Interesting site from someone pondering, actually figuring much out, about relationships.  http://thinksmart.typepad.com/

Weblogs and the links to other folks are wonderful.  One finds interesting people and contexts that mirror one's own situation.    One of the bloggers I subscribe to had a link to a post http://urlgreyhot.com/drupal/node/view/1612  on children's readiness to learn. 

This isn't only true of children, it is the human condition.  We are talking about this very same thing  in the context of heatlhcare, and patient's readiness to change things about themselves, their habits and behaviors to improve their health.  We are talking about physician's readiness to engage in real dialogue and relationships with their patients, and their readiness to accept the patient where they are.

At last we have been able to expand rollout of the Shared Care Plan, still for now within pilot sites, the two Family Care Network clinics and the hospital.  Online registration has simplified what has been a somewhat onerous manual process.  Now motivated and computer literate individuals can self register.  Within days of rolling out to St Joseph Hospital employees, 38 had used the online process to create their own plans.  Awesome!  Thanks to Dawn and Jonathan for their work to set this up.

Soon a marketing plan will be finalized to more make the Shared Care Plan more widely known and available to the broader community.  More to come.

A story of grassroots spread of the Shared Care Plan - courtesy of Dawn Gauthier~

 

Patient spreads awareness of the Shared Care Plan.

I've always suspected that usage of the Shared Care Plan will spread among healthcare professionals mainly by patients asking them to use it. Here's a story from a nurse showing how this kind of spread can happen:

My name is Ida Richards, and I am one of the pre-op nurses at Pacific Rim Surgery Center.  I was interviewing a patient by phone on Friday afternoon in preparation for surgery tomorrow.  He asked me to access his Shared Care Plan for the information.  I had to tell him that it was a new concept for me, but I was willing to look into it and learn about how to do this.

I called Jone Hoag and asked her, and she asked me to contact you on the protocol for this process.   I am assuming I would have to get a password set up, and clearance, and then the patient would have to give me their password.  I did not obtain his password – I wanted to see how to proceed first.  He is very willing for me to do this, so let me know if it is something that can be set up.     

Thank you.  I think this has great potential for the patients, when we get this set up.

This is an excellent example of an empowered patient realizing that he didn't necessarily have to fill out yet another admission form asking for all the same information as the last one he filled out: "All that information can be found accurate and up-to-date online in my Shared Care Plan!"

When I called Ida to orient her, she was very impressed at how easy it was for her to login (using her existing NT login) and use the application. In a follow up email, she added:

I did access the Shared Care Plan and found it to be wonderful!  The gentleman ended up not having the surgery at our Center, but it was nice to learn the process and to save him the effort of retelling all of his history.   I will look forward to having more patients have this option available to them as they gain knowledge and comfort in this new techno age!   Thank you,  Ida

As a result of this story, we started seeing more clearly the opportunities that might be possible with the Shared Care Plan. For example, our community has already agreed to standardize the "Patient Health History Questionnaire" that all patients have to fill out every time they need to have a procedure done. Wouldn't it be nice if this long and involved questionnaire could be automatically extracted from the Shared Care Plan when needed instead of asking patients to fill it out time and time again?

How many of the multiple forms used in our healthcare community could be supplemented with information from the Shared Care Plan? Imagine if patients only had to fill out forms that asked for information not already available in the Shared Care Plan: how much time, aggravation and guesswork would be saved if patients didn't have to write out their medication lists and diagnoses every time they had an encounter with system? Aiming toward having fewer and standardized forms throughout our healthcare community and having fewer data sources from which to fill them out is crucial for everyone's sanity, both patient and healthcare professionals, in this age of being overloaded by inaccurate, out-of-date, and isolated silos of information.

Thank you to the patient who was willing to ask a healthcare professional to try something new, and to Ida for being so willing to try it!

[Dawn Gauthier's Blog]

Terrifc news and recognition for terrific work, Thanks to Annie Gort, Dawn Gauthier, Jayson Olson, and Jonathan King for their most excellent efforts in developing patienpowered.org and Shared Care Plan web resources.  So nice to get confirmation that we are on the right track!

Please see Dawn's post below for more on the recent award and her weblog for more info on the design principles that led to this honor...

PatientPowered.org wins award!.

PatientPowered.org was recently recognized by receiving a silver eHealthcare Leadership Award in the category "Best Care/Disease Management Site". This award was presented by eHealthcare Strategy and Trends at their annual "Leveraging Technology and the Internet" conference that I attended earlier this month in Phoenix. At the awards ceremony I was impressed to learn that PatientPowered was selected to receive an award from almost 1200 entries reviewed by 104 judges!

