Marcus Pierson, MD: Cooperation in Health Care

Systems and Maps, Actions and Theories

Sun, 10 Oct 2004 14:51:45 GMT

Well I have been silent for quite a long time.

I have been trying to find my way forward for months.

The groups working on Pursuing Perfection in Whatcom County have accomplished much: Direct involvement of patients in the design of chronic care system and processes, Shared Care Plan, Clinical Care Specialist role, Groups Visits, Shared Governance, Teamwork and process improvement expertise, interaction and learning from some systems with some of the best practices in the country and in Europe. The patients who have experienced benefits of this effort are appreciative.

In order that we continue to improve our system of care (see by line above) we need to see it, literally have a map of Whatcom County as a health care system. And when we can see it, we must have some idea of what to do from there. We are lost without a shared map. A map of the system (parts and interactions between those parts) alone does not develop the territory of the map--the system which produces or limits the health of people in Whatcom County. We then must learn what ideas (theories) work and which do not work. We must use the theories and the associated tools to improve the system (a system which is currently invisible among the parts).

One year ago we learned that Jonkoping County Council, Sweden has taken a systems view, developed a map of the health care system, and made dramatic improvements in the experiences and health of their inhabitants--within the same budget. Well that is Sweden. They are slightly more disposed toward working together, cooperating, than the average American community, where the prevailing theory is that competition at most levels is the way forward. Win-Loose.

This week I have had the privilege of spending four days with a group of the gentlemen who worked with doctor W. Edward Deming for the last 10 or more years of his life. I have since reread "The New Economics, for Industry, Government, Education" Second Edition, by W. Edward Deming.

With the knowledge in that book, with help from those who have gone ahead, with maps of the system of healthcare in Whatcom County in hand, it is clear that we have the compelling reason to be hopeful, to be bold, to improve the system (interactions) that produce the quality of healthcare in this county. I would suggest the same is possible for each community where you can begin to mix theories of systems (cooperation, win-win) with our prevailing common sense that competition (isolation, win-lose, zero-sum games) are the route to improved value and happiness.

A Patient Responds

Sun, 28 Mar 2004 08:25:25 GMT

Shared Care Plan. This is a very exciting program. Shared Care Plan is clearly a major step forward in improving the communication between... [:: Chemo Chronicles '04 ::]

Craig Miles writes, "As a cancer patient, I deal with my cancer as a chronic illness and I found this document to be better than anything I had for keeping informed and for sharing with caregivers. I plan to share this with my healthcare team at Kaiser."

"Too often, we think empowerment is patient-oriented, I think this misses the point. The entire healthcare team needs to be empowered."

The Surprising Shared Care Plan, and what patients and families are doing with it

Sun, 21 Mar 2004 21:50:40 GMT

A few days ago a group of patients and their families talked to Ed Wagner about their experiences in Pursuing Perfection in Whatcom county. Each of these patients had a clinical care specialists and a shared care plan. What I heard changed my thinking.

They described the role of the shared care plan differently than I had expected. As I listened I came to see that for them it was a cultural artifact, an object around which improved conversations can occur. In the doctor's office, a paper copy is used to help the physician or nurse understand where the patient is in their goals and understanding. Likewise this piece of paper helps the patient learn from physician or nurse. They can write down and discuss medical concepts, diagnoses, medications, goals and plans. I heard that without this piece of paper the 15 minutes of an office visit is often confusing and less valuable. I heard over and over that this piece of paper help create a relationship between the doctor and patient that is more like a partnership than a trip to the principles office. One patient's daughter made the cute comment, "Dad is getting kind of uppity. He uses big medical words now." The point I took away is that now he understands the meaning of important medical concepts and that he, with his family and care team, can do a better job of managing his situation with diabetes.

Even more surprising was the story of a family. Before the shared care plan, "Dad, did not want to bother us with his diabetes." Little communication about his needs for special diet, exercise, and medications occurred, due to his desire not to be a burden. Since the daughters and wife have access to his shared care plan, they now print it out and talk together about what they can do to help. They have all changed their diets as they learned to change the cooking for their father. They understand more about what they can do to reduce the chances that they and their children will develop type II diabetes. This simple piece of paper has become the focus of new family conversations that help everyone. It has obviously added meaningfully to the lives of this family.

Something important is happening here. We are discovering with patients how to move beyond business medical records (which help physicians and nurses get the information they need and help insure that they get paid for what they did) toward a shared document about which learning and planning for improved self-care and partnerships can develop.

You can download a Microsoft Word version of the Shared Care Plan from https://www.patientpowered.org/PatientSite/Login.asp and you can look at the on-line electronic version which prints out for those who have assess to it. In Whatcom county, Washington, we are opening up use of the electronic version to patients and their families and caregivers.

