This is only a test of the aggregator emailing all new postings to a mail list. If a person is subscribed to that mail list, the intent is that Radio emails the new posting to the mail list, which then emails the posting to all subscribers. ... Right now there are only two subscribers, Marc and myself.

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

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

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

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

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

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

SOFTeNeD stories and maps.

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

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

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

experience, each person has a different one

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

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

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

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

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

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

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

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

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

 

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

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

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

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

A friend sent me a link to this poem. I pass it on to you. It is good and it rings true. It is by a doctor and more or less for doctors. But all may appreciate the sentiments.

A few lines:

"For the head will explain
      but the final common pathway is the heart
      whatever kingdom may come
For what matters finally is how the human spirit is spent"

Click here. 

Healthcare is science, reason and caring. May none be missing.

PatientPowered.org wins award!

My invaluable assistant, Jill Hickok, told me about an NPR presentation on the use of story telling in medicine. We are trying to do something similar in Whatcom County to heighten the awareness and understanding of the relational aspects of medicine, especially chronic conditions.

We are coming to believe that among all the change and stresses of medicine the experience is loosing it's meaning for some providers and patients. Focusing on people and their stories is one way to combat the cynicism fostered by a broken or non-existent system of care. Most of us came into the profession because of a love people and a deep interest in people and their stories.

Here is a link to the NPR piece: http://www.npr.org/features/feature.php?wfId=1480863   (I hope their RealPlayer download works better for you than it did for me. May be a firewall issue. I will try it at home tonight.)

Here is a link to a piece on the physician that is spearheading the effort, Rita Charon, M.D., Ph.D.

http://litsite.alaska.edu/uaa/healing/medicine.html

Here is a link to a biosketch on Dr. Charon. http://www.medinfo.ufl.edu/other/histmed/charon.html

I hope to learn more about this approach.

 

I have heard Dr. Rachel Remen talk about the power of story telling.  I find stories more transformative than powerpoint and analytical data. Perhaps it is because they contain what we find most interesting and important--other people.

Here are links to her work: http://www.rachelremen.com/; http://www.meaninginmedicine.org/about_fmm.html; http://www.almanacnews.com/morgue/2000/2000_04_12.hfa.html.

"Great ideas come into the world as quietly as doves. Perhaps then , if we listen attentively we shall hear, among the uproar of empires and nations, the faint fluttering of wings, the gentle stirrings of life and hope. Some will say this hope lies in a nation; others in a man. I believe rather that it is awakened, revived, nourished by millions of solitary individuals whose deeds and works every day negate frontiers and the crudest implications of history. Each and every one, on the foundations of their own suffering and joy builds for all." --Albert Camus -

On June 9th 2001, on another site http://marpie.weblogs.com/2001/06/09 I posted the above quote from Albert Camus. I like it so much I am reposting it.

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

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

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

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

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

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?

• http://www.patientpowered.org
• http://www.wwpp.org
• http://www.Google.com "Marc Pierson"
• Call Marc 360 756-6805
• http://www.ihi.org
• http://www.qualityhealthcare.org

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.

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

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

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

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

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

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

Let's hope.

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

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

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

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

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

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

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

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

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

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

Link to Bellingham Herald Editorial

Link to more about program

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

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

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

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

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

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

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

The Bellingham Herald, Whatcom County, ran a Sunday front page spread on Pursuing Perfection in Whatcom County, WA--Power to the Patient (the link to this edition lasts only two weeks)

Chronically ill patient finds a health-care advocate

(Original photo Unavaialbe at this time)

NEW OUTLOOK: The new Pursuing Perfection program aims to help chronically ill patients such as Keith Robinson, who suffers from diabetes, a heart condition and sleep disorders. MAME BURNS HERALD PHOTO

Balanced human interactions will make sense of some of the craziness that is US healthcare.

I would like you to read the very thoughtful and humane comments that Daniel Shurman makes. After a very difficult year he and his wife Bonnie have insights we should all reflect upon. There is nothing I can say that will add to his message.

Dan is responding to my post on Sunday, June 22, '03.

 

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.)

Group Visit for Heart Failure Patients Across Organizations. Click to read Terry Wagner's post.

Usually it takes a large organization to do this. I love seeing a community working together providing this patient centered care.

"Kudos to Erin Baumgart and Roland Trenouth ~ true pioneers. They piloted the First Heart Failure Group Visit across organizations (CSH and NCC) and did a wonderful job - the patients loved it and want to come back again! " ........

[Terry's Weblog]

If you want to have a public voice in health care innovation and improvement you can. Too few are being heard. Too few are taking a proactive positive approach. Join the discussion. 

Here are some testimonials and details about Radio the weblog tool that we use to create these web sites and web pages. One really nice recent addition is FM Radio, a user friendly place to write (and spell check) your material, as well as a great place to collect "news feeds" from other sources and review them.

http://radio.userland.com/

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

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

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

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

 

A nice "editorial" was published by the Institute for Healthcare Improvement on Whatcom County's Purusing Perfection in healthcare.

It begins,

"The Synapse Between Silos (Link to the article)

Patient-Centered Care in Whatcom County

In the human nervous system, dendrites reach into the synapses between nerve centers to gather and deliver information needed to perform almost every living function. When these fluid routes of communication break down, the entire human body falters."

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.

We have the streaming audio and video (QuickTime) server installed and will begin the learning curve to enhance the patients' and healthcare workers' stories with multimedia on the web. We have begun a discussion to track our progress: http://www.wwpp.org:8080/wwppDiscuss/discuss/msgReader$50. Follow along if you are interested.

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 ö 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     

á        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       

á        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.

Good news bad news...

The conference is full and so I won't be attending.  Although it is disappointing for me personally not to have that opportunity to meet others who are involved in conversations to understand one another's world views, I am greatly encouraged that there is enough interest in different forms of Dialogue and in getting these conversations started, that the conference registration exceeded the sponsor's expectations.  This is very good news.

original post ...

I'll be going to this, and hope that Cindy will be able to attend as well.

First National Conference on Dialogue. US health care crisis, a business problem or a community problem?.

Our local dialogue group has been learning together for almost three years. Dialogue may be essential for our Whatcom County Pursing Perfection in Health Care work is to grow and benefit the entire community.

I wonder if one or two folks (Cindie Manning and Lori Nichols?) shouldn't look into this conference for its networking potential.

"Dialogue is a process which enables people from all walks of life to talk deeply and personally about some of the major issues and realities that divide them."

It is interesting to note that the crisis of American health care is generally not addressed like other systemic community problems. It is framed like an industrial or business problem. I contend that it is one of the most important and largest systemic community problems facing the United States. Other such problems are perceived to need the ultimate approaches to cooperation and communication, rather than looking only to increases in regulation and competition for solutions. It is as much about communities as business if the Institute of Medicine's Chasm Report has it right. That report points out that the real paradigm shift for improved health care is about systems and patient centeredness. Both of these are beyond the boundaries of current health care organizations. That is close enough to community for me. Let's begin to work and think like a community.

[Marc's Weblog]

Gosh, what to write today? 

I've been focusing so much on Radio installs I feel that other things are sliding...However, I am confident that the need for this communication tool in supporting the transparency, spread, and shared learning of the grant is worth the investment of time and energy. 

The install process has stabilized, so now the focus is on getting the early adopters up to date...New folks are starting to join in as well.  Our community is growing.

I will continue to think about Annie's post and how I feel about the uncertainty of this new venture and my role in it.  I guess I've always been pretty comfortable with uncertainty, and am chronically optomistic, so while I may see and name things that are 'problems or challenges'...I don't feel powerless to address them.  I hope that we all feel comfortable sharing our personal visions of how this can move forward and how we can best participate and support one another.

As uncomfortable as the uncertainty and some of the frustrations we have yet to face might be, I must say the prospect of a changed healthcare world that we can shape together outweighs the momentary pains for me.  I am honored to be part of this committed, passionate, and talented group.

I'll close for now with an excerpt from the July-August Utne Reader's article "The Power of Talk".  "Conversation is the cornerstone of civilization, the very essence of culture and community.."  and some basic principles for conversation as a powerful tool in society by organizational development specialist Margaret Wheatley:

"...acknowledge one another as equals"

"... try to stay curious about each other"

"...recognize that we need each other's help to become better listeners"

"...slow down so we have time to think and reflect"

"...remember that conversation is the natural way humans think together"

"...expect it to be messy at times"

We give of ourselves when we give gifts of the heart: love, kindness, joy, understanding, sympathy, tolerance, forgiveness.

We give of ourselves when we give gifts of the mind: ideas, dreams, purposes, ideals, principles, plans, inventions, projects, poetry.

We give of ourselves when we give gifts of the spirit: prayer, vision, beauty, aspiration, peace, faith.

We give of ourselves when we give the gift of words: encouragement, inspiration, guidance.

Emerson said it well: "Rings and jewels are not gifts, but apologies for gifts.  The only true gift is a portion of thyself".  

Wilfred A Peterson

[Annie's Weblog]

"...it is highly unlikely that a brief process, like a one-hour speech, can lead to a true shared vision - a vision which draws out the commitment of people throughout the organization.  A vision is not really shared unless it has staying power and evolving life-forces that lasts for years, propelling people through a continuous cycle of action, learning, and reflection."  from the Fifth Discipline Fieldbook...

