In Search of Joy in Practice: Innovations in Patient Centered Care
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1 In Search of Joy in Practice: Innovations in Patient Centered Care Pri-Med Annual Conference Rosemont, IL Christine A Sinsky, MD, FACP Thomas A Sinsky, MD, FACP Oct 18, 2013
2 Agenda Introduction: Framing thoughts burnout ABIMF Study: In Search of Joy in Practice Discussion
3 Working at Starbucks would be better There is not much real time to listen to patients. The little things have become the big things I fear our roles as healers, comforters, and listeners are being lost. Working at Starbucks would be better Ben Crocker, MD Internist MGH 2008
4 Arch Intern Med 2012; E1-9
5 Arch Intern Med 2012; E1-9 Nearly ½ of MDs Burned Out General Internal Medicine Family Medicine
6 Burnout affects Patients Physician burnout is associated with o Mistakes o Adherence o Less empathy o Patient satisfaction Sources: Dyrbye. JAMA 2011;305: ; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16: ; Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:
7 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.
8 In Search of Joy in Practice Co-Investigators Christine Sinsky- PI Tom Bodenheimer-PI Rachel Willard Tom Sinsky Andrew Schutzbank David Margolius
9 Advisory Council
10
11 Places Where PC Physicians & Staff are Thriving? Where the work of primary care is do-able Enjoyable as a life s vocation
12 Group Health Olympia Joy in Practice Martin s Point- Evergreen Woods Multnomah County Health Dept Allina Fairview Rosemont Clinic Mayo Red Cedar ThedaCare Harvard Vanguard Medford Brigham and Women s Hospital Clinic Ole Sebastopol Community Health La Clinica la Raza de Univ of Utah- Redstone Clinica Family Health Services Medical Center Medical Associates Clinic Mercy Clinics Quincy, Office of the Future Cleveland Clinic- Strongsville North Shore Physicians Group Mass. General Hospital Newport News Family Practice West Los Angeles- VA South Central Foundation Site visits to 23 highperforming practices (most PCMHs) Workflow Task distribution Physical space Technology
13 Challenges Chaotic visits EHR work to MD Inadequate support Teams function poorly Time documentation
14 Challenges Innovations 1. Chaotic visits with overfull agendas Pre-visit planning Pre-appt labs Systematic Prescriptions
15 Fairview: Care Model Redesign MA pre-visit call Agenda, Med review Depression screen Advanced directive
16 Mayo-Red Cedar arranges for pre-visit lab
17 Same day pre-visit lab (15 min) ThedaCare
18 Annual Prescription Renewals Physician time 0.5 hour/day Nursing time 1 hour/day per physician 80 million PC visits/year 350,000 PCPs x 220d/yr x1 visit/d
19 Script Renewal Calls $10,000/yr per MD Surescripts estimate as reported in WSJ (Similar to our observation of 1 RN: 6-8 MDs) Each call costs $
20 Challenges Action Innovations Steps 1. Chaotic visits with overfull agendas Insurers Single co-pay lab/visit Institutions Hold future orders Regulatory Prescription 15 mo
21 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
22 Mayo Red Cedar : New Model of Nursing (2:1) Physician centric to team based model Immunizatio diabetic foot, lifestyle, HTN visits; even though 25% more visits/day, less harried; proud
23 Challenges Action Innovations Steps 2. Inadequate support to meet the patient demand for care Educators MA, nurse: MI, SMS Institutions/Regulators Staffing Scope of practice Payers Fund non-md services
24 Challenges Innovations 3. Vast amounts of time spent documenting care More time doc than delivering care Scribing Assistant order entry
25 I used to be a doctor. Now I am a typist. Personal communication. Beth Kohnen, MD, internist Anchorage AL
26 The Doctor 1891 Fildes Undivided attention
27 The Doctor 2013 Continuous partial attention
28 Challenges Innovations 3. Vast amounts of time spent documenting care Scribing Assistant order entry
29 Scribing: Newport News Family Practice
30 Collaborative Care Newport News What we all hoped for Team: 3:1 Nurse/physician primarycareprogr ess.org/insight/3/ profiles
31 Pre-visit Nurse with Pt (8-12 min) Nurse gathers, records Vitals, Med Rec., Previous two notes ER, Consult notes, New lab or x-ray Agenda, HPI ROS guided by templates
32 Visit Nurse, Patient and MD Nurse gives report M.D. Hx, PE M.D. verbalizes med changes lab, x-ray orders diagnosis/billing codes next follow-up appt. Nurse records
33 Nurse Reviews plan Post-visit Nurse with Patient Prints and reviews visit summary US Army
34 Scribing at Cleveland Clinic Kevin Hopkins M.D.
35 Collaborative Care Cleveland Clinic: Stonebridge New Model 2 MA: 1 MD 2 pt/d cover cost visits/d 20-30% revenue Spread to others We re having FUN
36 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.