For those of you who what to know more about the best thinking for how communities can support their citizens with chronic medical conditions, I recommend the Improving Chronic Illness Care site http://www.improvingchroniccare.org/index.html

Trust as a Verb and Insecurity as a Good Thing

Sun, 01 Feb 2004 20:13:27 GMT

Building Trust, by Flores and Solomon is a really good book. I rank it with The Wisdom of Insecurity, by Alan Watts as two of the most mind altering books I have read. Watts turned the conventional wisdom of insecurity on it's head, essentially showing that security or fixedness is closer to death and that insecurity or uncertainty is closer to life. When his wisdom sinks in, one comes to appreciate insecurity for what it is--the experience life-giving growth. On can then quit amplifying a certain amount of natural stress, by dropping the judgment that insecurity is bad.

Flores and Solomon turn broken trust and betrayal on their heads, as Watts did with insecurity. They allow one to see that trust and betrayal are sides of the same coin (one meaningless without the possibility of the other) and they also allow one to see that creating and rebuilding trust is the key act in creating a better and shared future. Without such acts of trusting and rebuilding of trust from moments of betrayal, no better future is possible. Trust is not a thing to be shattered. Trusting is a competency for all forward looking people to practice and learn--a verb, not a noun.

Below is a kind of relationship diagram that captures some of the ideas that filled my head as I read the book.

Clear Leadership

Sun, 01 Feb 2004 18:47:45 GMT

A friend of mine, Gervase Bushe, wrote a very useful book: Clear Leadership. The insights and framework are based upon his career as a professor and business consultant

Clear Leadership is full of practical and immediately useful mental models and advice. Organizations are beginning to use it as a framework for leadership training at all levels.

After reading this book, I created a mnemonic and a drawing that help me keep a few of the book's key points in mind and handy for my use. I give them to you with Gervase's permission.

SOFTeNeD stories and maps.

Sensing--what is my body telling me? Am I poised for a fight, to flee, to hear, to learn, to have fun, etc.

Observing--what would others agree happened, what was objective, what data can we agree upon and share?

Feeling--awareness of feelings is very useful early on, as feeling color everything else.

experience, each person has a different one

Need (want)--what do I want to happen, what do I want in the way of agreements.

experience, our stories come from our experience, we can share these and ask others to share their's. Experience is subjective and has numerous aspects (SOFTND)

Do--what will I do and what will I agree to do?

This little graphic represents for me Gervase's four profound senses of self and matching sets of skills:

Appreciative self--the halos, understand what you and the other have done that you would like to see more of. It is a kind of "assets based" approach or "appreciative" approach and comes form the appreciative inquiry framework.

Aware self--the recursive loop, suggests that we spend time first going over the SOFTeNeD algorithm personally, before trying to tell others or ask others.

Descriptive self--the arrow from my mouth to the other's ear, suggests that I must describe my SOFTeNeD stories and maps to the other in an appreciative frame and expressing understanding that it is only my experience, not all facts.

Curious self--the arrow from the other's mouth to my ear, suggests that I must have skill in asking and hearing about their experiences and if possible their SOFTeNeD stories and maps. I try to hear in an appreciative frame.

It has been about a year since I read this book and I have not reviewed it for this post. I hope you will pick the book up and work with the concepts in it. We can all do our parts to reduce the "interpersonal mush" in our organizations and communities as well as at home.

Which side of the bed?

Sun, 01 Feb 2004 15:36:24 GMT

I have gradually come to realize that I unconsciously make a binary choice each time I think or act. I get out of my bed either on the defensive side or the learning side.

I either start my day holding on to... you name it. Or, I start my day open, willing and interested in learning, being vulnerable, wrong, embarrassed, over worked, surprised, delighted...open to a different future than I had yesterday. I think that it is this almost unconscious step that determines what is possible and what happens.

This is a short and somewhat personal post. I doubt that it requires more explaination.

I am just trying to be more aware of that first step each morning and each moment.

QualityHealthcare.org, take a look around

Tue, 21 Oct 2003 20:46:34 GMT

The Institute for Healthcare Improvement and the British Medical Journal with support from Robert Wood Johnson Foundation and others have developed a very useful site, QualityHealthcare.org, for anyone working on healthcare improvement. If you have not seen this, log-in and take a look around. It is free.

From Programs to Movements

Tue, 21 Oct 2003 20:02:03 GMT

The Bureau of Primary Health Care has successfully jump started the 100% Access 0 Disparity movement in America. Spokane, WA area is implementing a similar approch.

There is a summary of the BPHC experience that is very enlightening, if you wish to switch from projects and programs to "movements". I highly recommend reading it if you need to scale up some initiative to include more stakeholders.

A remarkable overview of the journy and the liberating concepts is chronicaled by John Scanlon in "Extrordinary Results on National Goals: Networks and Partnerships in the Bureau of Primary Healht Care's 100%/0 Campaign". The PDF file can be downloaded from THIS LINK on IBM Center for The Business of Government site. The site section is "New Ways to Manage". I agree that it is a real revolutionary way to think about how to manage large scale change.

