Marc's Weblog

Phase I Feedback and Planning (with local reflections, responses, and plans)

Pursuing Perfection: Raising the Bar for Health Care Performance

St. Joseph Hospital - PeaceHealth

Site Visit: February 5, 2002

Strengths to Build on:

· Stakeholders:

Many stakeholders are involved in this project. Pursuing Perfection is well-positioned to be a community-wide effort aiming to involve all physicians in Whatcom County, all major health care organizations, and strong representation from consumers and governmental and private sector leaders. Even more of a "town meeting" system could prove helpful in creating an even stronger, community-based sense of engagement and oversight of the project.

**Learn more about "town meeting" ideas

I do think that this is perhaps the most important step to be taken. Several things favor this step. The recent health care summit is a first step toward a town meeting/future search/appreciative enquiry.

The open space meeting to reinvent CHIC is a successful "town meeting" technique.

E-mail lists, on-line discussions, on-line stories and explanations, FAQs, web places for everyone and every organization, useful navigation and searching.

Community involvement like the BPHC's 100% Access 0 Disparity apprach would be very useful to transition Pursuing Perfection to a community asset based approach.

**Connect to the social capital thinking and work

I suspect that the relationships among health stakeholders and knowedge holders need to be visible (visual), navigable, and meaningful. We man need a Wiki-like apprach to defining relationships.

Patients, families, government, organizations, providers, other communities...

**We need to develop a well defined (explicit) network of linkages between knowledge holders and opinion leaders. This network must connect all key stakeholders so that no stakeholder is beyond the knowledge horizon (three links) of knowledge holders.

I suspect that we must implement effective on-line community-building software (navigated by associative links determined by attributes of relationships) for these new relationships to reach critical mass and for them to remain vital.

· Honesty and Openness:

The Site Visit Team was impressed by the frankness with which you revealed areas of weakness and barriers, and the openness with which you greeted suggestions and ideas. There is a strong feeling of continuous learning throughout this project.

**Displaying and discussing frankly the identified challenges (weaknesses) below is the kind of openness that is necessary if we are to address these important issues in the time frame required.

**Radio is open beyond anyone's expectation.

Each of these challenges (listed below) deserves a web site/discussion thread.

**We need to make our results on our promises more visible through the www and the newspaper, etc.

**Link to developing thinking on learning and developmental organizations.

Make notes and presentation on the key thinking of :Karl E. Weick, Richare H. Axelrod, Peter Senge, Peter Block, etc.

**Link to the open curriculum of VOISS, as it relates to team building, quality improvement, conflict resolution, dialogue, etc.

· Vision:

Strong vision from leaders and the community. The longer term ideal of community-wide health care improvement and community-wide pursuit of perfection is deeply and widely held. Your vision is superb.

**Link to vision and/or mission statements for PPLB, P2 Grant, SJH, PH, FCN, NCC, Sea Mar, Madrona Medical Group, BSC, etc.

Ask staff to accumulate each and highlight similarities and conflicts.

**Write and then link to a "Radio Story" that contextualizes the geography and life style of Whatcom county, NWMB, GHC, Trauma System, consolidation of hospitals, consolidation of physician groups, WIDS, CHR, CHIC, COMPASS, EHIworks, and now Pursuing Perfection.

Title may be, "Whatcom County, WA, a Self Organizing, Evolving Community"

The attractor (in the sense of chaotic systems) may be the common interest in patients' well being.

· Leadership:

Strong and capable leaders of the project and the involved organizations. Your project directorate is competent, charismatic, and focused. PeaceHealth's senior leaders are fully involved and are creating good reporting systems.

**Link to PPLB minutes

**Link to PPLB materials on leadership, governance, decision making, dialogue, etc.

**Link to chalendar of meetings

**Link to a page that hilights each PPLB memeber, their thoughts and their history

**Link to the PPLB team measruement profile and trend

**Link to the promises to Patients, Staff, Physicians, and Purchasers

· Patient Voice:

Strong patient/consumer involvement and voice. Patients are at the center of most of your strategic planning diagrams. Patient centeredness and a bent toward patient control was a constant theme throughout the site visit. This is especially reflected in your attention to care management across the continuum of care for chronically ill people.