PatientPowered excelled in the following features for this category: medical management tools and news and information available online to help consumers manage a chronic condition, two-way communication between patient and health practitioners, and opportunities to monitor clinical care. These points are exactly what the PatientPowered website, coupled with the Shared Care Plan, was designed to do and it's great to be recognized for this.

A big shout-out to Annie Gort (missing from photo), who did incredible work with patients putting together the bulk of the site. Left to right: Jonathan King (Web application developer), Dawn Gauthier (Web development analyst), and Jayson Olson (Web application developer).

[Dawn Gauthier's Blog]

Due to an expressed interest by a local school district and a desire to spread the chronic disease model to a population that could start early on managing life long chronic disease states, a couple of us met with a Special Needs Coordinator and three school nurses to discuss their potential use of the Shared Care Plan.  This session was an eye opener which confirmed the value and need for truly coordinated Virtual Care Teams. 

Communication is sketchy between local healthcare providers, parents, out of area specialty providers and school officials trying to manage the daily education and healthcare needs of students with diabetes and other conditions.  The school district has an impressive set of tools and guidelines for handling variations in blood sugar levels, but much better coordination is needed among all who are involved in the care.  In addition to monitoring status and creating care plans for the students, the school nurses really end up supporting these kids as they learn to manage their own conditions. 

The Shared Care Plan, and the Virtual Care Team concept being tested here in Whatcom County have promise for bridging the communication gap for these students, their healthcare providers, and families.  We need to further explore how to make the other tools, such as the state's individual health plan more readily available to other care team members. 

Our encounter reminded me of the system in Jonkoping Sweden that Marc Pierson described after the recent visit by Pursuing Perfection Project Leaders and executives.  In that county,  children receive the majority of their primary care in the schools.  It makes so much sense.  How can we get there, or at least build a system to support the care and communication needs?  I believe we are on the right track.

We use the term 'patient-centered' frequently, but often it is more of a philosophical ideal that is referenced rather than a practical application.  Mary Minniti shared the following definitions of four models which were presented at the recent Family Centered Care conference she attended with our patient representative Hal Peterson.

How does your practice view and act on the relationship between patients and health care professionals?  Consider how you'd like it to be, and what it actually is now...Think about how you  might realign your practice flow, and language to move you closer to your vision. 

• Proponents of professional-centered models view professionals as experts who determine patient's needs from their own, as opposed to a patient's and family's, perspective.  Interventions are implemented by professionals with patients and families being passive participants in the intervention process.
• In patient or family-allied models, patients are seen as the agents of professionals, and are enlisted to implement interventions that professionals deem important and necessary for optimal functioning.  Professionals enlists patients and families to implement intervention under the guidance and tutelage of the professionals.
• Advocates of patient-focused models view patients and families as consumers of professional services, and assist patients and families in choosing among options that professionals consider necessary for best meeting patient and family needs.  Interventions focus on monitoring patient use of professionally valued services.
• Proponents of patient-centered models view professionals as instruments of patients and familiies, and intervene in ways that (a) are individualized, flexible, and responsive, adn (b) support and strengthen patient and family functioning (see Dunst, Trivette, & Deal, 1994; Dunst, Trivette, & Thompson, 1990).  Interventions emphasize capacity building and resource and support mobilization by patients and families.

These models refer frequently to families because they have been defined through studies focused on pediatric practices, however they are applicable for all patients and their support networks, whether they are based in family, friends, or other support environments.

Having just posted updates by pilot site, here now are the remaining updates by activity and staff member that didn't fit into site specific categories:

Project Coordinator Heather is returned from her conference and is planning for the transition to a new administrative support staffer to replace Zachorelli Frescobaldi, whose last day was this week.  There will be a gap in coverage, and as a result, some things, such as the communication committee, are on hold, or may be progressing more slowly than first anticipated. 

Our grantwriter, Cat, is using a Groove website info in her application for a Medication safety grant.  She is also exploring the possibility of funds from Microsoft.  Sterling/Olympic Health Care are submitting a demonstration project to CMS.  The Kellogg grant application is still in the queue to go to their board, now scheduled for September.  A donor database is finally complete and proving a great tool in her efforts.

Mary, Project Manager, is working on:

• Patient representative guidelines
• Connecting with Patient rep Hal regarding a Boston presentation
• P2 Report to the leadership board includes statistics on patient centeredness assessment
• Pursuing Perfection Leadership board reports now have 'green, yellow, red light' designation to signify which items are progressing as planned, needing attention, or have hit a barrier the board needs to address.
• Whatcom Pursuing Perfection effort has been nominated for an E-health award
• AHA highlighted P2 as 'best practice'
• Eric Coleman also wrote up the P2 project in an artcle to be published in January.
• Focus is on 'results' for pilot sites.