K.C. Bolton on Leadership

Mon, 29 Sep 2003 23:43:07 GMT

Some additional musings about leadership...

One of the hardest transitions I had to make as an officer in the Army was taking a command position (I had two company-level commands...I guess I screwed up the first one so they made me do it again!). The saying "you're only qualified for the position you just left" applies here, where a commander knows well how to lead and manage platoon level activities. But the path to success for a commander (and any other leader I have since realized) lies in the effectiveness of their subordinates. You could be a great doer of things at the hands-on level but that will kill you as a commander. Simply stated, you can't do everything and must trust your subordinates to pull things off. Here's what you must pay attention to:

*Ensure your folks know and have interalized the mission, vision, and scope of the organization. In this respect I spent much more time talking about what we were about (full-spectrum healthcare at the point of injury) than how we accomplished things. This is critical, and the tendency is to slip back into focusing on 'how' because that's what you know personally. Forget being the star player anymore, and even forsake coaching over pure cheerleading if you don't have time. Coaching is harder than you think, but cheerleading we all can do.

*Make sure your folks have the following two things: 1) a sure sense of ownership of the mission with the responsibility AND authority to pull it off, and 2) the resources to pull off that mission. Too many times we expect people to somehow just absorb ownership of the mission because you gave them the task to accomplish this. Think about the successful projects you have been on, and I bet you weren't doing them because you had to but because you knew it needed to be done. THAT'S ownership + responsibility + authority in action. And don't buy into the false buzzphrase of 'do more with less'. Resource the mission/project so it will succeed. And understand that much of the costs/time/resources will be expended well before much of the mission has started.

*Don't be afraid to push people to achieve tough goals...but make sure you are with them the entire way. I have had a reputation of asking for the moon from my subordinates, but I can tell you I was pushing them less hard than I have myself. But some amazing things come out of this push to excel. 1) People stretch their personal understand of what their limits are and gain tremendous confidence. 2) People WANT to be stretched. No soldier goes to field training exercises and enjoys playing cards 12 hours a day but it happens in some units. But good units train hard, back off, and ramp back up again to peak at the appropriate times in exercises. 3) The byproduct of this pressure is often some wonderful moments of teamwork, stories to brag about to their fellows, and an extreme sense of accomplishment.

*Leaders should be adept at finding good junior leaders under them, give those leaders increasing responsibility, and spend more time mentoring and nurturing those folks. Remember, you ain't Da Man anymore.

*Look for opportunities outside your normal mission boundaries. Coupled with an organization that expects to do miraculous things they will pull off more missions outside their normal operational scope. And it provides them an opportunity to show to others their multifaceted capabilities. My medical units were often called on to help provide primary security for the assembly areas we were in. Why? Because we often trained in environments other support units wouldn't attempt, and we employed the same tactics, techniques and procedures that a combat unit would in our operations.

*Make time to get together outside the work environment. Work hard and play hard but do it together. Have a beer (or three) with your folks. I found out more about the pulse of the organization by being available to talk in an informal manner with folks.

*Don't take yourself too seriously. You should account for what has brought any success your way, and if you followed the items above you know that somebody ELSE made the great things happen. Not you. I also think a great sense of humor can ease tensions, bring off-track conversations back to the forefront, and make for a more fun workplace. Especially fun for your subordinates is when you go along with them teasing you about some attribute you exhibit. If they feel comfortable enough to poke fun at you to your face then the organization is probably healthy. If they do it behind your back then something is dysfunctional. There's a great article in this month's Havard Business Review about humor in the workplace http://harvardbusinessonline.hbsp.harvard.edu/b01/en/common/item_detail.jhtml;jsessionid=BMRTF4MBXCGEOCTEQENR5VQKMSARUIPS?id=F0309A

*Reflect often on how you are doing as a leader. Are you the type of person that you'd want to have as a boss?? Be a reflective-practitioner of leadership and know that you will never 'arrive'. Some may mistake this process as some sort of second-guessing oneself, or a flaw in their confidence to lead. We all have blind spots, but if we never try to find them because of hubris then we will never grow as leaders.

*People sense a phony and respect genuineness. I can't tell you how many times I have validated this with both subordinates and superiors. I have been fortunate to work for people who appreciate candor. I have even had to tell subordinates things that were quite difficult but by speaking in a frank and honest way with them they have appreciated it much more. Even when disciplining them I have had feedback that the soldier appreciated knowing how things stood rather than me shirking away from telling them.

In my next post I'd like to share my feelings about visiting Marc Pierson in the flesh...what a special treat to meet a dedicated and talented group that Marc has formed.

[K.C.'s Weblog]

Advanced Access--a Key to System Improvement

Sat, 20 Sep 2003 21:29:31 GMT

Several doctors at the WA State Medical Society meeting ask for more information on what Advanced Access is. So I put a web page together with some good references. Just click on "web page".

I am skeptical that rapid improvement can occur until most physicians have taken this step. It is a happy circumstance that their profit should increase about 9% and their number of visits should simultaneously decrease about 16%.

