The H.R. Bob Brettell, MD, Memorial Lectureship January 29, 2013 Design Principles for Learning and Caring in Patient-Centered Primary Care Homes Judith L. Bowen, MD, FACP Professor of Medicine Oregon Health & Science University Physician Education Consultant VHA Office of Academic Affiliations Centers of Excellence in Primary Care Education
Roadmap Describe the big picture challenge Define the patient-centered primary care home Educational Context for PCPCH Design principles for the Academic Primary Care Home Recommendations
Triple Aim
IOM Aims Safe Effective Timely Efficient Equitable Patientcentered Individual Safe Effective Timely Patientcentered System Safe Effective Efficient Equitable IOM (Institute of Medicine). Washington, D.C: National Academy Press; 2001. Crossing the Quality Chasm: A New Health System for the 21st Century
IOM System Properties Patients experience Continuous healing relationships Customized care based on needs and values Control Free information flow and shared knowledge Care is evidence-based System is Safe, transparent, anticipatory Strives to decrease waste Encourages cooperation effective communication collaboration
Triple Aim and IOM Aims Safe Effective Equitable Patient-centered Safe Effective Timely Lower Costs Efficient
Simplified Chronic Care Model Community Health Care is evidencebased Data-driven care Population data Patient registries Evidence-based guidelines Patients as partners Patient-centered Self-management support Improved Outcomes Safe Transparent Anticipatory Reduces waste Continuous healing relationships Customized care Control Shared knowledge Encourages cooperation Delivered in teams Different roles and responsibilities Interprofessional expertise
Defining PCPCH.not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care AHRQ: http://pcmh.ahrq.gov/.is a patient-driven, team based approach to providing total health care and delivers efficient, comprehensive and continuous care through active communication and coordination of resources. VA Patient-aligned Care Team
Primary Care Homes AHRQ Patient-centered Comprehensive Coordinated Accessible Quality and Safety VA PACT Patient Driven Team Based Efficient Comprehensive Continuous Communication Coordination
Triple Aim and PCMH Quality and Safety Patient-centered Comprehensive Coordinated Accessible Lower Costs
Triple Aim and PACT Lower Costs Patient-driven Team-based Comprehensive Continuous Coordinated Communication Efficient
Educational Context Health System Design Better Health Better Care Lower Costs Primary Care Home Health Professions Education Academic Primary Care Home
Academic Primary Care Home Defined Team-based, patient-centered primary care practice that includes learners as one of its primary missions Learners have meaningful roles in care delivery Purpose Align education with practice Better preparation of graduates for their futures
POINT OF CARE Educational Reform Learning Patients / Populations Caring Practice Redesign HEALTHCARE SYSTEM
Learning Framework Workplace (experiential) learning Everyday thinking and acting in authentic settings Learners embedded in clinical practice Developmental Low complexity under high supervision to higher complexity activities with earned autonomy Task interdependence Every member of the clinical team influences learning
Questions to ask What structural and functional designs support learning and caring from the patient s perspective? Whom should we educate and what are our responsibilities to learners from different professions? How will clinical team members be assigned to and support caring and learning? What structures optimize patients access to their own primary care provider and team, and optimize continuity of care and continuity for learning? What structures facilitate communication between patients and their team members, and between absent team members? What assessments and metrics will drive care and learning?
Educational Reform Teamwork Learning Patients / Populations In Caring Continuity Practice Redesign
Design Principles Continuity Transition back to interpersonal continuity Patients Learners Teams Teamwork Transition from independence to interdependence Communication Coordination Integration Transition to a single system for caring and learning Measurement Essential for system performance feedback Essential for declaring values
Principle 1: Continuity Continuity of Care Informational (safe hand offs, care transitions) Longitudinal (familiar place, routine) Interpersonal ( My doctor knows me ) Continuity for Learning One to one continuity Learner-patient, Learner-preceptor Team continuity Patients, nurse care manager, medical assistant, clerk, residents, preceptors, other learners Saultz J Ann Fam Med. 2003;1:134-43 Bowen, Aagaard, et al (in preparation)
Principle 1: Continuity What continuity design is most patient-centered? best engages learners to be accountable for care and learning? Who is present and accountable most of the time to provide continuity and leadership for the team on behalf of patients?
Ambulatory Care Continuity in Clinic Setting* Residents Faculty Preceptors Clinical Team Patients TIME *How might technology change how we think about continuity?