Our Data Analyst Duo, Christine and Brian reported that:

• Graphic tutorial of Patient Satisfaction Survey results is complete and ready for deployment to the pilot sites.  This will be a screen saver for the touchscreen pcs, and will display the specific results for site.
• This month's leadership board report is ready.
• Both are working on the Chronic Disease Datamart to support reporting on all chronic disease states.
• Revamping the reports to IHI and pilot sites
• Evaluation Team Survey is coming, will be sent to all pilot site staff and half of hospital staff.  1000 responses needed for statistically significant sample.  Will go out on paper after consideration of electronic option.
• Patient activation scores are going down for reasons that are currently not clear.  Will be meeting with Clinical Care Specialists and Psychomatrician Bill Mahoney. 
• Patient activation surveys online still pending.
• Working to streamline data reporting processes and select a core set of tools with Measurements Outcomes and Methods (MOMs) Team. 
• Enthusiastic about Groove as a tool for collaboration.
• Pulled data for presentation by Nancy Stothart and Cindy Brinn.
• Assorted other 'ad hoc' report requests

Clinical Care Specialists - Connie and Nancy shared:

• Though at the limit, they are still taking new patients as referred.
• Major concern re the types of patients referred, focus should be on
• Complex issues
• Newly diagnosed diabetics
• Finding incompatible problem lists - need to design better referral form/process
• Question about whether or when to 'discharge' or reduce contacts for patients who do not want to be involved with Clinical Care Specialist - readiness.
• Very important to have PCPs and Specialists consult with each other..
• Maintaining SCPs continues to be a challenge.
• Receiving positive patient feedback
• Patients liked the picnic
• Patients like the opportunity to share
• Diabetes classes well received, they want more.
• Capacity affected by patients with multiple diagnoses, working with whole patient, not just their diabetes...
• Carol Boston-Fleischauer of PeaceHealth is researching and reporting on similar case managers in the US.  Report will be presented to the Leadership Board and Medical Directors.

And finally, our Project's Executive Sponsor, Marc Pierson, MD told us of his activities and findings:

• Idealized Design for Office Practice is critical for improved results
• Advocacy Concept
• CMS demonstration project
• Appropriations bill (Congressman Rick Larsen to visit in August  - efforts also in Ketchikan)
• eHealth Initiative - (Janet Marchibroda with eHealth Initiative and Carol Diamond of Markle Foundation to visit in August with IDX and GE representatives)
• Has met with representatives of large pharmaceutical companies, Johnson & Johnson, Pfizer, AstraZeneca...
• Patient Safety Institute
• Spread and Sustainability assurance
• Congressional and Senate representatives, Sen Patty Murray, (aide Mary Conway)
• Dennis Wagner, John Scanlon - Spread concept to 600 communities
• Spread beyond Whatcom
• Additional chronic disease states managed
• Community of Innovation necessary to spread wider
• Communicates to PeaceHealth & beyond
• Immunization registry work also spreading

 

The Whatcom Pursuing Perfection staff are tackling healthcare transformation on so many fronts that they are infrequently in the same place at the same time.  One day last week provided a happy exception with the staff gathering to share status of their various efforts and visions for the future.  Christine posted the hopes and dreams for a year and beyond in her weblog, here's what is going on right now at the pilot sites:

Family Health Associates

• 4 teams have been established to address transformation activities: 
• Communication - dubbed "Culture Club"
• Process Flow
• Planned Care
• Access
• Staff are overcoming historic barriers
• Not being listened to (Improved listening/Action)
• Communication issues
• Completed work includes
• Data Collection regarding Supply/Demand
• Changing appointment timing to simplify scheduling and increase flexibility
• Using the Patient Activity Report (PAR) to make decisions for change
• Defined Population for Heart Failure registry

Ferndale Family Medicine

• Reorganizing Teams - Next level of Evolution
•  Patient Outcomes Team
• Flow Team - Collaborating with outcomes Team to support improved outcomes
• Group Visits are going very well
• Good outcomes for patients
• 3 out of 4 docs are doing group visits
• Implementing electronic Shared Care Plans with patients
• Office Relocation postponed for as long as a year
• Trialing patient e-mail system 'In Touch' - Berdie Safford and Dave Lynch - Patients pay for svc.
• Collected data on Supply/Demand - will start redesign in October
• Restructured patient panels

SeaMar

• Continued implementation of Diabetes Registry
• Medical Student establishing Shared Care Plans for spanish speakers
• One physician to trial RxPad use for his patients _PCs installed in two additional exam rooms
• Reconnecting leadership communication pathways due to changes in organizational structure
• Data being pulled from billing system to ID HF patients for registry entry
• Superusers trained on electronic Shared Care Plan entry

Center for Senior Health

• Completed Supply/Demand data collection
• Working on the Delay data collection
• Re-affirming sponsorship
• Completed a 6 week intensive trial of small tests of change for Shared Care Plan utilization models with Erin Baumgart, ARNP
• Lots of learning about patient readiness/communication/medication list accuracy/encounter design