In our case the vision needs to be kept alive across the entire community, not just within a single organization.  The vision of patient -centered care has been alive in this community for several years, and drove the creation of Whatcom Health Information Network (HInet), and the Community Health Improvement Consortium.  We now strive to further develop that vision to cross the chasm identified in the IOM's report.

The vision  is Patient-Centered Care that is Safe, Timely, Effective, Efficient,  and Equitable.  These six aims, but foremost, patient-centeredness, is the enduring yardstick against which our choices, decisions and actions can consistently be measured. 

We are on this journey together, at each step or turning point let us do one another the favor of asking...What is the best option for patient-centered care? 

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.

Today, we spent some time with the Boston University Evaluators hired by Robert Wood Johnson Foundation.  Their job is to evaluate and learn from our transformational experience in Pursuing Perfection.  They asked us:  How will we sustain the effort beyond the initial funding...in light of the expectation that RWJF will reduce support signficantly in Phase 3.  Our answer was we weren't sure...the path was not clear before us.  No payers were coming to the table, offerring money and resources for a newly designed set of services aimed at preventing complications and the high costs of complications.  I wonder if it was difficult to people to get on the ships to sail to the New World?  How many had to be asked before a few signed on....

And I thought not just about financial sustainability but also what we would do to sustain the spirit and heart of what we are doing.  That truly is the challenge.   If we cannot capture the hearts and minds of a community, how will we maintain the intent/vision of a perfect healthcare system?  If we rely only on healthcare professionals in isolation from the larger community...we will not transform the system.  We need a space where everyone contributes to the whole and understands their role in promoting health and managing the challenges of chronic illness.  Patients and family members need to be invited and welcomed in to the help create those solutions.  We live in a community and we need the community to be partners who can lead the way.  When we have engaged others outside healthcare, I have been amazed at their resourceful, creative ideas and very mindful of the costs.  They want to be part of the solution.

As we talk about sustainability, we need to consider both...it will take both heart and money to truly transform a system.  As a community we have so much to gain...

It is now September 2003, and we have been on the journey of transformation for 15 months as part of the Pursuing Perfection Initiative.  [2 years if we count the planning and collaboration that occurred with patients, healthcare professionals, and support members such as education, information technology and quality improvement staff].  We have met many milestones and created infrastructures that support change.  Clinical outcomes have been improved for some diabetes and heart failure patients.  Methods of communicating between and among healthcare team members have been established.  We are not "there" yet....if there is a destination....and for some who want concrete signs of change, it can be discouraging. 

The healthcare system continues to be overburdened, with staff/doctors working frantically to keep up with the pace of change and expectations.  And those stories of the burden continue to be shared.  Sometimes, that venting can cloud our ability to notice that there has been change and that things are different....

However, it was undeniable that positive change had occurred,  when Representative Rick Larson and Mary Conway, from Senator Patty Murray's office came to visit on August 25, 2003.  They spent time with patients/family members whose experience of healthcare was positive and engaged them in partnership with healthcare professionals at their clinics or in relationship with a Clinical Care Specialist.  Stories of their growing awareness that they [ patients/family members] played a part in the solution for healthcare transformation, the clear role that new ways of getting support through group visits expanded their skills and connections to move toward improved health outcomes.   Rick and Mary also made visits to Center for Senior Health and SeaMar Community Health Center to see first hand how technology was shown as a useful tool to assist in the flow of information to better care for patients.

It is important to have those opportunities to step back from the focused and fast-paced work to notice the changes and to know each change has made a positive difference.  It helps us renew our energy to continue to work ahead.  However, it is important to remember we are not on this journey alone and that patient/family members can help us see the way ahead, if we ask for help, engage their creative minds and the resources/strengths they have to contribute to this transformation. 

So, if you as a healthcare professional begin to lose focus and lament, "I can't do this [change, transformation] "...know that is only true if you believe you must do "this" alone.  You are not alone....as I looked around the faces at the 1st International Family-Centered Care conference, it was clear those in healthcare are not alone...we have team members ready, willing and able to bring their gifts, talents and skills to bear on making a positive difference in their own health outcomes...we have to believe this is a team endeavor and not an individual event....and share the burden and possibilities of a future with those most invested in a positive healthcare outcome.

 

Just returning from the 1st International Family-Centered Care Conference sponsored by the The Institute for Family-Centered Care  www.familycenteredcare.org.  I was accompanied by Hal Petersen, a patient representative to the P2 project in Whatcom County.   There were many diverse groups represented who are working on integrating patient, family-centered care in the fabric of what is delivered in a variety of arenas.  The number of stories told by patients, parent of chronically ill children and others who partner with healthcare professionals was powerful...In a room of 700 people, almost 20% of the attendees were those individuals.  Sorrel King opened in the first plenary, sharing her story of medical errors that killed her 18 month old daughter at John Hopkins and the efforts being made to improve the system.  More information is available at www.josieking.org. Clearly much more can be done to integrate patients, family members into the fabric of what we are doing in Whatcom County.  Creating patient/family advisory councils and hiring paid patient/family coordinator reporting to top leadership at some organizations showed a level of commitment beyond lipservice.  Ideas, energy and commitment were in evidence at the core of the center.  Creative and innovative ways using videos, dialogue and role-playing with healthcare professionals to heighten awareness and build skills at true partnership were highlighted as interventions that changes culture and behavior.  I noticed that on a topical basis over 80% of the examples of patient/family-centered care was in pediatric and maternal/child services and much fewer with adult populations.  It renewed my commitment with the ever increasing number of people with chronic illness that expansion to working with patients as partners and members of the care team is even more important.  I heard many examples of the burden being lifted from healthcare professionals when they joined with patients in partnership...how they continue to take their responsibilities for excellence seriously...but how they didn't have to make all the decisions, know all the answers and that patient/family members could provide resources to reduce the burden on the healthcare professional and resulted in a better clinical, functional and satisfaction outcome. 

 

It has been 10 months since we began transforming healthcare in Whatcom County with patients on the design teams, new roles on the virtual care team [ie.Clinical Care Specialists] and a "tool for self-management"  called the Shared Care Plan developed within the context of  PatientPowered.org website.  It was a dream of community health through transformation begun in earnest in June 2002.  Today we sat together with healthcare innovators from 4 countries - Sweden, Denmark, England and the United States to review what we've learned, what great ideas and best results we have experienced and of course, the sharing of "one thing we would never do again!".  It was an amazing experience to celebrate the work countless people in 13 communities are doing.  And to be reminded by Don Berwick that our opportunity to model a new and better way of providing healthcare...a way that will reduce mortality, embrace the use of scientific evidence, provide relief from pain, reduce waste and reduce needless helplessness for patients must produce results.  And through this demonstration of results, we can create the experience and hopefulness we all want for our patients, our loved ones and ourselves from the healthcare system. 

We focused on three arenas of challenge;  True Patient Partnership, Execution of Large Scale Projects, and Working across Organizational Boundaries.  In small groups, we shared innovative ideas...ones that are anxiety-provoking and will result in infrastructure change.  And we committed to small tests of change next week on BIG IDEAS...so Whatcom County...the bar, it's moving toward perfection and we will be pursuing it...next week, and the next...and we will get results....our patients and WE expect no less.  I have confidence that if we do more of what we have learned in 10 short months...and mobilize the assets our community ...the possibilities are bright for our community and for all.   See you soon in Whatcom!

 

 

There is a saying, "My Brain is too full."  I think Gary Larson even has a cartoon with that theme.  These days both my brain and calendar are too full.  After 8 months implementing Pursuing Perfection- The Reality, I have had many learning moments.  Capturing them on paper often requires some reflective quiet time- something in short supply.  However, I will jot down a few soundbites for now...each one worthy of its own weblog...but those musings will be for another time....

• Living in another community [at least on the weekends], helps me detach from the decisions made in Bellingham.  I can be objective in discussions about the pro/cons.  I respect that each organization has to live with the decisions made.  I am better able to keep the patient perspective in mind and bring it to bear during discussions.
• Five weeks away from home is too long for me...I notice I become more intense [hard to believe] and the edge confuses/muddies communication - raising questions about intent...Creating a balance between home and work is important to the project as well as for me personally.
• Managing staff and managing this project are two distinct jobs and I am doing both.  It has challenged me in many positive ways.  Unfortunately, juggling both has caused a few balls to drop...I believe the P2 staff have shown an immense amount of patience and perserverance with me during this learning.  I hope I have shown them the same level of regard and graciousness.  They are juggling the pressure of the world and the pilot sites...supporting them through immense changes....As individuals they are resourceful, empathetic and creative...behind the scenesdoing what is a somewhat thankless series of tasks......ask them what it really takes...they know the ups and downs of the creative process...unsung heroes yet not forgotten...this project and its accomplishments would not be possible without them
• Despite the positive acclaim we are receiving outside the community for our patient-centered approach, we fall short of what is needed to sustain a patient-centered system.  No one organization has embedded the infrastructure to build it into the fabric of all they do...many are experiencing the value and an increased awareness of its importance.  As a result, the staff of P2 are spending effort to continually create these opportunties to link patients/organizations.  It is critical work, yet something we underestimated in our planning.  It is not getting the attention it deserves...and we are aware of the gap...and living between perfection and reality is difficult at times.
• Our website: www.patientpowered.org with its education and resource information and leading to the secured portal which holds the secured web-based electronic shared care plan is a beauty to behold.  It has been birthed by the dedicated efforts of patients, P2 staff and others.  So we have built it...will they come?  If the they is patients...resoundingly YES..they will come and help us make it even better through their feedback, involvement and insight.  If the they is busy healthcare professionals...doctors, staff etc...in the short term they will struggle...because the way the work is currently organized make this tool "more work in the short term".  In the long-term, YES they will come and find it immensely valuable...it is just there is a chasm between now and FUTURE.  Fortunately, we have 20 healthcare support staff in training at the community college who have volunteered to help create a bridge between now and future...a resource to help us in the transition...because they care...
• Patient outcomes...are they improved?  8 months later...we have more on registries but outcomes look about the same...why?  Why is because we are not doing two projects....we are changing healthcare through transformation and piloting all the changes with two patient populations....that is much harder to do...its building a foundation...not pretty but solid so that as we build the new system...it has something strong to build upon....antedoctal stories and patient experiences say we are on the right track...the charts going to IHI just don't show it yet....

