency, effectiveness, predictability and control
Optimize potential to co-evolve in ways that increase organizational fitness
Perspect-ive
Emphasizes what agents know todayAttempts to minimize effects of diversityStrives to reduce variationFrames future by planning/ forecastingTries to get everyone to conform to the formal organizationDoes not focus on social relationships
Emphasizes developing learning capacityLeverages diversityPromotes some types of diversityFrames the future by social interactionRecognizes/uses interdependence of the formal & informal organizationUses social interaction for sense-makingUses multiple methods/perspectives to enhance learning capacity and identify priorities
Continuous Quality Improvement
MAP & RAP
Teams Views teams as the way to implement organizational change and solve problemsPatients typically not members of teamFacilitator sometimes viewed as external to the team
Views teams as connected to the entire organization and a small complex adaptive system that may change the culture of the entire organizationPatient is a full team memberFacilitator acknowledged as part of team, not external to it
Orientation Improvement cycles to enhance one process at a time
Enhance relationships and information sharing around a set of interrelated processes
Stroebel C, McDaniel R, Crabtree B, et al. How complexity science can inform a reflective process for improvement in primary care practice. J on Quality and Patient Safety 31(8): 438-446, 2005