North Cascade Cardiology

• 2 Data entry clerks hired
• Entering information info Heart Failure registry, verifying through retrospective chart review
• Improving Anti-Coagulation Therapy registry process
• Nicole's interview results have been shared with followup action steps and continued assistance
• Experiencing leadership change - Roland Trenouth to retire and pass baton to Don McAffee
• Hiring two new cardiologists
• Developing processes for Implementing electronic Shared Care Plan
• Planning remodel and relocation of practice to consolidate from two floors to one

St Joseph Hospital

• Patient Centricity
• Launched Sensory 101 program
• Project Teams for P2 - completed
• Cardiovascular Center Staff - completed
• 2nd Med/Surg Unit (new teams) - completed
• Expect about 200 clinical staff will have been exposed by end of Summer (25% of clinical staff)
• Innovative Patient Education (IDEA team)
• Heart Failure and Diabetes
• Developing Info Packets for patients (to be available paper and web)
• Type I & Type II Diabetes assessment tool, critical skills, and additional patient selected learnings
• Heart Failure adapting materials developed by Clinical Care Specialists
• Developing screen in LastWord (EMR) for patient education and documentation
• Enhancing the Nursing Care Plans with Patient Education Information
• Developing protocol for staff to follow for patient education
• Includes scripts for clinical staff to use
• Staff Development
• Teach new process
• Computerized training module - will be mandatory module across organization
• Working on ideas for how to engage pysicians in these opportunities for learning
• Initial planning for community wide full day workshops
• Evidence Based Practice Guidelines
• Terry Wagner-Conner taking lead
• Heart Failure order sets being revisited -  ETA soon
• CABG order sets also being revisited
• Inpatient Diabetes order set will be reviewed next
• Implementing the Electronic Shared Care Plan and Medication Safety
• Pop up message in LastWord will turn on August 4th.  Notice visible to anyone activating a patient who has an electronic Shared Care Plan.
• Cross functional flow chart for updating roles in each department completed
• Updating existing shared care plans only at this time
• RX Pad meds display in Shared Care Plan and can be added to Shared Med List one at a time (future add all in design)
• Hospital will use RxPad for discharge medications for all patients
• Agreement among pilot units to update as they touch the SCP.  Social services staff to have ultimate update responsibility for goals etc.
• All patients will have a Shared Med List

 

 

A question continues to surface...Who should have a Shared Care Plan? 

Our natural tendency and focus as caregivers has so far been to go for the most complicated patients first...the multi-diagnoses, poly-med folks, who are frail and least able to accurately and consistently communicate their mass of information to their horde of health care professionals.  Indeed, for one of our clinics here in the Pursuing Perfection Project, almost their entire population fits this description.  Another clinic has an abundance of patients who are non-English speaking and, in many cases not literate in any language, so communication around healthcare issues is a special challenge.  

Shared care plans for these folks are clearly necessary, and require one on one conversation and explanation to complete and maintain.  These patients and their caregivers can see the value, appreciate the interaction, and can feel the safety the document creates.  However, this also presents a challenge of resources, the manpower, time and reimbursement for a care model which allows these conversations to occur.

As we strive to encourage self-management for the 'walking well' folks with earlier stages of chronic disease, and pre-cursor conditions to those diseases, we face a different challenge. Articulating the value of the conversations, goal-setting, and documentation of the much smaller number of conditions and medications is essential.  Yet both caregivers and patients can feel it 'isn't necessary'. 

I know I need a shared care plan. I consider myself a healthy person, and an activated patient with inside knowledge and comfort with the medical 'system'.  I only have three meds, two for hypertension and one for mild asthma.  I have tried other meds for the hypertension which cause reactions.  My chart reflected that I was still on one of those discontinued meds though I stopped it after a single dose.   I like most everyone else, have a Primary Care Doc, a Specialist, a Dentist, and Opthalmologist, and a Pharmacist.  They can all prescribe things that could have an interaction with the others, or healthcare conditions.  I've been in the Emergency Department and forgotten to mention the inhaler.  I might someday be hospitalized for a car accident and need my ongoing maintenance meds.  So, I carry my paper shared care plan with me.