Reflections of 2002- Here are the top ten stories for our initiative called Pursuing Perfection in Whatcom County

# 1 - December 10, 2002    Rebecca Bryson joins Maureen Bisogano as  IHI National Forum Plenary Speaker      Rebecca receives standing ovation from 4000 conference participants after she shares her story of living with heart failure/diabetes and her experiences in the healthcare system- challenging us to continue the work of Pursuing Perfection.  Whatcom County recognized for their commitment to patient-centered care by its use of patients on design teams, committees- helping plan changes to the system of healthcare delivery.

#2- August 2002   Expanding Patient Voice   Recruitment of more patient family representatives begins in earnest.  By October weekly patient focus groups in place, orientation to program held at office and out in community by invitation, patients/family members added to ongoing hospital, P2 design groups.

#3- July - September 2002   Services to Patients Enhanced   Patients receive services of Clinical Care Specialists including collaboration in development of a shared care plan.  One patient uses it to increase efficiency and safety of 911 and ER services.  Physicians, paramedics and staff involved in situation agree - "every patient with chronic condition needs one of these."

#4 - September 2002  Community Outreach to Diabetes Patients   Joslin Site Visit occurs in September with community healthcare providers.  Over 140 patients/family members attend an evening to share experiences and learn effective ways to manage their condition

#5 October-December  2002     Innovations in Planned Care Pilot sites began group visits, partnered with the Diabetes and Nutrition Clinic, conducted focus groups and expanded/redesigned services to patients.  This included development of new registries to help organize information and collection of patient satisfaction information using a touchscreen computer in the office practices. One site began office redesign focused on efficiency, planned care and patient flow.

#6 - November - December 2002   Innovative Website and Electronic Shared Care Plan Launched Use of a paper shared care plan with patients was in use and from that learning a prototype using a secured website was built.  Simultaneously, a website to meet the information needs of patients with diabetes and heart failure was designed by patients  and released. 

#7- June - August 2002-  Grant Staff Selected  Pilot sites, patients, physicians and staff screen and select project staff to provide support for community change.  Group Health's behavioral interviewing process applied across a community setting seen as an excellent tool for employee selection.

#8-  October 2002   Pursuing Perfection Leadership Board membership finalized.  Pursuing Perfection partners invest time and leadership skills to ensure success of initiative beyond boundaries of grant.

#9  March 5, 2002-  Community Awarded Grant Community members received call from Don Berwick announcing  our selection as one of seven sites to receive a  1.9 million grant from RWJF to assist Whatcom County in achieving their vision- consistent with IOM Crossing the Quality Chasm Aims and New Rules

#10  February 5, 2002    Community Sells Vision of What's Possible Site Visit for review of proposal to RWJF.  Over 100 community members attended all or some of visit.  Rebecca Bryson and Kathy Brown, patient representatives instrumental in grant application kicked off day with stories of how their care/experience will be improved by a new redesigned system of care.

 

•  Maureen:   Our vision is a decade ahead of others she's seen in the U.S.  Perhaps the world.  Our commitment to patient-centered and the efforts to integrate patient voices into the ongoing design of the system is much farther ahead of anything she's seen.  Our IT infrastructure is amazing.  Our communication methods outstanding.  She challenged us to keep a strong connection to clinical outcomes.  Are you, are patients healthier as a result of the change?  Run more cycles of change in small ways to move quickly.  Link the finance depts. into the work we are doing to ensure we are lowering costs.
• Connie:  Whatcom County is amazing, has a reputation in many areas as being a leader in this area...We are to be commended for taking on the difficult challenge of behavior change on three incredible levels:  patient, staff and system.  Remember the diffusion theory and start with people who are ready.  Renew energy to continue through the stories of patients whose lives are better because of changes made. 
• Polly:   Coming here is invigorating...the information and strategies we have in place gave her ideas for her own community and others she encounters.  The shared care plan may be the symbol of what this is really about and the best method for proving it.  Our vision-effort is broad in its enormity/complexity...and challenging to keep one's arms around.  Our greatest success 10 years from now will because word-of-mouth in the community will create the spread.  Stories need formalizing....in the patients she met today...there are stories to share....powerful and compelling.  She encouraged us to celebrate the little successes...look for them everyday.  She reminded us that  problems teach us and that the learning can be profound as we solve them.

Today, I had the privledge of sitting with the Pursuing Perfection Project staff in Whatcom County and hearing their thoughts, dreams and frustrations - the human experience of being in the inside of innovation.   I heard many messages: 

• a desire to innovate, push themselves and the project outside the boundaries of what the community had agreed to do because of their passion for patients, and people trapped in a system that doesn't work anymore and creates distress among the healthcare workforce. 
• I also heard a desire to share as a team some of the ideas that have risen to the surface as we explore what we might do- the possibilities if we chose to focus our collective energy, resources toward new ideas that enlarge and move toward the vision of  patient-centered care. 
• And then there was a questioning and yearning for influence- having immediate influence that moves those sites who struggle with the gap between vision and what might be and today- and what they have capacity to add to their already busy day....
• and then the desire to have influence for patients by creating tools that make a difference from their perspective....

 

It seemed clear that there also was an interest in influence beyond one's individual role and the deliverables of a grant.  We are individuals who come together for a common purpose;  we do not necessarily play with innovation, ideas and influence with the same perceptions and experience.

So what is the right balance between innovation, ideas and influence within the context of what we agreed to deliver...and how do we as a team and individuals maintain a balance that nutures the project and the people?  I'm not sure there are easy answers...but I have some ideas.....

• Look for ways to make a difference today and in the moment by doing what you can within the context of your role.  Assume permission to innovate, engage patient, team members to create the best that resources and time will allow. 
• Share your ideas about the future state and ways to get there freely and write them down so others can see them and think about ways some kernal of the idea can be integrated as opportunities may present themselves. 
• Understand that control over others or the direction- something as big as tranformation in healthcare - cannot be controlled by one idea or one individual.  Influence through interaction and sharing ideas is the best to influence in this complex adaptive system.

I wonder what other ideas to create positive influence others may have as we continue the journey of change?

Alas, we won't be hearing from Annie here again soon, as she has left the Pursuing Perfection Project to pursue another adventure, this time on the high seas.  Annie was scheduled to depart the Port of Bellingham today with her new beau, headed for points south and salty. 

The Project staff sent themoff with a good bye dinner and best wishes for safe passage....Bon Voyage Annie & Brent!

This category was designed to keep you informed on what's happening with the PatientPowered website. This is also an experiment in utilizing categories for information exchange.

Another aspect of this trial is the development of a discussion group about PatientPowered. We welcome your participation.

Patient Voice. 

What weâve done so far as a small test of change.

 

 

September 2002 ö present:  Recruiting Patient/Family Representatives

• Brainstormed ways of recruiting patients and family members.
• Developed an information hand-out on the desire for and role of the patient/family representative.
• Developed an informative sign-up sheet to collect names of interested people.
• Developed on-line patient/representative sign-up sheet and made available at strategic locations on the Internet.
• Placed patient/family representative sign-up sheets in visible place at Pursuing Perfection clinics.
• Placed an ad in the Bellingham Herald and other news sources.
• Interacted with patients at the diabetes support group, Joslin Community Forums, and other community outreach arenas where we recruited patients and family by having them complete patient/family representative sign-up sheets.  

September - October 2002:  Weekly Drop-In Focus Groups. Tuesdays 3:30-4:30 & 5:00-6:00

• Contacted about 15 patients who had expressed interest in patient voice and focus groups in particular ö about 10 were very interested.
• Topics:  Optimal education, optimal website, feedback on website, feedback on shared care plan.
• For the first meeting, I mailed each interested patient a description of the group and directions to the meeting place. After the first meeting, I sent a letter to all those who attended thanking them for their efforts.
  • For meetings that were important to get attendance, I called and/or emailed most of the interested people ö this typically resulted in attendance of 5-10 people.
  • For other meetings, I didnât take any reminder steps ö these meetings typically resulted in low attendance (0-3).
• I reserved rooms for the meetings, typically a computer room, provided minimal food and beverages for the meetings, and provided transportation for one of the participants, when needed.
• Feedback from these focus groups has been previously posted on radio: General thoughts on Websites and Patient Education.  

October 2002:  Orienting Patient/Family Representatives to the Project and their Role

• Created a Website designed to keep patient/family representatives up-to-date on opportunities that are available to them for participating in the project.
• Maintain list of opportunities to offer interested patients.
• Developed a curriculum for and held a 1-hour Patient/Family Representative Orientation that all of the interested patients/family have been encouraged to attend. We evaluated our efforts - it should have been 1.5 or 2 hours) and hope to offer this orientation again in the near future.