**Link to Nancy Stotahrd and Connie Golas' Radio sites

**Link to a concise deiscreption of scope and role of the liasion/navigator/trainer

**Link to the work on Patient Education

**Link to every patient that is willing to be quoted, photographed, or published (Radio)

· Information Technology:

A sound base in information technology (IT) at the community level and in PeaceHealth. Your community-wide IT system (HInet) provides substantial connectivity in most clinical offices. PeaceHealth's inpatient electronic medical record (EMR), used at St. Joseph Hospital, is directly accessible from physicians' offices.

**Link to HInet site.

**Link to EHIWorks site (Is there one?)

**Link to IDX site

**Link to explaination of PeaceHealth and SJH measurement and data capability

· Physician Cooperation:

Many physicians are clearly committed to participation. Several important medical groups in Whatcom County, most crucially "Family Care Network," have formally agreed to be full participants in the project, accounting for about 30-40% of the Whatcom County doctors at this stage.

**Link to physician web sites where they address cooperation in P2

**Link to Radio sites of physicians in P2

**Link to professional society web sites professing similar aims and means

**Link to professional journal articles supporting similar aims and approaches

**Link to letters of commitment to the project

· Quality Improvement Experience:

A pragmatic and experienced approach to quality improvement. The hospital has a skilled facilitator cadre, and a good history of well managed improvement projects. You use a wide array of helpful frameworks, such as elements of the Toyota production process and "lean thinking," as concept bases for projects (though deployment is not complete even in the hospital).

**Link to HCDI curriculum

**Link to ICSI site

**Link to CHIC and discuss the history and possible next phase for CHIC

**List bibliography and web links to the "helpful frameworks"

**List local resources for QI

· Chronic Disease Model:

Mastery of the Wagner chronic disease model. The Site Visit Team saw pervasive use and understanding of a good systems model for chronic disease care.

**Link to Wagner model

**Link to Planned Care web site

**Link to Whatcom model (systems)

**Link to patient centered model (Turkovich)

· "Systems Dynamics Model":

The "systems dynamics model" that you have built with two consultants is a breakthrough. This model would be of help to every Pursuing Perfection site, and gives a new tool to the industry for exploration of the "business case for improvement."

**Link to Chasm appendix B, CAS

**Link to a web site specifically on System Dynamics and our process and results.

**Get Gary and Jack a Manila site

· Will for Change:

The need for change is great. Your community has the will for change, since there are strong threats to your continuing excellence, especially a declining physician population.

Challenges to Address: (link each into project plans that the public can see on line)

· "Governance Model":

Develop the community-wide "governance model". Establishing details of the authority, commitments, review procedures, and other key aspects of the "Pursuing Perfection Leadership Board," would secure a more stable leadership foundation. (For example, the project could create "winners" and "losers" among the members of your current guiding coalition. Will the leadership group remain together and a true team if, for example, the improvement of chronic disease care leads to a shortfall in hospital revenues or a shift of visit income from physicians to care coordinators or from specialists to primary care clinicians? ) Like all coalitions, this one is always fragile. Your Board could be especially helpful in maintaining constancy of purpose for cooperation.

The issue of winners and losers is very important. Not only will the relations on the PPLB need to evlove toward trust (thorugh dialogue and repeatedly positive experiences) but we must have decision making practices that ensure fairness. This is where group system dynamics modeling and simulation comes into its own. Creating shared understanding of the parts and simulation of the results of policies, ahead of the decision and implementation. Much of the uncertainty that generates fear from working to gether can be removed.