Presentation to WA State Medical Society House of Delegates

Sat, 20 Sep 2003 21:12:51 GMT

Yesterday I had the privilege of talking about our Pursuing Perfection initiative with the house of delegates for the Washington State Medical Society. Below I have included to content of my 11 slides and my notes.

PURSUING PERFECTION in Whatcom County, WA

SLIDE 1, TITLE SLIDE:

PURSUING PERFECTION

WHAT'S IN A NAME?

Perfection? ...when things seem pretty bleak. When the pace and complexity of practicing medicine is at this highest yet. When frustration or even cynicism seems ready to overwhelm many. But in a culture that takes the charge "first do no harm" seriously. A culture where each of us carries the desire and burden for faultless care with us each working moment. I suggest that by admitting to ourselves and to the public that we are all in the pursuit of perfect care may allow each of us to get some help. As the Chasm Report points out, the problem is with the system. The system that should help us do the right thing. The problem is not with the effort of doctors and nurses nor with a lack of desire or to do the right thing. The pursuit of perfect care leads directly into systems thinking.

SLIDE 2, OUR JOURNEY

1990 vision
Persistence
Access for uninsured, level 2 trauma system, seamless care?, Whatcom Integrated Delivery System, Community Health Record, Whatcom Health Information Network, Whatcom Community Health Improvement Consortium, diabetes collaborative, registry system
IOM: To Err is Human & Quality Chasm
Pursuing Perfection, Robert Wood Johnson Foundation & Institute for Healthcare Improvement, +16 others

Like many of your communities, cooperation has a long history in the community. Community wide efforts developed access for under-insured OB patients and others including dental patients. The community developed a common sense, yet bold vision to have seamless care and the best outcomes in the state within 10 years (It will happen but it will take 20 years. Who knew?) A series of large-scale initiatives have occurred in Whatcom County. The most audacious effort may be the current P2 initiative to transform healthcare in our community and in the nation.

SLIDE 3, PARTNERS & FRIENDS LOCAL AND REGIONAL
This P2 initiative has caught the imagination of lots of folks.

3000 patients with diabetes & congestive heart failure
Family Care Network
SeaMar Clinic
NorthCascade Cardiology
SJH Center for Senior Health
St. Joseph Hospital/PeaceHealth
Group Health Cooperative
Regence Blue Shield,
Community Health Plans of Washington
Olympic/Sterling/Aon

SLIDE 4, PARTNERS & FRIENDS NATIONAL & INTERNATIONAL

NATIONALLY
Cambridge Health Alliance,
Cincinnati Children?s Medical Center,
Tallahassee Memorial Hospital,
Hackensack University Medical Center,
HealthPartners,
McLeod Medical Center, and
Whatcom County coalition
INTERNATIONALLY
8 communities in Great Britain,
1 in the Netherlands,
1 in Sweden

SLIDE 5, LEARNING

Advanced Access
Patient input into design
We did not have to wait
Collaboration among all sectors
Leadership by physicians for collaboration

So, in this P2 initiative what have we learned to date: a year and a half into it? Doing Advanced Access, in primary care and specialty care, seems to me to be the only thing that can free up people and time to take on the work of redesigning the acute care system into one that provides chronic care. HealthPartners and Jonkoeping County, Sweden point to this conclusion. We have been working with Catherine Tantau, RN. Others have worked with Mark Murray, MD. Patients are of surprising help in redesigning care systems. Their insights are generally lead to simpler and cheaper solutions that we imagine on our own. We could have been doing this 5 years ago. Without working together little will occur. The innovations almost all require cooperation of others beyond your organization. Fortunately the benefits are that diffuse too. Physicians can lead their organizations into cooperation. It will not happen otherwise.

SLIDE 6, 80/20 SYSTEMS THINKING

Baby boomer demographic bulge
Chronic care in acute care system
Winners and losers (modeled)
Collaborators (relationships between parts on behalf of all stakeholders)

There are a lot of things we all consider doing. but which are the most important? The biggest problem and opportunity is heading our way--the aging baby boomers. Chronic care accounts for almost 80% of the healthcare costs and it is going to get higher. If we can effect this dynamic it will have more impact that almost any other change. (Possibly at the same or lower cost for a given population.) We have reviewed the literature on chronic care, we have worked with our patients and our physicians. We have designed a system for patient-centered, community-wide chronic care management. We have modeled the outcomes. We know who the winners and losers are likely to be. Nothing big will happen if the winners don?? help the losers. Medicare, pharmaceutical companies, employers, and taxpayers will need to rethink their roles if the benefits are to be gained and sustained.