 November - December 2002:  Web Site Development Team.

• I called about 20 people who had completed the patient/family representative form, most of which I had already met in my focus groups, and offered them the opportunity of joining me on a team of patients that would be designing a new patient website. 7 patients committed themselves to 6 weekly meetings of the team. An additional 10 people agreed to act as feedback; I would email them the link and gather feedback from them virtually once the site was basically complete.
• Each meeting focused on a particular aspect of the site.
• Each week we picked a time for the next meeting that everyone could make, and I made reminder calls and emails the day before to confirm attendance. I also provided minimal munchies and beverages during the meetings and transportation for one member.
• The result of the six successful meetings of this team was the website www.PatientPowered.org
• At this point, Iâd like to convene more patient teams to help with further content development and guidance.

    It has been both an immense pleasure and a total inspiration working with these patients.

 

 

In addition, we have developed some tools that have not yet been integrated into what weâve done, including:

• a proposed process for recruiting patients,  

• a possible process flow diagram for obtaining information on and from potential patient/family representatives,

• a script for follow-up/screening calls for people expressing interest in becoming patient/family representatives,

• an outline for the more in-depth training and preparation of patient/family representatives who are interested in becoming committee members,

• an outline for the training of Team Leads and interested Committee Members of committees that are interested in integrating patient/family representatives into their meetings and/or team.

 

Please feel free to contact me if you have any questions on any of this information or if I can answer questions or be of assistance in your effort to involve patients in the process.

 

Yesterday marked the first official meeting of the patient wing of the new Pursuing Perfection Web Site Development Team. The team consists of 6 patients working with Dawn and I on developing a website that fills their needs. We will be involving clinicians and other P2 staff members on the team as the site develops, but will be creating the first prototype based strictly on these same, committed patients working with us on a weekly basis. I've collected a list of an additional 10 patients who are willing and anxious to review the site after it's been created, giving their perspective, feedback and insight to make the final product even more accomodating for a variety of patients and family members.

It's difficult to summarize the specific feedback that we received.... a lot of ideas were presented for both the type and presentation of the educational content and the functionality of the shared care plan. Dawn and I have a lot of work to do over the next week to have something to show them next week that is updated in response to all of the wonderful feedback. In general, I think the comment "they don't want to know about diabetes... they want to know about their diabetes" summarizes it well. We need to find new and innovative ways of asking people questions and providing information responsive to where people are at.

Other general types of information the patients seemed very interested in getting from the website were finding information, finding local resources, finding support, and who to call when. They also showed interest in connecting with other patients through discussion groups or listservs and connecting with professionals through secure messaging, ask-an-expert, and FAQs. Up an coming research was another desired topic.

Our next meeting will be Thursday, 11/21 where we intend to go over our upgrades based on the input and feedback we received, and going further and deeper with development plans.

Last night the focus group discussion centered around patient education. I was absolutely amazed at the awareness and sensitivity the attending patients had surrounding the pressures of the system on their providers. One of the first thoughts to surface was that doctors are so short on time and are reimbursed too little for their efforts, that adding educational time (although very much desired) seemed difficult or impossible under the current system. The thought was voiced that perhaps doctors should be more transparent about the pressures they are under.

So, in the perfect health care delivery system, what does patient education look like? Well, these patients were of the opinion that "If you're really interested, you've gotta find the information yourself." Concern was discussed for those patients who aren't activated enough to search out the information and rely on the limited interactions with their providers for their education. Perhaps creating accessibility to a conciencious, concerned and informed nurse when you have a question would help(hmmm... does that sound like our Clinical Care Speicalists?). A large benefit was seen in hearing the same information from all of your providers -- knowing that they are talking with each other and agreeing on the best method of care. Communication is key: communication with your provider, with a nurse, with other patients. Being able to ask the questions on your mind and receiving answers that make sense in a caring, compassionate and informed manner. Connecting with others in a similar situation who can share their experiences. Having access to information at the time that you have a question, sometimes preventing unnecessary visits to the ER.

Another thought involved access to information. It appears to patients that many providers are hesitant to share test results and other health indicators openly with their patients. One patient said "Giving people information requires them to become more involved in their care". I thought this very insightful... imagine hearing "your blood sugar levels are fine" from your doctor versus "your HbA1c is 6.2 this month, which is up slightly from the 6.0 last month" and possibly a bit of education on the value. Which approach would be more engaging?

I found it intriguing that the discussion centered primarily around access to people in order to exchange information. To me, the underlying conclusion from this is that these patients saw communication as a primary modality of education. Use of the Internet, pamphlets, videos, etc... was typically a result of recommendation from a person. The Internet and flyers at the hospital and Doctor's offices were seen as key ways of connecting people to opportunities where they could learn from others.

I think, perhaps, we should focus a bit more effort on connecting people to people and facilitate opportunities for communication. Could this be a use for Radio?

Another opportunity to sit in on a focus group exists next Tuesday -- 3:30-6:00 at Birchwood (small computer room). I'll be gathering feedback on some innovative ideas for a website.

As part of the "patient voice" effort, we have been soliciting patient/family representatives to sign up, giving us contact information and letting us know a bit about themselves and how they might be interesting in participating. So far, we have about 30 people who have signed up and about 10 of those have already begun participating in some way. 

One current opportunity for participation in the project is a weekly focus group aimed at obtaining feedback from patients and family members. Interested patients, family members and all others interested are invited to come to the Birchwood Computer Room (600 Birchwood Ave. 2nd floor) on Tuesdays anytime between 3:30 and 6:00. These will continue to be held at least through November 2002. The Patient Voice section of the P2 Communication Web contains more information and the calendar shows other opportunities for patient and family participation.

I plan to post the happenings and learnings from each of these focus groups on Wednesdays. So far, there have been 3 focus groups and lots of sharing has occurred.

The first group consisted of 5 patients, all with diabetes; the second group consisted of 2 patients (1 is both a patient and caregiver); and the third group consisted of 6 patients and 2 spouses. We gathered valuable feedback on what they currently found good and not-so-good with finding health information on the internet, and thoughts specific to our patient diabetes website. Here is a summary of what I heard these patients say:
* Some kind of listserv, discussion group or chat room could be developed or linked to - patients want to be connected to other patients. Would it be possible to develop a "local listserv"? Legal questions have held this back. Perhaps have peer group chat rooms with a specialist for education. 
* This site could be localized... information on the site could be specific to the Bellingham area. It could provide information on our health care system here, facts about clinics, how to navigate the system, etc... 
* This site could link to general disease registry information to provide patients with population data to compare themselves against (this will probably happen within the shared care plan). 
* The search strategy could be evaluated for effectiveness and possibly redesigned based on functionality for the users. Patients found the search tool ineffective for finding relevant information (likely due to the fact that a large amount of our content is actually located on external links).
* The navigation strategy of the site could be evaluated for usability and updated as seen appropriate. Patients had a difficult time locating information that they wanted to find given the existing strategy.
* Other features such as Help and Ask-an-Expert could be evaluated for functionality by users and updated. Patients expressed that they would have more comfort in using the Ask-An-Expert if they knew that the doctor responding was local. The thought of utilizing interns for this was mentioned, giving them a chance to hear more of patients' "real concerns" and give them a chance to interact when the question is still something new. Their preference would be secure messaging with their doctor, however.
* Information on diet was a very popular request.
* Complementary and Alternative medicine should be integrated with the presentation of more standard medical care, rather than a separate section.
* Contact information for various aspects of care could be integrated within the health information delivery. One patient likened web sites to a voice phone system ("Press 1 for diabetes", etc...) and very much wanted a "Press 0 to speak with a person"-type option. This may take the form of simply providing a name/email of someone specific within a topic.
* Information on "etiquette for interacting with a person who has diabetes" could be provided in printable form so that patients can distribute this to family, co-workers, etc. Or possibly some kind of "Please Understand Me" guide for people with diabetes.
* Patients felt that it was extremely important that a lot of information and support be provided soon after diagnosis. Perhaps other patients' stories, expectations, helpful hints, etc.
* We could create a "What do I have control over" section.
* Activated patients are wanting to use the web to educate themselves and their physicians on complicated issues pertaining to them (e.g. dealing with both diabetes and post-polio).
* Patients very much expressed displeasure in having the disease treated rather than the person. The perception is that a website that is strictly educating on diabetes is common and not very effective - how do I balance my list of issues?
* Family is wanting to know what to expect might happen that will affect ADLs, etc. with their loved one and how they can take care of it. The desire is to be able to plan ahead and be able to provide good care.
* Patients seem to like the FAQs... perhaps these could be organized and incorporated into the delivery of educational information.
* A request was made for contacts with other patients who are willing to act as mentors. Perhaps the diabetes support group could somehow grow into this role.

I'm certain there's more.... I attempted to summarize.