"True team" is essential for the PPLB, even to a greater level than any of the organizations may have internally in their organizations. The streach goals of the PPLB are likely more stressful that the goals of any of its member organizations. Thte board is very aware of the need for teamwork, vision, and leadership. The questions of authority and ability to commit their organizations are still unanswered and are of concern.

It may be that the PPLB and ultimately CHIC will need to govern such a valuable set of resources that they have influence born in their ability to supply scarce resources to important problems that providers and payers want addressed.

**Link to the structure of the PPLB and CHIC

· Spread Strategy:

Plan more precise spread of improvement strategies. The proposed spread strategy for chronic care management to all physicians in the community seems informal and intuitive, rather than self-conscious and planned. (This could be a strength, also, reflecting the tight-knit culture of Whatcom County where personal relationships may well be a sound spread plan in part.) Spread of changes within the hospital also seems rather informally designed and guided.

Considerable thought has been given to the concept of spread. Some of the spread can be planned in a rather mechanical way. Some of the spread will occur in a complex adaptive system (non mechanical). The strategies are different by definition.

**Links to our discussion of spread in social networks and complex adaptive systems.

It is reasonalble for each of the four participating organizations to plan the spread within their organizations.

**Links to the plans for each organization

The specific details of the plan for spread within the hospital must follow the development of the virtual care teams, the roles of the nurse specialists, the shared care plan, and the medication handoff approach.

**Link to the plan for spread in the hospital.

Spread to other organizations and physician groups is a different kind of problem. We are working hard to learn the best way to visualize the networks that will support or hinder spread.

**Stay tuned.

· Human Resource Strategy:

Build a more complete overall human resource strategy. No plans were in evidence for building needed skills and capabilities in the physician workforce. Nor did there seem to be a tightly designed plan for hospital workforce development linked to Pursuing Perfection as a strategy.

We do have plans for developing the skills in the staff.

Some of the physician leaders have extensive training, skills, and capabilities. What is not clear, nor do we have a plan around it, is which physicians need enhanced skills and what might those skills be.

The demonstrated success in leadership of physicians is spotty.

It may well be that redesigning the micro-systems to support care that meets the Six Aims of the Chasm report is the best way to engage the physicians, rather than some sort of wholesale marketing and sign-up approach based on philosophy. Perhaps this is to cautious or even wrong-headed.

· Transparency:

Continue working on transparency issues. You seem somewhat tentative in your position on complete transparency. For example, you have a lot of information on your performance on some key service and clinical variables. You have a tentative commitment to internal accessibility of that information, but are chary of releasing data to the public on matters not currently booked for improvement. Legal concerns were mentioned several times. Therefore, it is uncertain whether progress and defects regarding the pursuit of perfection will or will not be available to the public.

There is an adoption curve here too.

I suspect the resistance will drop when there is emotional commitment to patient-centered evidence-based care.

The growing evidence that this kind of transparency does not increase liability payouts is reassuring.

· Electronic Medical Record (EMR):

Increase your pace of progress towards the "community-wide electronic medical record" (EMR). An EMR already exists on HiNET for inpatient records, but is not yet very far along for an outpatient EMR. The slow-down is in achieving a consensus among the community physicians about the specific record system to be purchased (IDX or not), and the EMR plan could run into trouble if different physician groups have strong and different preferences. (Additionally, IDX can be a helpful vendor, but, as a vendor, it will have its self-interest in mind and could create an unhelpful dependency.) Your IT capabilities are very strong and could move quickly if progress does not founder on these issues of consensus about the EMR. This delay may compromise some elements of the project's proposed progress toward integrated chronic disease management. Given the capability, you could probably move more quickly.

We need to create the forum and the process of decision making that is supra organizational and that focuses on patients.

· Information Technology:

Develop a more specific, clearly articulated, step-wise IT development and deployment plan. Your current plan for further development and deployment of information technologies is vague at the detail level. Your vision to have a community-wide EMR, widespread use of consistent care management plans, a single master patient drug list, and many other features is exciting. The roadmap for how that will be achieved seems hazy at present.

