Visualizing complex systems is difficult. Trying to navigate without a map is also a perilous undertakinng. Two years ago we created a mathmatical model of the system which made the potential winners and loosers clear. We have not made as much progress toward our promises and goals as we would like--we have had a plan but not a map.

I have been talking about Jonkoping County, Sweden for more than a year. They have mapped their health care system in one county and begun the process of whole system improvement--a cross multiple organizations. Here is a presentation that I put together after the first trip to Jonkoping.

Finding ways for lots of folks to focus on improving a system is a challenge. API and the County Council of Jonkoping, Sweden have done that.

We have built upon the work done in Sweden. It is interesting that the API (Associates in Process Improvement) methodology called Quality as a Business Strategy (QBS) translates well to the national Baldrige Award quality framework. Here is a first pass at matching their approach with Baldrige. If you want to see our high level map in three parts here they are: Healthcare Processes, Support Processes, and Driver Processes. One can even map the Chronic Care/Planned Care model onto this high level framework. The trick will then be to locate the processes in the system, link them and then improve them.

Whatcom County created a map of it's healthcare system last May. We are be ginning to move this work forward in various ways that I will report on in this web log as we make progress.

 

In the local paper: See bullet # 6.

Of course Pursuing Perfection in Whatcom County is a collaborative effort of several organizations in addition to the hospital--in fact that is what makes it a unique and powerful agent of change. See these two links: one page summary and detailed overview.

Funding bill has millions for county
APPROPRIATIONS: Transportation projects are big-ticket items in federal bill.

Aubrey Cohen, The Bellingham Herald

A massive new federal spending bill includes $1 million to help prosecute cases stemming from the Canadian border in Washington, and millions more for Whatcom County.

The $388 billion appropriations bill, approved over the weekend, covers most domestic programs for the budget year that began Oct. 1. The measure is one of the leanest in years and includes a nearly 1 percent across-the-board cut in most line items.

Mike Spahn, spokesman for U.S. Sen. Patty Murray, D-Wash., said Murray sought the border prosecution money in light of lobbying by Whatcom County prosecutors and police, who have said costs to jail, prosecute and defend suspects arrested at the border have increased dramatically since Sept. 11, 2001.

Murray is a member of the Senate Appropriations Committee and the highest-ranking Democrat on the Transportation Appropriations Subcommittee. She announced millions in transportation funding, including:

[>] $1 million to build San Juan Boulevard between Yew Street and Samish Way.

[>] $1 million to help establish a border policy research institute at Western Washington University for the study of transportation, mobility and border security.

[>] $3.314 million for improvements to Interstate 5 south of the border in Blaine and to rebuild the Peace Portal Drive exit, which will be displaced by expansion of the border crossing.

[>] $1 million for improvements to Western Washington University's Lincoln Creek Transportation Center.

U.S. Rep. Rick Larsen, D-Lake Stevens, also announced funding for several projects, including:

[>] $121,250 to enhance Mount Baker Theatre's sound system as improvements are made to the building.

[>] $500,000 to continue and expand St. Joseph Hospital's Pursuing Perfection Program, which is working to implement a nationally recognized chronic care model by coordinating efforts and resources across the county.

[>] $634,000 to help ease congestion at the Blaine truck crossing.

Reach Aubrey Cohen at aubrey.cohen@bellinghamherald.com or 715-2289. The Associated Press contributed to this story.

 

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 their 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.

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I was reading this article this morning. All the websites mentioned here are in the UK, but I was wondering how the questions raised in the article applies to the way websites for medical information are built in the U.S.? One thing I did notice is that all the sites are different. Each site requires learning new navigational information. There are no standard rules for presentation on the web. Would it not be better to find a way to optimize the presentation of certain types of information? Should there not be a medical group, in concert with a web design group, be working to create a "Roberts Rules of Order" for the presentation of medical information on the web. — Jack

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BBC NEWS | Health | Diabetes websites too complicated:
Diabetes websites too complicated
Language used was beyond average comprehension

Online health advice for people with diabetes is often too complex to understand, analysis suggests.

A scientist at Bath University looked at pages about diabetes on 15 internet health sites run mainly by charities and official bodies.

He found people would need a reading ability of an educated 11 to 17-year-old to understand the sites.

However, he said the average reading age of people in the UK was equivalent to an educated nine-year-old.

Complicated language

Dr Maged Boulos from Bath University found the NHS Direct Online site was the hardest to understand.

People would need the reading ability of an educated person aged 16 to comprehend information, he estimated.

Other difficult sites were NetDoctor.co.uk, Juvenile Diabetes Research Foundation UK, and the British Diabetic Association which required a reading age of at least 15."

(Related link Diabetes UK.)
(Related link NHSdirect.)
(Related link netdoctor.co.uk.)
(Related link Juvenile Diabetes.)
(Related link Prodigy.Net.)
(Related link University College London Hospitals.)
(Related link BestTreatments.)

Medical Records May Go Online
Mon Aug 23, 3:00 AM ET
Mark S. Sullivan, Medill News Service

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This is the kind of story that may spark the imagination of some people. — Jack

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It's five in the morning. You're in a hotel room having a serious allergic reaction to something you ate. Do you know where your medical records are?