As part of the latest focus group, we introduced the concept of the shared care plan and presented our vision of the eventual product. The feedback was surprisingly insightful, with the group identifying immediately some of the issues we're finding to be our biggest challenges (namely Who will update it? and expressing doubt that their doctors would have time to integrate this new tool into their care without a monetary incentive). They seemed very excited, in general, about the concept and were surprisingly curious about the logistics surrounding its implementation (even questions on security were raised). The primary "take home" suggestions that we captured were that patients would like the SCP to:
  1. Hyperlink meds to more info about them
  2. Be able to look at an archive
  3. Be able to check drug interactions
  4. Be able to look at lab results
  5. Be able to translate (yes, like into Spanish) at the push of a button (ouch!)
  6. Again, there's more, but more difficult to enumerate out of context.
We happily realized that we have plans already to integrate most of the suggestions that were brought up - it was very nice to hear the desire for such functionality come straight from the patients, however.

Each of these focus groups has proven inspirational. It's wonderful connecting with the voice of the patients and family members - those who we hope will benefit most from our efforts. I welcome all to come to one of these sessions if only to eavesdrop and become re-inspired by the thoughts and insights that are shared.

 

 

Almost 6 months ago now Connie, Nancy and myself met to brainstorm how we might be able to have patients evaluate the value of the CCS / Patient relationship.  We came to a conclusion that a paper survey with two distinct sets of questions would work best.  The survey would start with the usual format of question and categorical response options. (ie, I feel cared for by my Clinical Care Specialists? Stongly Disagree, Disagree, Agree, Strongly Agree, Not Applicable.) The second part of the survey would have questions that would allow for open ended responses.  It is the content of the answers to this second questions that I would like to share.  (We do not yet have enough surveys completed, we have 30 and need 50, to perform a Rasch analysis of the first group of questions.)

(The answers to these questions have been copied verbatim except (My CCS) has been used as substituted for the names of the Clinical Care Specialist)

Open ended question #1:     What would you like to add or change to this program?

 Response #1: Very happy with relationship - couldn't be any better

 Response #2:  More interaction between the various physicians and providers as a cross check for patient care.  I fell very strongly that the role of CCS should be expanded because the CCS provides a very vital contact for care providers and patients, note many patients are in isolated situations and cannot interact with others.  The very fact that some would call is most important.

Open ended question #2: What other comments, concerns, and/or ideas do you have?

 Response #1: Anything that can be done to get patients to participate in their care is positive and can be very helpful for their care providers, keeping a journal that is guided by a MD or other care provider could be used to provide very important information that would aid in caring for a patient it would also empower a patient with a felling of at least partial control of the outcome of treatment.

Open ended question #3:  Share a story with us·Often times a great change begins one person at a time.  We strongly feel sharing stories of success and failure will help us and others learn.  If you have a story about your interactions with your Clinical Care Specialist or others in the health Care Community that you feel you would like to share please tell it out below or fill out the contact information and a staff member will contact you.

 Response #1: I am beginning to feel that I can live with diabetes.  My family has had this disease for many years.  All have died of complications. I have information that my cousins are guessing at.

 Response #2:  When I need to get a test or see a specialist and can't get an appointment, (My CCS) gets me what I need very fast.  When (My CCS) comes with me (My CCS) always asks the questions to help me and helps directing areas to assist me to get feeling better.

 Response#3:  (My CCS) has helped me in too many ways to comment.  (My CCS) has improved both the safety of my care and my ability to care for myself.  (My CCS) has been an educational resource for both me and for my family.  I don't even want to think about coping with heart failure and diabetes without (My CCS).  She is the best!

Whatcom P2 is using 4 distinct individual patient surveys to assess the physical and emotional well being and capabilities of patients that have been admitted to a Clinical Care Specialist (CCS).

These 4 measures are: Depression, Simple Quality of Life, Physical Function, and Activated Patient.  Each patient admitted to a CCS is asked to complete each survey at the time of initial evaluation.  After the initial evaluation they are asked to complete the surveys once every 3 months.  Currently we have both English and Spanish versions available for each except the Activated Patient measure, which we are working on the translation right now

Once the surveys are complete they are handed in to the P2 staff and the surveys are then key-entered into a Microsoft Access supported key-entry form specific to each survey.  Once a week we (Data Analysts of P2) run a MS Access macro that extracts the results for each survey and saves it off to a text file.  This text file is then loaded into Winsteps, which is the application that performs the Rasch analysis of the data.  Once Winsteps crunches the data it automatically writes off a text file.  Another MS Access macro is run that imports the patient scores back into the database.  These scores are on a 0-100 scale.  The macro also produces a report listing only those scores that have come into the database since the last time the analysis was run.  (For a more complete description of what this MS Access based process looks like please read my other weblog titled: Automating Rasch Based Survey Analysis)

The results of the surveys are analyzed in a couple of different ways.  First, the scores are loaded into an SPSS (Statistic/Data Management program) table that supports the graphical display of a patientâs progress.  On a single chart, each survey is graphed over time.  This allows the patient and caregiver to not only see the results of each survey but to also see how the dependent relationship between the surveys, ie as physical function increases depression levels decrease.

Second, within the Winsteps application an analysis tool is used for a detailed evaluation of a single patientâs set of responses.  This tool, Person KeyForm, is able to compare how the patient actually answered each question with how Winsteps approximated they would answer it.  The approximation is base on the patientâs 0-100 score.  This table is particularly useful as it is able to quickly pinpoint areas of concern.  For example, a patient takes the Depression Measure and analysis shows a low score. (Low score for depression is good!)  If on the question: ÎI worry a lot about the past.â  the pt answered ÎAgree Stronglyâ.  The Person KeyForm table could possibly show that their answer is significantly different than what would be expected from someone with that low of an overall score.  The Clinical Care Specialist will immediately be able to identify that the patientâs answer to this question is an outlier and that it might warrant further discussion with the patient.  The CCS may then be able to have a discussion with the patient about why they worry about the past and how that worrying is affecting their overall health.  The Person KeyForm is able to instantaneously identify outliers, ie areas of possible concern or even areas of positiveness.

This individual analysis is able to produce the remarkable effect of creating a tool that works for the individual patient.  This is a paradigm shift in many ways.  The shift isnât that we have produced a survey that seems to accurately collect data on the levels of patient depression, physical function, etc or that the data is then reported in an aggregate form that describes the overall status of the population we are working with.  Instead, the shift is that this data gathering and measurement tool does all that AND is able to be applied, in a timely fashion, as a clinical tool to open dialogue with a patient about where they are at and why.   It aids the clinician in evaluating a person in their entirety.  It is the beginning of treating the patient as an entire individual as opposed to treating their chronic ãmedicalä conditions without addressing their physical and emotional well being.

In summary, these tools that are being developed and utilized with our P2 patients are beginning to bridge the gap.  The gap between the type of care the patients have been receiving and the type of care they need.  The tools are new and their

Some specific learnings that we have had are:

With the activated pt measure ·.acute episode eliminates their activation.

Other learning··all interrelated.  It has been seen in some patients that as their physical function improves so does their activation and their depression.

Automating Rasch Based Survey Analysis:

This weblog will be designed to explain how we store patient survey data as well as explain how we have automated many of the steps of the analysis.  It will be very technical in nature with the thought that the treasure is in the details and available to those that can recognize it·..meaning, that if I generalize much of this it wonât do anyone any good and by keeping it technical it will be very useful to those that may have the skills to implement some of the ideas and learnings we have had.  With the understanding that all of my contact information is available and that I am always very happy to explain further.

Initially, it would take us almost 2 hours to take a patient survey (Activated Pt, Depression, or Physical Function) and analyze it into a useful result to be used by the Clinical Care Specialist.  It did not matter if there were 2 or 200 surveys, it still took 2 hours to run through the multiple step process, ie storing the data, cleaning the data so it could be brought into Winsteps, exporting the data into SPSS so it could be graphically displayed, and then storing the data for use at a later date.

After learning and understanding the reporting needs, data structure requirements, and limitations of each application we were using for this process: Excel, MS Access, Winsteps, MS Word, SPSS, and Wordpad we were able to lay the groundwork to automate many of the steps.  It is important to note that it is our expectation that with each step of automation we will not only save ourselves time but we will make the process easier to understand and less prone to user error.  Each step of automation will decrease the likelihood that a mistake can be made.

The OVERVIEW

Once the surveys are complete they are handed into the P2 staff and their responses are key-entered into a Microsoft Access supported key-entry form specific to each survey.  Once a week we (Data Analysts of P2) run a MS Access macro that extracts the results for each survey and saves it off to a text file.  This text file is then loaded into Winsteps which is the application that performs the Rasch analysis of the data.  Once Winsteps crunches the data it automatically writes off a text file.  Another MS Access macro is run that imports the patient scores back into the database.  These scores are on a 0-100 scale.  The macro also produces a report listing only those scores that have come into the database since the last time the analysis was run. 

The FIRST Step:

The first step was to set up the MS Access database, which we have been using to store the results, to handle a key-entry form specific to each survey.  The form would allow the surveys to be key-entered directly into the database.  The results had previously been key-entered into an Excel spreadsheet.  We have the functionality to use the Teleform technology but an efficient process could not be set up to utilize it.  The advantage of a MS Access based key-entry form is that it is easier to read for the end user and it has the ability to have better control over data quality.  The forms can be set up to not allow duplicate entries, tight controls can be placed on the type of data entered into each field as well as not allowing fields to be left blank.  The user is not required to save the file during or after entry.  Further more, the volume of surveys is fairly small currently <10 per week.  A short cut is placed on the user desktop that takes them directly into the MS Access dB menu screen that allows them to choose which form to key-enter.