SLIDE 7, SOLUTION SPACES

Care management and managers
Navigators and insider advocates for patients
Activated informed patients
Group visits
Shared care plan (electronic and paper versions)
Advanced access
Results based advocacy

Our approach combines community-based care managers (nurses). Improved access to information for patients with DM and CHF and for the members of their care team. There are group visits, web access to tailored information and to a personal medical record called the shared care plan. I now call our previous medical records business medical records, not patient medical records. The shared care plan may be a step toward a real patient medical record. None of the changes are manageable in physician offices or with physician staff until excess capacity for seeing patients and for improvement work is created. Advanced access has this great side effect. Modeling the effects of the changes and getting those affected to participate in the solution is essential. Otherwise it is not sustainable. Medicare (thus Congress), pharmaceutical companies, local businesses and government, and patients as purchasers and voters.

SLIDE 8, INTERESTED PARTIES

Robert Wood Johnson Foundation
Institute for Healthcare Improvement
Medicare (CMS)
Healthcare insurance companies
Our community as well as other communities and healthcare organizations
Other foundations

The work and learning going on in Whatcom County has captured the interest of numerous organizations and communities. Many of whom we are working with. There are now 17 communities or healthcare provider organizations. We are hoping to spread this to Ketchikan, AK. beginning this year. We hope to spread to more of the patients and providers in Whatcom County.

SLIDE 9, COOPERATION

Necessity or preference?
System? ...or only parts?
How? or YES!
Leaders?

Somehow we think this is optional, on an organizational level. We do cooperate as individuals. Our organizations must understand the experience of the patients and design and connect our processes so that they work as a system. Peter Block has written a book called The Answer to How? Is Yes! It is a kind of Nike "Just do it!" attitude. On can delay starting assuming the worst and endlessly asking how, rather than experimenting and working our way forward together, with the patients. A new kind of leader is needed--courageous in collaboration, not in war.

SLIDE 10, MORE?

You may find the details and the tools at these websites. Do feel free to contact me. I put some of what I think on my web log, as do many of the people working in this endeavor.

SLIDE 11, PARTNERS?

Already down this road?
Learn together?
Tipping points?

The Institute for Halthcare Improvement is attempting to spread the learning from Pursuing Perfection communities.
We have time for those who want to transform healthcare locally, in their communities.

Thank you for your time and attention.

Community meets leaders of its EMR venders

Fri, 15 Aug 2003 00:11:44 GMT

When we began the Pursuing Perfection journey with IHI and Robert Wood Johnson foundation, IDX leadership started that journey with us, traveling to Boston and meeting with all the participants.

Today we had the good fortune to meet Mark Leavitt, MD, an internist who started Medicalogic company and developed the ambulatory medical record Logician.

I must say that the similarity of vision that among Mark, Malcolm Gleser, (founder of Phamis--now IDX LastWord and CareCast), and this community is remarkable. Kindred spirits.

In an complex environment of medical information software and mal-aligned economic incentives for connecting and deploying electronic medical records--this alignment of vision and value is cause for hope and continued collaboration.

Mike Raymer, head of LastWord division of IDX, joined us for discussions with patients and several of the participants in Pursuing Perfection in Whatcom County, WA.

I hope to report on opportunities that arise from our common vision and from a real intention to work together on the behalf of the patients in this community.

Let's hope.

Health system innovation, ORGANIC or MECHANICAL?

Mon, 11 Aug 2003 21:29:07 GMT

Imagine this. You are asked to create a human body. You choose a hospital in California to create a gastrointestinal system, a health system in New York to create a heart and blood vessels, a city in Vermont to create a brain, a hospital Iowa to create a peripheral nervous system, a group of hospitals in Illinois to create the lungs, etc., etc.

Enough. Some things can't be done separately, some can. Organic things typically cannot. Some complex things can be "componentized" and assembled, some things must interact to even come into existence.

Some people at the Robert Wood Johnson Foundation read the Institute of Medicine Report, Crossing the Quality Chasm and ask organizations to make proposals to radically improve American health care.

Experienced people in organizations in Whatcom County took the request very seriously. We had the same hopes and desires and we had been working separately and collectively for the same goal for more than ten years.

With much thought and discussion and in collaboration with patients we developed a radical plan for a radical change--no individual piece of it was radical, it was the understanding that it all had to be done together that was radical. To extend the analogy started above, we understand the we needed a small GI system, a small cardiovascular system, a small nervous system, etc. for any of it to work. And that with all the essential systems working to support each other they could grow together to a mature effective health system of care--better than anything in existence.

We have been at this for just over one year. It no longer seems unattainable. It is clearly attainable. What is difficult is getting all of this done in less than two years so that it is self-sustaining.

We are hopeful that some of the agencies and foundations that fund parallel, sequential, or distributed "demonstration" "projects" can see the difference here and fund an organic, systematic approach. Nothing less will create the radical transformation called for by the IOM Chasm Report and needed by the American public.

Reductionist approaches can do much. They cannot build an organism, not yet, perhaps never. Supporting the growth of a small, complete, organism (community health system) may be the right approach to radical transformation of US healthcare. We believe it is. Do you?