The Purusing Perfection Leadership Board (PPLB) must work together to even have a vision on this topic.

We must engage the patients and the payers in this visioning.

We must, as a group engage the participant organizations' membership and beyond in the vision.

We then must develop a specific, feasible plan to implement the vision.

Right now there is not general agreement that the patient must be at the center of EMRs. Some still feel that the provider is the center.

The parts of a "system" (using the term very loosely here) that are needed are:

Shared medication list

Shared problem list

Shared plan of care

Shared medical record

Shared educational material

Shared clinical outcomes measurements

Shared chronic disease "registeies", really population data management systems

Perhaps what we need to do at the PPLB level is set up time to work on the vision and the decision making process.

· Specify Results Targets:

Your results targets are bold but not as specific as they might be. The "promises" you propose are inspiring and ambitious, but they are not yet linked to targets or benchmarks to be achieved "by when" along the way. This is work that each organization must address.

**Link to our promises here.

**Link to our measuress and results here.

We need to create a matrix with Promises/Targets/Organizations/Results.

The British Health organization prblishes thier results openly and we need to do the same. We should be able to get at least the results they are able to since we spend twice the money for our results.

· Communications and Marketing:

Develop further your communications and marketing plan. Your current plan has the feel of an afterthought. It is good, but not particularly innovative. Your "town meeting" approach to keeping consumers informed, for example, videotaping the site visit for later use in explaining the project to stakeholders and the community, is right on target.

We have a communications plan.

This "revolution" in design of patient-centered health care delivery must be infectious. It must resonate with the values and deepest beliefs of providers and patients. It must be economically feasible. There must be clarity about what we are doing and how it impacts those who join in. It must spread from trusted collegue to rusted collegue.

We are considering haveing the perfoming troop from Minniapolis come out.

We will use very open web based communicatoins that allow anyone in the community to follow along and participate in the dialogue.

We will enage the business community.

We have parterned with several of the payers and we are talking presently with Medicare and Medicaid.

We will continue to use on site poster boards, articles in the newspaper, TV spots, radio spots, talks to community groups and political groups.

· Physician Sign-up:

Secure more complete physician sign-up to the project and aims. Move as quickly as possible in this area. The current work is incomplete and may be fragile if the economic climate for the physicians of Whatcom County continues to worsen.

We essentially need to develop a "marketing plan" that engages most or all physicians in Whatcom county. The question "what's in it for me?" must be ansewered.

The normal addoption curve is to be expected.

The pilot sites are the innovators. We must devise a strategy and implementation to cross the chasmin order to reach the early adopters. They will convence the early majorty, who will lead to late majority.

We must estimate the resources needed to sustain such an adoption curve.

· Business Case:

Develop a more precise and complete "business case" for improving chronic care. If the chronic care project works, admissions and associated revenues will fall substantially. The hospital's current business analysis assumes that this will relieve pressures on beds and reduce capital needs in the future. This analysis seems more intuitive than precise.

System Dynamics modeling and simulation is a key strategy to generate a more precise and complete DYNAMIC business model for this community.

· Develop Succession Plans:

Several leaders seem especially key. Succession plans may be helpful.

The PPLB need to take this issue on directly.

· Constantly Assess Decision-making Processes:

Some decision processes are slowed by the need for consensus (e.g., the EMR, public release of clinical performance information), which in turn may slow overall project progress. Reviewing decision processes may be helpful.

THIS IS CRITICAL AND URGENT AND DIFFICULT. We need help here!

· Keeping the Provider Community Vital:

Practice conditions, especially physician incomes, are deteriorating steadily in Whatcom County. To succeed, you will have to find ways to make this an attractive community to practice in.

**Link to the Access work being facillitated by SLF.

**Write a story on the relationship of IDCOP, IT, Activated Patients in making this an attractive community for physicians to work in.

**Link to the System Dynamic work and the Business Case section.