The SECOND Step:

Next, functionality had to be put into place within the dB structure to allow us to identify patients and all of the surveys they took.  Within the dB is survey data that may not be specific to P2, meaning that there is survey data from the large groups of folks that were used to test and calibrate the instruments.  The functionality put into place allows each survey completed to have a unique id as well as to be labeled as a to whether or not it is a P2 patient.  The database is also set up so that by using a patients PeaceHealth medical record number we can link a single patient to every survey they ever took.

The THIRD Step:  Looking for new surveys

A 6 step macro is run that looks for new surveys, ie surveys that have been key-entered but not analyzed.  This macro takes ~10sec to run.

Step 1 of the macro is to change the MS Access default so that all program warnings are turned off.  A query that comes later in the macro is a MakeTable query which when run will produce various program warnings asking the user to confirm that they want to make a new table, etc.  This first step just turn these warnings off which allows the macro to run in its entirety with out any further input by the end-user.

Step 2 is a MakeTable query that identifies all new Activated Pt surveys.  This first query is a MakeTable query while the queries in steps 3&4 are append queries.  The reasoning behind this is as Step 2 is run it is actually deleting the table currently there, which contains the listing of unique ids from the last time this macro was run.  By replacing the table this MakeTable query is able to list just the unique id of the new surveys.

The structure of this query is parallel with the structure of the queries in steps 3 & 4.  The table holding all of the key-entered surveys for the Activated Pt survey is joined to the Crosswalk table in a LEFT OUTER JOIN.  The unique id filed is brought into each query.  (The unique id field in the CrossWalk table is updated much later, during the export process. Therefore if the survey is new it will not have a unique id in the CrossWalk table.)  A criterion is placed on the unique id field coming from the CrossWalk table to only bring back results that are NULL.  The effect of this is that a new survey is identified IF it has a unique id in the key-enter table but not in the CrossWalk table.

Step 3 & 4 are append queries that identify new Depression and Physical Function surveys and appends their id to the table that was created in Step 2.

Step 5 is a select query that counts up the number of Ids, which represents the number of new surveys.

Step 6 turns warning back on.

The FOURTH Step: Exporting the data to Winsteps

The process to export the data of all 3 surveys is controlled by one macro.  The macro consists of approximately 11 steps.  The result of the macro is that 1 text file for each survey is written off to a specific network folder.  The text file is in the exact format needed for placement of the data into the Winsteps control file.  The only input required by the end-user is for them to hit the start button to initiate the macro.  The macro takes about 1 minute to run completely.

Step 1 of the macro is to change the MS Access default so that all program warnings are turned off. 

Steps 2-6 are a set of queries that select the survey data and ready it for export.  Each survey requires 2 queries; currently we are analyzing 3 surveys so that is why this section has 6 steps.  The following steps will describe the process for only one of the surveys with the understanding that the process for the others is separate but exactly the same.

The first query points at the table that supports the key-entry form for the Activated Pt survey.  This table contains all of the responses for all of the Activated Pt surveys.  This first query is a MakeTable query that grabs the unique id (a MS Access generated AutoNumber) of each completed survey as well as converts that id to a format that fits well into the Winsteps control file.  The Winsteps control file requires the id field to be fixed width so the query reformats the id by adding 10,000,000 to each id that way the id will always be 8 digits long.  For example, an id of 15 would become 10,000,015 and an id of 115 would become 10,000,115.   These two fields are written off to a holding table.  The purpose for this holding table is that it acts as a type of CrossWalk table that allows the pre-Winsteps and post-Winsteps survey results to be linked.

The second step of this two step process is another Make Table query that brings in this newly created 8 digit id and adds all of the responses to the survey question.  These are responses that are in a numeric format, ie a response of Poor=1, Good=2, etc.  This table has the sole purpose of holding the data in a place where it can be exported using predefined export specs. (A side note:  if the responses were in a text format the functionality of converting them to numeric could easily be accomplished in this step by simply adding a link to a conversion table.)

As mentioned above the previous two steps are repeated 2 more times within the macro, once for each survey.

Steps 7-9 of the macro export the contents of each export table using a predefined export spec.  Each text file is given a predefined name and written off to a predefined folder.

The last step of the macro turns the MS Access warning back on and produces a message notifying the user that export has been completed.

The FIFTH Step: Integrating Winsteps

Again, this set of steps is separate but parallel for each survey being analyzed.  Winsteps is opened and the control file is opened for editing.  The text file written off by the MS Access macro is opened in notepad.  The contents of the notepad file are copied and pasted over the previous results in the Winsteps control file.  The programming commands of the Control File are not pasted over, they are left as is.  It is only the survey data that is replaced.

The end result is that the control file now contains all of the same results as it did previously with the addition of any new survey results that have come in since the last time the survey was analyzed.  The Winsteps control file is saved and then run.  Winsteps automatically writes off the necessary person file to a predefined folder with a predefined name.

The SIXTH Step: Cleaning the Winsteps Person File

MS Excel is used to open the just created Person File.  The person file is cleaned up: all columns are deleted except for id, score and error.  The file is saved as a text file. (Side note: this step will be looked at for possible automation.)

The SEVENTH Step:  Import the results back into the MS Access dB

The MS Access import macro is an 8+ step process that automatically brings the results into the dB and creates a report listing the results of only the new surveys.  ãNewä meaning surveys that have come in since the last time this analysis had been run. This macro takes ~~3 min to run.

Step 1 of the macro turns all warning off. 

Steps 2-4 imports the cleaned up person files into 3 tables, one for each survey.  There is an index on each table to prevent duplicate entries.  This index prevents any unique id to come into the table if it is already there.  At the end of step 4 there is 1 table for each survey.  In each table is unique id, score, and date stamp.  For the surveys that are new the date stamp field is blank.

Steps 5-7 run a query for each survey that places a date stamp, todayâs date, in the blank fields of the new surveys.  This date stamp is required for the next step to function properly.

Step 8 creates a report that is based off of the 3 score tables.  This report grabs all survey scores, survey ids, and patient names for all new surveys.  This is why the date stamp field is critical as well as the previously created Crosswalk tables.  The actual score table only has 3 fields in it: unique id, score, and date stamp.  The crosswalk tables are used to grab patient name and medical record numbers. 

The last step turns all warning back on.

The EIGTH Step:

Now, the user has a report that lists the results of all new patient surveys.  This printout is used to update an SPSS file that is used to graphically represent the patientâs results of all surveys over time.

REVIEW

To set up this automation in its entirety took approximately 16 hours.  This investment will pay for itself within 9-10 weeks as we usually analyze new surveys 1x per week and that analysis would have taken approximately 2hrs each time. Above and beyond the gained efficiency, the automation of this process has made the analysis less prone to error.  Multiple manual steps have been reduced down to a few with the remaining ãworkä being done automatically.  Another large benefit is that all survey data is now being stored in a stable environment and it is being stored in a way that allows us to easily extract it.  We are able to quickly and easily extract the data in just about any iteration and format that is needed.  A single patient can be linked multiple ways to multiple surveys and multiple scores.  This database will provide us the flexibility required to meet the reporting needs that have not yet been anticipated.

A simple tutorial has been created that will allow just about any analyst to step in and adequately perform the analysis.  Prior to this it would have taken several days of training and extensive documentation for someone unfamiliar with the analysis to complete it from start to finish.  In a work environment where task and assignments are shared with a partner, the simplification and standardization of any process is a huge benefit.

History and Timeline of the Whatcom County Pursuing Perfection (P2) Clinic Patient Satisfaction Survey.

Although still in the process of change, the Clinic PSAT has gone through a long journey.  This log is intended to describe some of that journey, not a comprehensive description but rather some highlights along the way.  Highlights that may help others build off of the challenges and success we have had.

Prior to the launch of Whatcom P2, PeaceHealth created a sixteen-question survey that was designed to measure the level of satisfaction of a patientâs office visit experience.  Whatcom P2 decided to build off of this fully functioning tool by adding 7 questions that specifically addressed the Pursuing Perfection promises made to the patients of this community.  It was decided to administer this new survey by implementing the use of TouchScreen technology.  The survey was to be web based, using the connectivity of PeaceHealth and HiNet.  The patient would be able to simply touch the monitor screen to log their responses.  With questions and response categories written in a large font and a user interface that seemed to have no barriers a successful implementation seemed easy as pie.  Only identified by clinic, the data would be extracted and then analyzed using Rasch methodology.  Every month, the clinics would receive a score between 0 and 100.  This score would represent the satisfaction level of the patient.  It was thought, as we implement the strategies and interventions of the P2 project, we will see scores climb.  Patients will become more satisfied.

That was the plan.

With a tight deadline in place, Touchscreen Go-Live in all clinics by August 5, 2002, we set the wheels in motion to make it happen.  Those given the new responsibility of implementing the survey naively felt that we would just walk over to each clinic, plug the device in, and turn it on·.Presto, Good to go! 

Not quite. 

The barriers to implementation came fast and furious.  Beginning with the discovery that it had not been decided where in the clinic these devices should be placed and quickly moving to the identification of a lack of process to identify which patients would take the survey (ie Would every pt on every visit take the survey?  If not, how would they be selected? When during their office visit would they take the survey, etc).  Further more, some clinics did not have network connectivity in the area that had been selected for the device to be placed and some did not have proper furniture to place the devices on.