 

v    Patient Satisfaction Survey in place at all pilot sites     

?         Results shared regularly with P2 sites and RWJ      

?         Implementation team adds meaningful measures of progress toward goal

   

v    PatientPowered.org site developed  

?         Grant information       

?         Documents, Teams, Calendar       

?         Shared Care Plan access      

?        Links to medical reference resources for patients and clinicians 

 

v    Shared Care Plan application developed and in  use

?         Clinical Care Specialists' have ~50 patients with Electronic Shared Care Plans

?         Phased rollout of Shared Care Plan use in progress by P2 sites 

?         Download of demographic data for 3400 patients done to faciliate SCP creation    

?         Links from Diagnoses to HealthWise database

?         RxPad display activated

?         Patients Love It 

?         Non P2 health care professionals enthusiastic upon encountering SCP

?         Identified LW screens for expert rule to display notice re existence of SCP   

SHARED CARE PLAN

Implementation Status, Successes, Learnings

       

Sites Start on Schedule

 

 

v     Ferndale  Family Medicine 

o       Primarily updating existing electronic plans    

§         Using paper process at time of visit      

§         Have process to identify Shared Care Plan on Charts, in Practice Mgmt System             

§         Tested and timed creation of a Shared Care Plan    

§         Medical student will work on plans during internship

 

 

v     Center for Senior Health    

o       Multiple small tests of change      

§         Group visit with 2 patients  

§         Updating existing Shared Care Plan(s) during visit  

§         Group visit with 6 patients  - sent paper version in advance     

§         Timing entry of data   

 

 

v     SeaMar     

o       Preparing for use now 

§         Planning to pilot RxPad (prescription writer in LastWord Electronic Medical Record)

§         Need to identify their Heart Failure patients   

 

 

v     SJH  

o       Implementation meetings now happening      

§         Have seem demo of Shared Care Plan and received operational definitions 

§         Team to identify where Shared Care Plan would be of most benefit during hospitalization

§         Patient team members will complete Shared Care Plans on paper during meeting      

 

v     Operational Challenges  

o       Information Technology resources to make needed changes/maintenance       

o       List of application adjustments/maintenance issues ranging from small to larger scale            

o       Server Performance - Application Performance     

o       Time required for completion of a Shared Care Plan     

·        minimum 45-90 minutes each  (5000 patients = 5000 hours - 2.4 Full Time Eqivalents working for one year)

o       Patients who 'need Shared Care Plan most' are least computer savvy - have most info to enter - need 1:1 assistance HF patients not readily identfied in all sites   

o       Lack of Staff in clinics to register patients, enter Shared Care Plan data 

o       Need to identify reimbursement mechanism for Shared Care Plan visits  

o       PCs in exam rooms still not prevalent

 

 

v     Strategies     

o       Prepopulate as much data from existing sources as possible

o       Send paper plan out to patients in advance for completion and interim use    

o       Secure Community resources to assist in interview/data entry, i.e. Whatcom Community College Medical Assistant program students, nursing students, libraries

o       Create Value added functionality to encourage Shared Care Plan use (i.e. Med Flow sheet for paper charts)    

o       Explore feasibility of donated Personcal Computers to expedite use       

·        Cost to upgrade and configure approaches cost of new pc       

 

Only through awareness of the impact our language can have, can we communicate effectively and work successfully with others.   I am thinking perhaps we should build a lexicon or at least share here our thoughts on words that 'set us off', commonly used terms that you or I might use - that unintentionally offend those we mean to work with.  Words that can get in the way. 

All of us frequently speak from habit.  We repeat terms we've heard and used and know what we mean by them.  But these words can create unintended problems for the collaborative work we are trying to achieve.  So, in the interest of getting the discussion ball rolling, here are a few I've become aware of, please share any terms that you suspect create a different reaction in you, than you believe the user intends.

I am a chronic user of the term Providers, I believe I first started using it when working in the Community Health setting, where ARNPs and PAs were prevalent alongside Physicians.   I later became a Provider Relations representative at a local payor.  I believe the original intent was to have one term that covered all health care professionals...however this innocuous term can be offensive to people who have dedicated their lives to the health care profession...For some the preferred term is 'Health Care Professionals'.  I am endeavoring to break my habitual usage of providers and switch to Health Care Professionals.  Please bear with me, old habits die hard.

Empowerment is used as a good thing...giving power to someone who has or feels they have none.  It is about balancing the power in a collaborative relationship vs total shift, black and white, "I had the power, now someone else has it' manner, however the latter perception exists...

Strategy - a commonly used term that elicits military images for some.

Community - an oft used word that can have surprising reactions based on communities with which one has been associated.

Patient - there is a school of thought that asserts we should refer to patients as customers.  The intent there is to be more cogizant of what they want, vs what we think they need.  A good intent regardless of the term used...

Diabetics and other 'Person as disease' terms - Again an attempt to economize on words by having a term to group all the "people with diabetes or epilepsy".  Patients are people first, let's remember that with our use of language and not simply label people as their disease or injury. 

Ultimately, our language shapes our interactions and our outcomes.  We must try to use language that creates the world we want to live in.  That said,  language is habitual and requires practice to change consistently.   As listeners, I hope we can control our reactions to those terms that set us on edge and assume good intention on the speakers' part.  At any rate, we should continue to let one another know about these things so their unwitting bad impact can abate.

