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.
My Weblog Comments