Quickly, we re-grouped and identified the issues and possible solutions.  A key note here is that in a time of extreme high stress the P2 team worked well together, staying on task and positive at all times.  Looking back, it was one of those moments where the power of the Team is really quite amazing.  The discussions were not about blame but instead they were about ãWhat do we need to do to make this successful?ä  Put into place during our team building retreat this was to be a real world test of our strength and commitment to each other and to the success of the project.  An excellent foreshadow of what our team dynamics would look like throughout the entire grant.

Over the next 8 weeks barrier after barrier was identified, addressed and solved.  Each week we felt as if Go-Live was to be ãsometime early next weekä. Some may look at the date of actual Go-Live, late October, and see it as not meeting expectations or even as a failure.  I think within the Project Team we look at it as a 100% success.  Together, Project Staff and Pilot Sites, acknowledged the barriers and created solutions.  Concerns were listened to and not ignored.  As a result we have a fully functioning tool in each pilot site with over 4 months of complete data showing PSAT scores for each clinic.

Within each monthâs anlysis each clinic receives their overall score as well as a frequency distribution graph for each question showing the percentage of respondents to each response category.  Further more, each clinic will be receiving a run chart that charts their score over time.  This run chart will also points of interest marked.  These being large and small scale implementations the clinic has undertaken, ie the implementation of the Congestive Heart Failure Registry.  The hope with including these markers is twofold: build a historic timeline showing

An interesting note is that the story doesnât stop here.  Listening to concerns about the questions specific to the Pursuing Perfection Promises we, as a group, decided to create a proposal of how we might evaluate how well these question work.  This proposal includes holding at least 2 patient focus groups where we will ask for patient feedback on what they think of the questions. We will compile and evaluate their comments and use their comments as the driving force behind any revisions we make.

More to come·..

 

Learning from a patient focus group.

This past week we held our first of what we hope will be several patient focus groups to help us re-design the P2 specific questions on the Clinic Patient Satisfaction Survey.  The intent of the P2 specific questions is to help determine if we (Pilot Sites) are fulfilling the P2 Promises to Patients.

A few of the many highlights of this first group were:

P2 Survey Question: The evidence-based guidelines for diabetes (heart failure) that we used to develop my written Shared Care Plan were easy to understand.

It became obvious that the phrase ãevidence-based guidelinesä was not understood by all of the patients.  Even the patients that did know what evidence-based meant felt that they would not know if their doctor was using them or not.  Paraphrasing, it seemed that the patients all assumed that the doctor would not use guideline that were not evidence based.  The patients recognized that guidelines change over time and what was important to them AND what they felt better defined the intent of the question was replacing ãevidence-basedä with ãup to dateä.  A patient mentioned that they are aware of the ADA guidelines for diabetes and how they have changed over the years.  It was important to him that his doctor was using the most recent or ãup to dateä version.  It seemed that using the phrase ãup to dateä was in the minds of the patients analogous to the intent behind ãevidence-basedä.

P2 Survey Question: I have complete access to all of the clinical information, either about me or my health, that I need.

The big learning from patients on this question was that just because patients are given physical access to their clinical information, ie given a copy of there medical record or operation report, does NOT mean that THEY have access to it.  Meaning that the medical jargon is impossible for them to understand and having copies of their reports isnât giving them access to anything because they canât make any sense out of it. 

Complete access would mean having both physical access as well as being able to read and understand what has been provided to you.  I found this to be very insightful especially as we think about P2âs spread to non-native English speaking members of this community and to those that are illiterate.

We look forward to holding more patient focus groups.  I have a feeling we will refine our methods as we go and become a bit more efficient at getting more quality feedback from patients.  It is a challenge to provide enough context so that the patients can understand why it is that they we are asking for their help and at the same time leave enough room on the agenda to make sure we get all of their ideas and feedback.  We want the patients experience at these focus groups to not only be positive but empowering.  We want them to continue to want to participate because it is obvious that we canât do it without them!

 

Radio Weblog ö A story of a concept that has outpaced its technology?

Those of us heavily involved in the Whatcom County Pursuing Perfection (P2) are beginning to feel as if the experiences we are having, trying to write our stories, is a parallel of the patient experience in our broken system of health care.  Most of us agree that in order for the power of patient centered health care reform to take hold we must be able to spread our stories; our stories of success, missteps, and learnings.  The World can learn from us and we can learn from the World. 

Creating that paradigm is the problem.  For the project staff of Whatcom P2 we have many issues with the Radio user interface, the interface that is designed to help us create our weblogs.  For some, knowing that all of their written thoughts will be read by anyone in the world is enough to create a chronic condition, ie writerâs block.  For others, written thoughts come out easily but the lack of usability of the tool creates further barriers.  Wonderful stories are carefully written only to be lost in the void.  Distantly analogous to being discharged from the hospital without any discharge instructions.  Halfway down the road of spread we loose our way.  Others publish to the WWW only to find that the beauty they have sculpted is just a jumble of words that have lost all formatting. Analogous to the patient end of the patient/doctor experience.  Paragraphs run together, words bolded that were never intended to be, sentences missing, etc.  Lots of words and good intentions but really just a jumble of text that has lost most of its meaning.

Much to the dismay of those that feel Radio is THE answer the P2 staff fail to write their stories.  The P2 staff are asked why they are not in ãcomplianceä.  Pressure is put on us to write, to share our important stories with the rest of the World.  The need is acknowledged and we try to comply.  We remember our stories and carefully articulate them only to be stymied by the technology.  The Radio believers ask again, but again we give the same response: ãWe want to but the barriers are too much.ä  Radio believers use a stronger voice: ãYou must complyä. Unable to navigate the system, our activation plummets and our depression rises. Puzzled, frustrated, and ultimately defeated we give up.  The Radio believers push harder for compliance as we move further away.

A seemingly sad tale with a dismal outcome·..then again maybe not.  Leave it to the P2 team to band together, to see the problem, and to find a workable solution.  A user-centered solution!!  Remove the barriers and we will write our stories.  Instead of using Radio we will write them any way we can: in Word, Notepad, on paper, etc.  We will write them whenever we have time: at the office, at home, together at lunch. Complete or incomplete we shall leave traces of our thoughts so that every revelation, every ãah haä, every oops, and every WOW can become a story.  We may not write the entire story but we will leave a trace that will allow others to learn.  Once written we will have the believers, those that have mastered the system, translate our stories to Radio.  Together we shall post them to the World and they shall be found and read by all·····

outine diabetic/CHF check.  Christine had been doing all of the work around this measure and to be honest I was dreading it a bit.  Knowing how busy the staff are in the pilot sites I was not looking forward to interrupting their day.  To say the least they were all very VERY helpful and my unease quickly subsided.  Some questions did arrise on how some of the calculations were performed and their opperational definitions.  I will be attempting to touch base with Christine about these.

The holidays will play a role in the stats for this month, as many clinic staff will be out of the office a lot over the next few weeks.  Will be sure to put a footnote on the graph to make a note of this effect.

2) Patient Surveys: Depression Measure, Physical Function, and Activated Pt.

Worked closely with Bill Mahoney and Sara Jane Satre, both of the Methods Outcomes Measurement and Statisitics team to analyze or implement the above listed surveys. 

With both, the Depression and Physical Function Measure we completely analyzed the results and then met with the Clinical Care Specialists to walk them through how to interpret and act on the results.  Bill provided a wonderful tool that attempts to utilize a pts score to determine what level of intervention, if any, is required from the CCS.

The Activated Pt survey was finalized and a Teleform, form that allows the survey to be read as a fax and automatically stores it in a data file, was created.  An initial process was established on how to score the survey.  In some instances the CCS will score the completed survey with the pt and they will then discuss the results.  The CCS will then return the survey to us so we can perform a more detailed analysis and provide that to the CCS as well.

Feedback from the CCSs was positive and thankful for having such excellent tools at their fingertips.

3) In an attempt to address the concerns that were expressed at the 12/4/02 Implementation Meeting about the Clinic Pt Satisfaction Survey I created a rather thorough document with the intent of this document being: to provide background knowledge of Rasch, clinic PSAT, and HCCC.  It was designed to provide the reader with as much detail that was desired, no more no less. ie simple overviews with links to further detailed description.  The link to this document is: 

http://www.peacehealth.org/apps/p2/document/DocumentDisplay.asp?DocumentID=178
 
This is being stored on the Hinet based site so it may not be accessible to the entire WWW.

4) Worked with the Clinical Care Specialists to brainstorm and create an informal survey that we will use to gather feedback from the patients, and members of their care team, who have been admitted to a CCS.  The basic rules that we followed were:
1) Keep it short
2) Keep it simple
3) 1 page front and back
4) Anonymous with option to provide id if pt wished to discuss the survey results and/or feedback about the survey itself.
5) One version for the pts and one version for members of their care team.  The same questions but worded differently.

5) P2 Goes to Orlando
 
Much of the time spent the few days prior to the IHI Conference in Orlando was focused on producing charts and graphs for the presentation storyboard and other meetings/learning huddles.

End product of the storyboard was most impressive!

6) Continued work on System Dynamics ö Congestive Heart Failure data pull. 

Except for financial and procedure data we have completed both the SJH CHF and Center for Senior Health CHF data pull.  Pulled all visit and pt info and sent off to finance.

Had extensive discussions, in person and over email, around the procedure data that has been requested.  More specifically, what are the relevant cardiac/cath lab procedures that we are to pull.  After getting feedback from the Nancy and Dr. Lomabardi I think we have identified what it is we are trying to pull.  Also worked with Dee Garcia, SJH Coding Manager, to identify the correct corresponding procedure codes.  As always, Dee provided very timely and valuable information.