As we transform healthcare, the hardest parts of the work are related to cultural change and human interactions...The parable below reminds us that we all bring unique experience, perspective, skills, and flaws to this process.  Let us continually appreciate these differences and build on the richness they contribute...

A parable, author unknown...If anyone can cite the author, please let me know...

A water bearer in China had two large pots, each hung on the ends of a pole which he carried across his neck. One of the pots had a crack in it, while the other pot was perfect and always delivered a full portion of water.

At the end of the long walk from the stream to the house, the cracked pot arrived only half full. For a full two years this went on daily, with the bearer delivering only one and a half pots full of water to his house.

Of course, the perfect pot was proud of its accomplishments, perfect for which it was made. But the poor cracked pot was ashamed of its own imperfection, and miserable that it was able to accomplish only half of what it had been made to do.

After 2 years of what it perceived to be a bitter failure, it spoke to the water bearer one day by the stream. "I am ashamed of myself, because this crack in my side causes water to leak out all the way back to your house."

The bearer said to the pot, "Did you notice that there were flowers only on your side of the path, but not on the other pot's side?

That's because I have always known about your flaw, and I planted flower seeds on your side of the path, and every day while we walk back, you've watered them.

For two years I have been able to pick these beautiful flowers to decorate the table. Without you being just the way you are, there would not be this beauty to grace the house."

Moral ~ Each of us has our own unique flaws. We're all cracked pots. But it's the cracks and flaws we each have that make our lives together so very interesting and rewarding. You've just got to take each person for what they are, and look for the good in them........

As I read Marc's post, I have to agree that interest in the concept differs tremendously from commitment to making that concept a reality.  Practice redesign, and implementing the shared care plan means that for right now, doing things differently may mean doing something extra.  Working within the constraints of a grant means the clock is ticking.  We can't defer taking the steps necessary to meet our commitments.  Without that we won't have a true test of the new model.  The benefit of doing this will accrue to us all, as we develop a true system of healthcare delivery that provides financial support for providing patient-centered care that safe, effective, efficient, timely, and equitable.

 

Convenience vs. Commitment.

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.

[Marc's Weblog]

I just returned from today's Dialogue session.  The memory fails for the details, but the feeling of community remains, of being connected to my companions in Dialogue, of being incomplete without their shared perspectives.  Once again we arrived at the common themes of trust and relationships that so frequently surface.   Here's where we started.

What would it take to have a culture in which healthcare mistakes are fully disclosed,  viewed in a human light, without fear of reprisal or litigation, with a shared understanding that there was not intent to harm,  with intensive efforts to understand the causes of the error with  the goal of creating safety nets, systems and processes to prevent reocurrence.  

It will require shedding the cloak of fear and secrecy; emphasis on personal relationships and responsiblity, admission of fallibility, and forgiveness.  Dedication to change the way things are done in support of better more reliable care.

A recent Pursuing Perfection (P2) staff meeting began with  a request that each person name two successes. As the stories were shared, the energy of the team built.  All realized that although much was still to be done, much has already been accomplished.  Everyone had experienced successes, here are just a few:

• A palpable change in the morale and climate of one pilot site was described as a change in greeting from a dread-filled question "What do you want?" to an enthusiastic and pleasant "What can I do for you?"
• Diabetic educators report that several formerly non-compliant patients had been able to lower their Hemoglobin A1c levels
• Spread is already occurring to include Hoagland pharmacy who will work with the Clinical Care Specialists and even accompany them on certain home visits to patients with complicated medication profiles
• The Shared Care Plan is beginning its rollout, with positive responses to those who see it for the first time even without prior involvement in P2
• Collaboration is making things happen that couldn't otherwise occur, such as North Cascade Cardiology's Mary Woodmansee's efforts to supply source data for the Systems Dynamic Modelling
• Even prior to a formal rollout, the patientpowered.org website is having a positive effect.  A pilot site reports a patient who hadn't been seen in 18 months had decreased a Hemoglobin A1c levels and was proving to be quite a cheerleader of the web resources at a recent group visit
• A deeper, applied understanding of the real meaning of 'continuous healing relationships' has been achieved
• Cambridge MA group is excited about the Shared Care Plan
• Pursuing Perfection Participants across the nation are proposing a demonstration project with CMS
• A recent meeting with the Senior VP of Marketing for IDX showed promise for needed funcitonality for SNF MDS reporting and receipt of Pharmacy fill data
• An Audio and Video server for our Radio Community is in the works
• UpToDate is now avialable to HInet and PeaceHealth providers  (this is a web based subsciription reference resource that Dr Jim Reinertson mentioned during the February 2002 site visit for the RWJF Grant application)
• SJH patient advisory council is creating enthusiasm for patients and hospital staff  around creation of a patient centered care environment.  It is changing beliefs that say 'nothing will be done' through feeback based actions and collaborative thinking
• IT and administrative staff are understanding that no one is more than three steps removed from patient care, including them!
• SeaMar is doing real time entry into the diabetes registry, providers and support staff are fully engaged
• A staffer at a pilot site report that 'patient centered' was just a phrase the last few months, now she 'gets it'
• Nicole, the intern, did a great job interviewing staff at NCC
• Attendance at the Joslin community form (~200) and CME (68) were terrific!  We are making a difference by providing access to needed informaiton.
• 9 community trainers came out of the most recent Joslin Diabetes visit.
• Heather did a fantastic job of pulling together the film crew and Joslin Team visit schedules and all the associated resources!  THANKS!