The minimum essential small "parts" or "organ systems" that we have in Whatcom County, WA are:

1) direct patient involvement in all teams and in governance,
2) using evidence as the basis for care design,
3) starting with two chronic medical conditions[heart failure and congestive heart failure] and then moving to all others over a few years,
4) information systems designed and deployed so that everyone including the patient has the information that the patient wants them to have when and where they need it,
5) clinical office and hospital work flow reconfituration so that the new work is integrated into the old and the old is made less frustrating and more efficient for everyone, and finally
6) modeling of the health care benefits and the economic impact on all of the stakeholders so that potential winners and losers can cooperate for the good of the patients and the whole community.

"...program is so simple, it's brilliant, "Bellingham Herald editorial board

Tue, 15 Jul 2003 15:52:41 GMT

Link to Bellingham Herald Editorial

Link to more about program

Helping chronically ill manage care improves lives, cuts costs
HEALTH CARE: "Pursuing Perfection" program is so simple, it's brilliant.

The whole point of "managed care" started out, at least in theory, as an attempt to contain health-care costs through prevention. It's no secret that's not what happened. In fact, navigating the medical maze has become more difficult than ever, it seems.

But there is a solid movement afoot to change that and Whatcom County is one of the ground-zero sites for a program called "Pursuing Perfection: Raising the Bar for Healthcare Performance." Its method isn't complicated. It seeks to help people manage their own health care, sometimes by doing something as simple as regular telephone calls to check up on patients and answer their questions. By heading off potential problems, extensive and pricey hospital visits can often be avoided and a patient's health better maintained. It's so simple, it's brilliant.

The Whatcom Community Health Improvement Consortium last year was one of seven groups in the nation to win a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement that funds the program. It's not just some kind of feel-good program, either. The foundation wants to document measurable results in improvement of patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors.

Caring for chronically ill people consumes as much as 70 percent of the nation's health-care dollars, so it makes sense that helping them manage their own conditions would reduce those costs and help those people lead more productive and less frustrating lives.

In Whatcom County, two of the most common chronic illnesses are diabetes and congestive heart failure. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure.

Empowering patients with better information and better access to people who monitor their progress and can quickly answer questions can help keep many from becoming dangerously ill and compromising their health further. Medical advances happen quickly as new drugs are developed, more information is discovered about drug interactions and new technologies help people monitor their blood sugar. Keeping patients active in helping to make their own decisions will result in better outcomes. After all, who better to "manage" the care than the person living with the illness?

Weblogs in business, candor, openness, abundance

Thu, 26 Jun 2003 03:38:46 GMT

Some interesting thoughts about weblogs in corporations: http://www.mcgeesmusings.net/2003/06/16.html#a3376

Weblogs in Business would change everything.

Thu, 26 Jun 2003 03:33:05 GMT

Here are suggestions from Todd Brehe on weblogs in business. Sooner or later this level of openness and commitment to what we think and do will arrive. I believe that organizations that can take this step, from paternalism toward their employees to partnership will begin to dominate their industries. Yes it is a prediction.

http://www.optinnews.com/read-article.php?id=1718

Reductionism vs. Wholism. Where is the patient in all of this?

Sun, 22 Jun 2003 17:58:56 GMT

After reading the though provoking article Chronic Illness, Comorbidities, and the Need for Medical Generalism, by Kevin Grumbach, MD, in the first edition of Annals of Family Medicine. I had these thoughts:

The idea of non-reductionist thinking and wholistic planning is so important and so non-western. A reductionist nightmare.

Placing the patient at the center begins to make sense of things. I am not yet sure that we aren't trying to put the PCP at the center; even though that may move in the right direction in some cases.

With the help of Robert Wood Johnson Foundation, we in Whatcom County, WA are building a system to deliver "patient-centered, community-wide, chronic disease management" based upon Wagner's chronic care model. Even that model may be too physician centric. See my post.

Conidering the chaotic non-system and it's misaligned reimbursement, I am not sure that the overburdened PCP can help all the patients navigate. We are using nurse care coordinators Connie Golas and Nancy Stothard to assist, and we also use a patient centered/patient designed Shared Care Plan

I will follow your new journal with interest. As you poit out in the article, we should not be too self congratulatory. For even the best approaches in the US are very inadequate from the patient's perspective. See the Commonwealth Fund report (pdf)

A chasm exists. Any narrow focus on the parts, even the PCP role, risks a further Balkanization of US healthcare. We must focus on the patient and their family, we must include the patient in all the discussions. So long as the journals exclude patients from the dialogue they will miss an opportunity for truly integrative solutions. Even the PCPs may be a "specialists" compared to patients and their families.

Our weblogs, with others, mentioned in American Medical News

Tue, 03 Jun 2003 20:35:58 GMT

Whatcom's Pursuing Perfection weblogs mentioned in American Medical News.

Welcome to the blogosphere: A brave new world of Web dialogue (CLICK here)

A growing number of physicians are sharing their thoughts and opinions on online diaries known as Web logs, or blogs.