Principle 2: Teamwork
Salas Teamwork Competencies Team leadership Mutual performance monitoring Back-up behavior Adaptability Team orientation Salas E, Sims D, Burke C. Is there a big five in teamwork? Small Group Res. 2005;36:555-599. Leasure E. et al. There is no I in Teamwork in the Patient Centered Medical Home: Defining Teamwork Competencies for Academic Practice. Acad Med, 2013 in press
Salas: Team Leadership Team leadership Enhance the team s ability to perform Coordinate team members activities Assure tasks are distributed appropriately Evaluate performance Provide feedback Inspire the drive for high-level performance Team leadership is fluid Depends on team, task, problem Best person to detect system breakdowns, coordinate improvement
Salas: Mutual performance monitoring Mutual performance monitoring Develop a shared understanding among team members regarding Intention Roles and responsibilities Accurately monitor each other s performance Purpose: collective success
Salas: Back-up Behavior Back-up behavior Anticipate the needs of other team members Shift workload in real time Goal: to achieve and maintain balance during times of variable workload or pressure Requires Familiarity with each other s roles, responsibilities Cross training when appropriate Trust and effective communication skills Shared mental models
Salas: Adaptability Adaptability: capability of team members to adjust their strategy for completing tasks based on feedback from the work environment Situational awareness Knowing what is going on around you Knowing why it is happening Knowing what is likely to happen next
Salas: Team Orientation Team orientation: Tendency to prioritize team goals over individual members goals To encourage different viewpoints and perspectives To show respect and regard for each team member Requires communication Requires time for team work Performance assessment focuses on team
Turning a Team of Experts into an Expert Team
Does Team Training Work? Team training is a strategy for systematically improving teamwork competencies the knowledge, skill, and attitudes underlying effective teamwork Team training significantly improves team: Cognition (ρ =.42) Shared mental models Behavioral process (ρ =.44) Communication, coordination, collaboration Affect (ρ =.35) Mutual trust, collective efficacy Performance outcomes (ρ =.37) Task outcomes, satisfaction, viability Salas et al., Does Team Training Improve Team Performance? A Meta- Analysis. HUMAN FACTORS, 2008: 50:903-933.
Communication Skills The lifeblood of teamwork Communication failures are the root cause of nearly 70% of sentinel events reported to TJC Techniques Teach-back, Check-back, Closed loop SBAR (Situation, Background, Assessment, Recommendation) Webster JS et al. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies. In: Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools, 2008, AHRQ). http://www.ncbi.nlm.nih.gov/books/nbk43683/
Briefs, Huddles, Debriefs Briefs Leader-driven, pre-flight discussion Goal: Be all on the same page (shared mental model) Huddles Involves the point-of-care team Anyone on the team can convene one Standardized process ( sports team huddle ) Characteristics: short, patient-focused, efficient, problemsolving, information sharing, and action oriented Not a time out Debriefs High quality feedback in real time focused on team performance
Team Continuity Team members should Know they are actually on a team Know they are assigned to each other Patients should Know their team Perceive their team knows them Be a member of the team
Team Continuity Challenges Characteristics of academic teams Have many part-time providers (faculty, learners) Have predictable turnover (end of training) Have teaching roles (known and unknown) Optimizing team continuity Academic team is often lower priority for assigning staff support Support may not be at the same level as for faculty Training program scheduling rules add complexity
Principle 3: Integration Health Care System Care silos disconnected from learning Emerging teamwork & coordination Training matches workplace competencies Institution Educational and clinical missions compete Aware of potential alignment, low investment, low ROI Educational and clinical missions are aligned Point of Care Learners participate in care delivery, no collaboration Learners participate in care delivery, improvement efforts separate Collaborative team care, learning, & continuous improvement are priorities LOW Integration HIGH
Principle 3: Integration Ambulatory Education Design Space and Teamwork Traditional continuity clinic Allocated exam rooms as available, random team Traditional CC plus 1-2 ambulatory blocks/year Improved predictability of team assignments Interprofessional block immersion 8-12 wks in length: clinical, education, redesign Learners on teams, shared work room, learning space Professional Development Physician faculty for clinical CPD Emerging team training, separate from teaching roles Shared team development for teamwork, improvement, CPD LOW Integration HIGH
Principle 4: Measurement Measurement as a statement of values Measurement drives behavior Individual versus team performance Measurement provides system feedback Assess alignment with system goals Detect work arounds Identify improvement targets
Potential Metrics Clinical Care Panel size 60% Staffing ratio 4:1 Based on shared panel size of 1200 patients (VA) 2 RN care managers, 1 LVN, 1 clerk Population registries in use CAPHS-PCMH Inter-personal continuity Q s Patient survey can identify team members Continuity index (ratio of PCP/ total encounters) Learner-patient Patient-team 3 rd next available with Team Education Training completed (process) Teamwork Panel management, QI Communication Shared decision-making TeamSTEPPS (TAQ, TPQ) or TDM Continuity index (ratio of primary/total encounters) Supervisor Team Coverage plan/handoffs Learner perception of accountability for patient care Space metrics Professional development % of team completing teaching skills program
Triple Aim, IOM, + Academic Primary Care Homes Safe Effective Equitable Aligned Educational Program Outcomes Continuous Improvement Lower Costs Efficient CURRICULUM Patient-centered Safe Effective Timely Integration Continuity Teamwork Metrics
Recommendations Keep big picture context in mind Is it better for the patient? (Berwick, D. IHI 2011) Integrate education and practice Workplace learning demands this Form, develop, reinforce teams / teamwork Communication skills are critical Education to mimic collaborative practice Strive for continuity, test new models Measurement is essential for successful and sustained organizational change