 

I am going to start sharing my Dialogue notes with you all, and invite you to comment and continue the Dialogue here.  The comments are not attributed to specific individuals but clearly reflect a variety of perspectives.  Please understand these are 'notes', not a transcript, and so contain incomplete thoughts/phrases.  

Our December Dialogue sessions began with consideration of the following questions from the Encyclopedia of Positive Questions by Whitney, Cooperrider, Trosten-Bloom, and Kaplin.

"1. When you think back to your beginnings with this organization (community), what were your most positive and powerful first impressions?  What first attracted you to the organization and its people?

2. When you reflect on your time with this organization (community),  what is the greatest contribution it has made to you and your life?

3. When you think of organizations(communities), that you consider to be the best employers in your community or profession, what is it about their culture that makes them attractive to you?  How might we create more of that quality within our own culture?"

What is most valuable to me in this organization is opportunity, growth, freedom, allowances for learning, tolerance.

Values are important, human life, dignity.

I have been an both an avoider and a seeker in different situations.

I like to feel my contributions are valued. 

I feel a void of contribution.

How can we have transformation without leaving the organization, within the organization?

I like to take a fresh look, suggest something different, bring forth ideas, challenge old ways.

How can this become commonplace?

The main reason I came to this organization was the way that the mission statement and values were articulated, they were in line with my personal vision. 

I was impressed with the people, they were honest about the state of things.  They were "authentic".

I am still hopeful about being on the verge of  'possibility'.

There is a synergy or focus on making a difference.

There are things that don't make sense due to defined culture.  Things that are inconsistent stand out.

This organization has a huge impact on community, yet it is not involved, others are more involved in the fabric of the community. 

There is an opportunity for increased involvement in community.

I have a problem with the term 'community', organizations and communities are not automatically synonymous.

I came to the community to be near friends, and for the lifestyle and happened to get a job at the hospital.

Community is not always a good thing, especially if holding on to old ways, it can become dysfunctional

Our culture allows individuals to be themselves and achieve personally beyond 'locked in' definitions.

Community and self are interrelated.   Interactions shape individuals who then shape community.

Our program is well known to the community, but not well known to be a hospital program.

We have freedom to do what meets the need.

There is a tension between freedom & organizational viability.

I object to 'fake' sense of community .  It is hard to keep up links to community due to other business of hospital  - there is an inability to keep committments.

At new employee orientation, there is a lot of energy around mission, values & culture.  People leave excited and then run smack into 'real world'.  How do we get people engaged, long term employees?  How to avoid or overcome loss of spirit?

We articulated the spirit and engaged the heart.  We've disengaged the heart.

We have strategic initiatives to support new nurses, how we provide mentoring.  We have the Student Nurse Apprentice Program (SNAP) we could change it to Senior Nurse Apprentice Program.

There are people who don't know who the CEO is, how can they know who or what they are working for?

We could have a 'reorientation' program, ask 'why did you come to St Joe's?"  What if we took that appreciative approach with senior employees?  'Why are you staying?"  Would that be enough?

 Not at PH.  Some say, if you expect the organization to care about you personally, you are in the wrong organization"  The organization has little to do with what value I find personally important.

Most things are postitive, sometimes though it's acting out of character, or inconsistent.  What do we do with that?

Lots of people know or see these things.  How then do you engage them in discussions of mission & values?  Must trust one another, without talk, there is loss of credibility.  Must admit that organizations are fallible too.  Be open, admit mistakes.  Who brings up the discrepancy?  We've let it go, no one has broached the subject.  Without talk, the organization suffers.

It is a privilege to hear new stories, 'not perfect' still 'great'.  Reaffirming committment helps, but doesn't always work.

Every ten years, there needs to be a revolution.  Blow it up - start over, if not, patterns become institutionalized.

What barriers do we put up?  Think about it?  What do we do that creates distance?

It is exciting to contemplate organizational transformation, but big bites can choke you.  Remember - one patient at a time.