By Bob Cook, AMNews staff. April 28, 2003.

Tools for Rules

Sun, 18 May 2003 17:10:06 GMT

John Udell reports on seperating rules form databases. Boy do I ever agree. We have looked at Blaze Advisor to do this sort of thing. I am hopeful.

http://weblog.infoworld.com/udell/2003/05/16.html#a692

Today we program this stuff in procedural languages, and we make a hell of a mess doing so. Wouldn't it be great if we could declare a bunch of rules and have a rules engine work out the consequences? As Ted points out, this is the moral equivalent of using SQL to say what you want done with data not how. [Full story at InfoWorld.com]

Convenience vs. Commitment

Sun, 18 May 2003 15:03:04 GMT

Pursuing Perfection in Whatcom County is not an undertaking of convenience. It is a matter of commitments. Commitments have been made.

The prior five or six years of work by CHIC memebers were agreements and collaborations of convenience, we publicly promised nothing, we did things in our own time. Pursuing Perfection is different, we have made difficult promises to patients and we must keep them. As Karl Weick points out, to have true commitment one must state voluntarily, personally, publicly, and in an irrevocable manner what you will do. We have done this.

Groove, a safe collaboration space

Tue, 13 May 2003 20:41:03 GMT

I have been using Groove (http://www.groove.net) for a little while. I think that it is the third and essential piece of information technology needed for cross-organizational communities of learning. (not counting e-mail which I take for granted). The first is Weblogs--the place to hold context, to get to know people. The second is something like WebCrossings--a place to have and keep discussions and documents by topic. And third, Groove for private, secure, multi-participant collaborations.

Here is a link to a web post that describes how I think Groove fits in. I like the idea "center to edge to center". We get what we know from the center, we take it off and work on it and we return it with our innovations and learnings to the center for others to then elaborate and improve upon. So Paresh Suthar, in his own words http://radio.weblogs.com/0111019/2003/05/08.html

LEADING COALITIONS, a few observations from Whatcom County, Washington

Thu, 01 May 2003 00:41:08 GMT

A few local ideas about leading community coalitions: It is about shared values--creating, unearthing and polishing them.

Jim Reinertsen, on behalf of the Institute for Healthcare Improvement, ask me to prepare some thoughts on leading coalitions from our learnings in Whatcom County's Pursuing Perfection work.

First I disclaim: I don't know. We are improvising. In fact, the key is probably improvisation.

Next, a recommendation: find at least one person that is or will become consumed by the opportunities.

Here are ten ideas we seem to be using in Whatcom County Washington as we pursue perfection in health care delivery across a community.

1. Bring the outside in.

Don't assimilate it. Protect it. Pay the money. Don't expect double duty.

Trust is the key. Find those known to be "pure of heart" and help them stay that way. If you have this role (outside brought in) understand that the relationship with the outside is the key value on the inside. Invite the Trojan Horse in. Don't lose the affiliation and affection.

You are looking for someone who represents the positive values that you share with the community and who understands the conflicting values.

2. Hire and empower successful revolutionaries as leaders.

Transformation is a kind of revolution.

They must want and see the new way more and clearer than you do.

You must support and protect them. Trust them. Trust your job to them--to the cause.

Be willing to be overthrown if necessary (but try to keep up with the revolution--the loss of your job probably helps no one except your successor.)

Ask your team and others in the coalition about their credentials as revolutionaries. Encourage a radically transformative stance. Model it. Be irreverent.

We have wonderful revolutionaries. We have people with years of successful experience with coalition building.

3. Become a story junky.

Find them, tell them, get others tell them. Make them up if necessary.

Stories around campfires have created and sustained the tribes and communities for thousands of years. Long before Excel and PowerPoint. We are programmed to create meaning from stories. Stories go to the heart and heart is what is needed for transformation.

Become the story you need.

Make sense, create new meaning with stories. From the chaos of "facts" pull out the relevance you need and storify it.

This is the job of a leader.

4. Revert to common values. Technique will not work here (yet?).

Explore values all the time.

Talk about values.

Tell stories about values.

Hire strong value-based leaders and staff for this work.

Values trump power (status quo). You must ensure this.

5. Make it up as you go.

Karl Weick talks about bricolage. A French word that does not translate well. A bricoleur is a person that can routinely make what they need from what is at hand. They can make a uniquely useful machine from spare parts in a barn and it may do the job better than anything on the market. Gather all the bricoleurs you can find for this kind of work.

Bricolage--A form of improvisation practiced by some, using whatever resources and repertoire come to hand, in order to perform the immediate task. A person who practices bricolage is called a bricoleur.

In a paper called Organizational Redesign as Improvisation, Karl Weick identifies the following requirements for successful bricolage.

intimate knowledge of resources
careful observation and listening
trusting one's ideas
self-correcting structures, with feedback

Improvisation is a related idea. Quite different than "experimentation".

Think of the "improvisational organization" as a variant on the "learning organization." More real time, more masterful. That is what is needed.