If you're like most Americans, they're resting peacefully in a manila folder at your doctor's office. And the writing inside looks something like Sanskrit.

Someday, that information could be only a modem away--or closer, perhaps in a keychain drive in your luggage. The Bush administration has released a strategic plan for every U.S. citizen's health information to be stored in an "electronic health record" central database within ten years. Each person would have a "personal health record," an electronic file the individual would manage, that could exchange information with the EHR database.

The PHR would contain information on a person's insurance plan, prescriptions, allergies, medical history, and conditions such as asthma or diabetes."

(Via Yahoo! News.)

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

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.

Bertha Safford has shown the way to improve patient care as long as I have know her.

She helped shape the disease registry collaboration between Family Care Network and PeaceHealth.  She can clearly see her way across organizational boundaries in support of patient care. She goes for what is best for patients, not what is convenient for herself.

Here is a link to Washington' Doctor of the Year-County family doctor recognized by peers. (I don't know how long the Bellingham Herald keeps this archive links available.)

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

I have been a delinquent weblog writer. And tonight I would like to catch you up. Since my last entry in October, I have turned 50 year old; hosted the IHI Technical Assistance Site Visit Team of Maureen Bisgnano, Jim Reinersten and Andrea Kabcnell. They brought along Alan Goldstein, a Group Health Cooperative cardiologist as well. We have applied for a grant through Connecting Communities: an E-Health Initiative, and we are in the process of speaking with patients who receive the services of a Clinical Care Specialist about ways they think we can sustain and spread the services without additional positions/funding.

Additionally we have talked with patients/community members about what patient-centered care is and how they yearn to be a full partner in their care and what aspects of connection with their doctors and clinic staff invite them into the process. As a result of their feedback, we are improving the patient centered care experience survey for the clinics. This includes feedback from the clinics, too...so that the information is meaningful and they can take action to improve it.

Data to prove our work has value and is making a difference is not easily available as we have such disconnected data systems across the community...however, we have identified the % of patients receiving the services of a clinical care specialist that prevented hospitalizations, an office visit, ER visit and found and corrected medication errors. We used conservative estimates of these cost avoidance efforts and estimate we have possibly saved $368,215. And that was for 69 patients only.

We are being asked by community members when they can have a shared care plan...we are connecting with the Volunteer Resources in the community who are interested in providing people to help support others in starting their own shared care plan. We have connected with community assets such as the Technical College to begin dialogue about including training for nursing staff on the patient-centered model and use of the shared care plan as well as conversations with the University Wellness Program. The City of Bellingham and Ferndale School District is interested in spreading the use of the shared care plan to employees and students. A small trial is underway.

At times progress seems slow..there is no big bang in transformation, subtle shifts occur that are the result of conversations occuring on the local, regional and national levels. There is a yearning for a new way and an impatience and despair with the old. Change is sought and resisted in the same moment within the same individual...much as a person with a chronic condition bargains and denies there is a need to change, yet knows change must come to move toward a healthier outcome. Others read about what we do, call for information and amid the many questions- I hear an unspoken question...does it work...will it make a difference....what proof do we have this is the "right" way.

I wonder did the pioneers, pilgrams, native americans moving to new lands or embracing new ways to respond to changes in the environment want to see proof before moving toward a desired state or destination...did they wait for all the maps to have specific roads drawn, miles calculated, gas stations/way stations identified before they began the journey? I think not, I think they had a vision, they created teams/partnerships that worked and were forgiving and forged ahead. Sometimes supplies ran low...both in terms of resources and resilience....yet they moved on...adjusted their course with new information and insights...sometimes they had to partner with others different from themselves to move to a new understanding.

The other thing they did is look around at those on the journey, and stop to be grateful for how far they had come and to celebrate those who came along. I had the opportunity to celebrate with patients who have come along with us by listening to their stories. I heard through their own experiences how they were enriched by the experience, more self-confident and willing to pitch in and assist not only in their own health but to connect with others. The community assets are people: they have many titles, they come from many walks of life...but they are resourceful, dedicated, connected and caring. Together within a community, the change will occur...outside of the clinics, hospitals and inside.the walls of institutions- everywhere..we must notice the value and riches that are right here and cultivate the will to continue learning and exploring the roles and contributions each one of us will make to build a new way of providing and being in service to each other.

I am grateful to have the opportunity to participate in this journey.

This is an article I found very interesting. I include an image of our site, because I think this is one of the things we are leading the way.

Frustrated by the hospital industry's achingly slow adoption of basic technological safeguards, the Bush administration and Congress are gearing up to put more pressure on doctors and administrators. For perhaps a decade or more, however, millions of patients will continue to endure the high risk of deadly medical mistakes because there's no computer to catch the errors.

Internal Revenue Service. Physicians can spend entire days without touching a keyboard, and nurses routinely track patients' progress through a series of handwritten notes passed from person to person.

"It's this huge, ridiculous game of telephone," said surgeon Dr. Robert Wachter, co-author of a new book exploring why medical errors kill tens of thousands of Americans each year.

More potential disaster looms on the medication front, where the "chicken scratch" on prescription forms often confuses pharmacists, who end up providing the wrong drugs and, in some cases, killing people.