Thinking about the movie ANTZ - colonies are organizational systems, new organizations over time develop more rules, they get frozen.  Need to pull down the structure and keep the substance.

Going back again to 'the situation' the external view is different from the internal view.  Information sharing/lack of sharing contributes to the difference.  A person 'gets the shaft' by the external view when internal information isn't shared. 

Thinking more about reorientation of employees - look at where they were originally, where are they in their personal and professional growth and development?  Do nurses shift into other areas like computers, education? 

Is it unique to SJH - with mergers, different CEOs?

Must idealism fade?  What is possible?  What is success?

Need to look at the long view, consider "better" is success, vs considering it failure if total transformation isn't achieved.

Increased turnover in directors and managers.  Why does the turnover occur?  Are we asking?  Maybe it is okay to leave?  How do we keep idealism alive?  How do we support transition?  Need to focus on authenticity, renewal.

Sensing a major assumption that needs testing about turnover.  How many people have been here forever?  Is turnover 300 or 1200?  Are the same positions turning over frequently, or have that many people left in all areas?

Eugene's Renewal Experience is a two day program.  How can we bring it here?  Who should go?

Culture is organic because it is people based, and therefore must be dynamic.  It must support growth and change.

For those good people who participated in this Dialogue, I recognize that only a fleeting shadow of your perspective is captured here.  Due to my own delay in posting these, my judgements and filters, perhaps it is an offbase representation at that.  Please feel free to expand through comments or your own posting so that it better reflects the richness of our sharing. 

All other kind readers,  please share any thoughts these questions or our commnets evoked for you. 

Carolyn's post got me thinking about  if and when it might be advisable to 'wear the same thing'... the 'team uniform' concept. Is it ever a good idea, and if so, how can we make it work and still retain flexibility and hear individual voices?

It seems there is both value and danger in having a uniform...The team has a sense of unity, and it is recognizable as a group with a common purpose, shared goals. At the same time, the 'uniform' (or even just a label like a team name) could create a perceived barrier to those who might want to join the team and provide invaluable contribution.

The openess of the team and its willingness to accept new members and alter the uniform must be explicitly and often stated. Embroider the motto 'we are open to suggestions and new members' on the uniform!

 

My world has changed, I am a new mom again, though this birth was hard on someone else.  Someone furry.  We have a new puppy, and I am once again faced with the differences between veterinary and human healthcare. 

There is a great video, "Its a Dog's World", that addresses some of these differences...If you are in Bellingham and haven't seen it, you can contact the SJH Education Department to arrange for viewing.  I'm getting more info on obtaining the video for others outside our immediate area and will post it later. 

How is it different?

Visits to the vet don't feel rushed, the vet takes time and establishes a real rapport with the patient (my little furry girl, Kali).  He understands that she is scared and focuses on helping her feel comfortable first of all.  He listens to my concerns and answers questions.  Her medication says what condition it is for.  He talks about future development, and what to expect.  He shares his personal philosophy about her care along side other schools of thought.  He gives her a treat.  It is obvious he truly cares about her and her kind.

How can we incorporate some of the best features of veterinary care into human healthcare?

Slow it down, make sure the patient is comfortable.  Establish personal connection with the patient.  Ask what the patient needs/wants.  Include the 'care team' in the communications.  Label medications clearly for lay understanding.    

 

Brian's story reminds me of the backpacker's creed...'Take only pictures, leave only footprints', I agree that there are many who have gone before to lay trail.

I think however, that there is also a similarity to the forestry crews that come through after big storms...some trees have fallen over the path, a portion of the path has washed into the stream and the bridges have washed away. There are some areas of burn or clear cut, where new planting or growth will need to occur.

We need to make certain that patients are on the trails with the healthcare equivalent of what outdoor legend Harvey Manning calls 'the ten essentials' in Mountaineering: the Freedom of  the Hills. Otherwise they may be out there in the elements without what it takes to survive.

We need to reestablish or create some new and reliable ways for patients to get between the havens that are our medical practices.

On this day of reflection I am reading Marc's post about creating a system, and the reactions that terminology provokes.  We often talk about healthcare as though it is a system, but today it is not.  The similarities to our 'national intelligence system' come to mind.

Thoughtful dedicated people, gathering information, mountains of it, some of it duplicated at many points.  Too much information without the ability to have it sorted and flagged relative to its importance.  No connection between the collectors.  Key information is lost or identified too late.

Our healthcare providers in their practices are also thoughtful, dedicated people, gathering and sorting through information. This has too long happened in isolation, without the information sharing between providers that can avoid near misses, delays, catastrophe for patient health.  This isn't about the people, it is about creating a real system...a woven safety net, a system that supports and sorts through the information to prevent patients from falling through the cracks between indivdual practices and providers.