37 Collaborative Care University of Utah: Redstone 2.5 MA: 1 MD
38 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 personal communication
39 Office Practice of the Future Quincy Family Practice 2 MA: 1 LPN: 1 MD
40 Collaborative Care Six sites Similar results Access 30% Costs covered Satisfaction Quality metrics Physician home hour earlier no work at home
41 Challenges Action Innovations Steps 3. Vast amounts of time spent documenting care Regulatory Team log-in Meaningful Use Stage 2 Institutions Staffing ratios Assistant order entry Technology Seamless transitions between users
42 Challenges Innovations 4. Computerized technology that pushes more work to the clinician Verbal messages In-box management
43 The task list is unbearable. I spend 1.5 hours clearing out my task list before leaving and another 1.5 hours at home after the kids go to bed. Primary Care Physician, Des Moines, IA; 2011
44 Fairview: Filtering Inbox Reduce backpack 90min/d to few min (HP: Inbox = 25% of MD s day) Line of Sight
45 Verbal messaging at Fairview rather than series e- messages going round and round the office
46 Semi-circular desk, APF
47 Iora Health, Dartmouth-Hitchcock
48 Challenges Action Innovations Steps 4. Computerized technology that pushes more work to the clinician Institutions message generation Nurses filter inbox Regulators Security modifications to accommodate workflow Technology Improved usability Team-based design
49 Challenges Innovations 5. Teams that function poorly and complicate rather than simplify the work Co-location Huddles Team meetings Workflow mapping Structuring the physical and personnel environment to support trust and reliance
50 Flow station at North Shore Physicians Group HP: Saves 30 min/day/physician
51 Printer in every room University of Utah Redstone HP: Saves 20 min/day/physician
52 Fairview Co-location of scheduler
53 Co-location at South Central Foundation, Alaska
54 APF, Massachusetts General Hospital
55 Team Meetings Do Work + Make Work Better
56 Health coach running meeting we all own the outcomes of the practice, we all own meeting
57 ThedaCare: All staff trained in QI, Pulling in same direction, capacity for change
58 Clinic walls lined with data ThedaCare
59 Lean Problem solving Harvard Vanguard Medical Associates
60 Harvard Vanguard Medical Associates
61 26 Improvement Specialists South Central Foundation, Alaska
62 Challenges Action Innovations Steps 5. Teams that function poorly and complicate rather than simplify the work Institutions Co-location Line of sight Space for huddles Time for meetings Improvement specialists Aligned reporting (MA/ nursing to clinical lead)
63 Conceptual Model: Matching Work to Worker Y Worker is under trained for the work Unsafe Complexity of work Sweet spot: worker and work are well matched Inefficient (Waste) Worker is over trained for the task X C.A.Sinsky; Modified from A. Mulley Training
64 Current Work Distribution in PC High value Good match Dx and Rx plan Complex chronic Relationship bldg Shared decision making Complexity of work C.A.Sinsky PAs Vitals Script renewals Inefficient (Waste) MA RN RN NP PA MD Training Inbox mgmt Med rec Script renewals Data entry Data gathering Prior authorization Sign for hearing aid battery
65 We have developed a new mental model: Pull the doctor out of the infrastructure (typing, EHR, etc) and get them back to being present to the patient. David Moen, MD Director Care Model Innovation, Fairview Clinic Mlps Personal communication
66 Matching Work to Worker Bio/psycho/social Shared decision m Chronic illness ca E/M acute sx Complexity of work Vitals Allows greater MD focus on high complexity Inbox mgmt tasks Med rec Script renewals Data entry Data gathering Prior authorization Sign for hearing a C.A.Sinsky MA RN RN NP PA MD Training
67 Key Lessons For Burnout and Joy Share the care with team 2:1 or 3:1 staffing in stable Physician-centric to team-based care Clear communication Co-location Team meetings Systematic Planning Pre-visit planning Workflow mapping
68 Standing orders In-box management In-visit scribing Pre-visit planning Health Coaching How innovations relate to Patient-Centered Medical Home? Share the Care Care Coordination Co-location Huddles Team meetings Panel management
69 Standing orders Patient-Centered Medical In-box management Home Scribing Pre-visit planning Health Coaching Access and Continuity Manage Populations Plan and Manage Care Self-Care and Support Track and Coordinate Care Measure/Improve Performance Share the Care Care Coordination Co-location Huddles Team meetings Panel management
70 Checkback 2011 The biggest difference -- is team, culture and time. Time with patients to better understand who they are, their story Ben Crocker, MD Internist MGH I wouldn't trade that for anything. I'm loving it.
71 Our Work Going Forward How can we contribute to transformation Starbucks would be better I m loving it Ben Crocker
72 What patients want is that deep relationship with a healer; this is the foundation upon which we need to build healthcare. Paul Grundy, MD IBM, PCPCC personal communication
73 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. Sir William Osler,
74 Discussion
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