For an in depth understanding of this concept and also a related exploration of "wisdom as improvisation " see these articles by Karl Weick .

The Attitude of Wisdom: Ambivalence as the Optimal Compromise, Karl E. Weick. At this web link (on Tuesday March the 4th, '03) is a useful simple diagram and explanation.

6. Appreciative Engagement.

I have coined this term to combine two profound yet simple ideas. "Appreciative" points to a stance and techniques that are well explained by David Cooperrider of Case Western Reserve and Gervase Bushe of Simon Frasier University as well as others. The idea most simply stated is look for what you appreciate and want to see more of instead of focusing first on what you don't like and want to see less of. "Engagement" points to Axelrod's thesis that many of the problems of change can be avoided by investing in the engagement up front, at the beginning of the exploration, in all the folks who have to implement or change. Pay, listen, and engage now to avoid failure in the implementation phase.

7. Systems thinking must trump liner, simplistic planning.

Complex adaptive systems (CAS) are a useful way to think about health care and especially across organizations--coalitions. Plsek's Appendix B in the Chasm Report is the most important part of the book. The challenge of the book is to create a coherent system that will dramatically reduce the burden of illness in the citizens of this nation. Success is impossible without understanding the way complex, adaptive systems work.

Rules for optimizing a CAS:

Agreement upon clear aims (patient-centered, safe, equitable, etc.)
Follow a few simple rules (cooperation, relationship, transparency, etc.)
Ensure effective communication among the agents/parts
Provide opportunities and resources for experiments (fertilizing and watering)
Pruning (removing resources from experiments that fail to move the system closer to the aims)

Explicitly model the sytem for policy making if you can afford it.

Robert Wood Johnson Foundation paid for the modeling of Congestive Heart Failure and Diabetes care in Whatcom County. The understanding of the local health care system's dynamics is already helping our key stakeholders to come together and prevent misaligned incentives preventing cooperation. I have never seen anything like this before.

8. Get committed.

Karl Weick gives a useful operational definition of commitment. I am probably paraphrasing but my memory of it is: 1) personal, 2) voluntary, 3) public, and 4) irrevocable statement of intentions and agreements.

In a coalition, don't assume you have commitment without having all parts of this formula for each key stakeholder and leader. Get boards, CEOs, opinion leaders, and front line staff to tell their stories in a way that fulfill these criteria. Model it yourself and invite others.

9. It's about LOVE, FAITH, and FORGIVENESS.

The fuel for transformation is passion and freedom.

Only love of others and self will get you through the maze and confusion. It is the beacon and fundamental value.

Generate your faith that others will find their love and their forgiveness and that you will continually rediscover yours. Generate your faith that something great will result even if it is not what you anticipated. Generate your faith that transformation will come from clear and agreed upon aims with a few simple rules all of which are guided by love and forgiveness.

Forgiveness of self and others is the moment-by-moment skill and key competency for transformation. Pursuing perfection is not about punishing self or others for lack of perfection. We are all so hard on ourselves and others that we create an unbearable burden. Drop it. Again and again.

10. Give away (through stories) all the success.

Take responsibility for all the screw ups. There will be plenty.

--------------------------------------------

MY REQUEST--please invite new IHI faculty, specifically:

Karl E. Weick (Sensemaking and High Reliability Organizations)
David Cooperrider and Gervase Bushe (Appreciative Inquiry and Clear Leadership)
David Snowden (Cynefin Model and Cynefin Centre)
Jack Homer and Gary Hirsch (Group System Dynamics Modeling and Simulation for cross organizations, cross industry policy making.)

Totally Inadequate Context for Total Quality Improvement

Mon, 10 Mar 2003 05:58:41 GMT

Total quality management (TQM) and continuous quality improvement (CQI) have not had the expected results in healhtcare. Much effort and resources and enthusiasm has been spent. Some have said the TQM and CQI don't work in healhtcare.

Let's look deeper.
Click here to see a larger image.

I have just begun to document what will become a rather lengthy "story" or article with lots of reference and links. Click here to read it.

Lynne Brengman recalls a time of greater teamwork in nursing.

Mon, 10 Mar 2003 01:28:13 GMT

Lynne, I read your post of Jan. 27 with much interest. Teamwork is going to be key to improving the healthcare system and the work lives of healthcare providers. Nurses and doctors are not alone in the increasing isolation that has accompanied the accelerated pace and the heightened pressure to be accountable for costs globally. A book has been written by Robert D. Putnam, titled Bowing Alone. Follow this link for more information. http://www.bowlingalone.com/

I think this issue of teams and "community" are key to any useful improvement in our work and our lives.

Update from England on Pursuing Perfection

Mon, 03 Mar 2003 05:21:05 GMT

British National Health Service Magazine features article on Pursuing Perfection in England.
In a related article they say, "It is amazing how the mapping of care processes across organizational boundaries is fundamental to quality improvement."