7) Completed the monthly Diabetes and CHF report for IHI as well as the Pilot Site Specific reports.  These were submitted to IHI and to each clinic. Still have been unable to cement a meeting date with the Bellingham Fire Department to discuss the sharing of Emergency Medical Information

8) Have been intermittently doing a significant amount of research into the new HIPAA regs (Federal confidentiality laws).  New regs go into effect April 1, 2003 and am hoping to have a very solid handle on what is ok, what is not ok, and also what is changing.
9) Pt Satisfaction Data for SJH-Inpts was received for the month of September.  Survey questions specific to P2 were analyzed and the results were distributed to the hospital guidance team.
10) We continue to report the number of clinic PSAT surveys completed per day.  Although variable from day to day the results are beginning to show a stable pattern.  Overall it looks as if we are receiving enough completed surveys to meet the minimum requirements for analysis.

 

1)  Completed and submitted the analysis of the SJH Inpt PSAT P2 specific questions for the month of August.  In addition, August data was compared to July using a line (run) chart.  This chart will be transitioned into a SPC chart once we have enough data points to do so.  Thanks to Sarah Jane Satre of the PeaceHealth MOMS Team for her strong knowledge of SPSS and continued help with this analysis.

2)  Later this week we will begin the first analysis of the Clinic PSAT Touchscreen Survey data.  We currently have >250 completed surveys in the hopper which is a perfect amount to create the necessary anchor file.  In addition to the creation of the anchor file we will also be able to provide the clinics with actual PSAT scores.  With the feedback gathered from the most recent Implementation meeting we will hope to reformat the clinic specific PSAT report into a more user friendly manner.  The PeaceHealth Survey Subteam of Aaron Ignac, Sarah Jane and of course Bill Mahoney will be instrumental in making this analysis a reality.

3) Began work on the Systems Dynamics data pull for Congestive Heart Failure.  This has proven to be a bit confusing and more complex than the Diabetes data pull.  At the very least it looks like an impressive challenge that we look forward to tackling.

One of the main challenges is staying in compliance with the patient confidentiality rules and regs, especially the new HIPAA regs that go into effect April 2003.  While all of us truly have patients at the center and have an enormously high regard for patient confidentiality the new HIPAA regs are creating some challenges not previously experienced.  Simply relying on our self judgment of what is "reasonable" doesn't cut it anymore.  The HIPAA regs are very specific and have teeth.  Violating these regs, even inadvertently, could sink our efforts, on a personal level as well as community level.

The first step of the Systems Dynamics pull is fairly straight forward and we should be able to submit "Phase I" data to the consultants in the very near future.  The phase I data does not involve the release or sharing of any pt identified data so we will be able to move quickly on completing this request.

Many thanks to Dori Robart from SJH and Sarah Donelson of the MOMS Team for providing their continued support and guidance with the security and confidentiality rules and regs.

4)  We created a database to assist us in tracking the rate of completion of the clinic PSAT survey.  This has proved useful in providing the clinics with immediate (daily) feedback on the # of surveys completed at their offices.  Run charts are faxed or emailed to each pilot site on a weekly and/or daily basis depending on their preference.

5)  Data collection for the measure: 3rd Next Available Appt was conducted and completed.  This is the second month of data collection for this measure.  The processes, established last month, created a very useful and efficient template for this month's data collection.  We hit a few barriers with contact folks being out of the office but in each instance the specific clinics responded positively and quickly to getting the issues resolved and helping us complete the data collection.  A big thanks to all of the pilot sites!!

 

 

 

PeaceHealth makes every effort to begin each meeting with a "reflection."  This is a particularly meaningful experience for many as we take time to think about things related to the work that we will do.  I was in a meeting the other day and was quite taken with the following story that Doreen Putnam, Ambulatory Services Manager, offered as our reflection.  Here it is.

A True Story

There was once a man named Fleming.  He was a poor Scottish farmer.  One day, while trying to make a living for his family, he heard a cry for help coming from a nearby bog.  He dropped his tools and ran over to the area.  There, up to his waist in black muck, was a terrified boy, screaming and struggling to free himself.  Farmer Fleming saved the lad from what could have been a slow and terrifying death.

The next day, a fancy carriage pulled up to the Scotsman's sparse surroundings.  An elegantly dressed nobleman stepped out and introduced himself as the father of the boy that farmer Fleming had saved. "I want to repay you," said the nobleman.  "You saved my son's life."  "No, I can't accept payment for what I did,"  the Scottish farmer replied, waving off the offer.  At that moment, the farmer's own son came to the door of the family hovel.  "Is that your son?" the nobleman asked.  "Yes," the farmer replied proudly.

"I'll make you a deal.  Let me provide him with the level of education my son will enjoy.  If the lad is anything like his father, he'll no doubt grow to be a man we both will be proud of."  And that he did.

Farmer Fleming's son attended the very best schools, and in time, he graduated from St. Mary's Hospital School in London, and went on to become known throughout the world as the noted Sir Alexander Fleming, the discoverer of Penicillin.

Years afterward, the same nobleman's son who was saved from the bog was stricken with pneumonia.  What saved his life this time?  Penicillin.

The name of the nobleman in this story?  Lord Randolph Churchill.  His son's name?  Sir Winston Churchill.

So, as you face life's challenges, think of this:

• What goes around, comes around.
• Work like you don't need the money.
• Love like you've never been hurt.
• Dance like nobody's watching.
• Sing like nobody's listening.
• Live like its Heaven of Earth.

I just read Marc's New Years Day post on leadership lessons he learned from his daughter Isabella.  It made me smile...partly because I have always believed that you can learn a lot from kids and animals if you just pay attention; and also because it made me think about lessons I've learned over the years working with groups and individuals, who by the way, were once kids themselves.

 

In thinking about this, I'm trying to draw some parallels to Marc's walk with Isabella.

 

People like to be in charge of their own destiny.  I believe people articulate what they want at times, but mostly when they sense some control over what it is they want, or when there is an environment that makes them believe that they have permission to do so.  Isabella could control what she wore.  In the grander scheme of the walk, she may not have sensed the ability to control her desired destination and decided to just follow.  How often do we go on a walk in the rain with the individuals and groups we work with?  And, how often do we realize soon enough that the pace is slowing before checking in or changing direction?  I think we let folks "come dressed" the way they want to begin the journey most of the time.  We engage them, at least initially, but often fail to pay real attention once the journey begins.  I'm thinking the pressure for deadlines and outcomes or our own need for control makes us lose sight of the tears and disengagement.

 

In thinking about my work, I realize that sometimes others ask us to go on walks and even have a destination in mind.  We cheerfully agree and if we're not careful, we end up in a place we shouldn't have gone.  We exert lots of energy, navigate the rocks and potholes on the path, and eventually end up at the predetermined destination.  The trip may not have even been extremely enjoyable but as long as we reached our destination, we both seem satisfied.  So often, we are asked for help and given our need to please, give others exactly what they ask for.  This makes me wonder how often we spend energy walking to the wrong places.

 

Reflecting on work I've been involved in over the past several months with one particular group, I realize even more, the importance of considering the desired destiny of others.  Several months ago, I was engaged to facilitate a retreat.  The requestor had a clear goal in mind, wanting to begin building a team in her area of responsibility.  We had an admirable plan!  The retreat went well and the requestor was very happy.  The team enjoyed the day and even said so, commenting on what they had learned.  We conducted the normal debrief of what worked and what they would have liked more of.  But what I realize now is that people "came dressed" with the desire to "go on the walk", but they had their own ideas about where we should go and how we should get there.  It is sad that they did not believe they could change the destination. The group was willilng to walk along for a while and they kept the pace throughout.  But because of the time it took to build the foundation, they left without a finalized task list, something that was critical to their need for detail and accomplishment.  They also left without confronting issues with each other, something that would surface later.  Not everyone sees building a foundation for relationships as real work so it was not the group's priority, even though they were willing to do the work.  It took the activities of the entire day before they believed they could have changed the destination.  Isabella would not have skipped home!

 

Weeks later, the requestor was still happy and the participants were using what they had learned about each other.  Everyone was still anxious to get on with the work and dealing with others. Relationships between two team members failed, and more work began.  This new work required going back to the foundations built in the retreat.  We were working to deliver some mandated outcomes.  This time, the desired outcome was all about the "soft stuff" and building a foundation.  Suddenly, the perception and energy level changed.  Now, all of the things we were trying to accomplish at the retreat became "important work."  It was clear that it had become the destination of choice.  The two worked diligently, accomplished the desired outcomes, created a healthy foundation, were determined to share their work with others, understood why the work was successful, and were committed to making it work.  They had turned a corner in their relationship.  The difference?  They really wanted to go th the place I was taking them.  They helped choose the path and they were controlling their own destiny.  And because of all of the previous work, they now believed that they could.

 

So Isabella, next time someone asks me to go on a walk, I will still make sure they "choose what they wear", will make sure they believe they can negotiate the destination, and I will stop more often to ask if we're going the right way!  I will also do everything in my power to make sure that they "skip all the way home!"  Thank you, Isabella for this reminder!

Iâve been consumed of late with words that begin with ÎAâ.  I feel particularly reflective on these words right now as I consider Annie Gortâs post today.  Iâm especially struck by her willingness to demonstrate personal capacity to make these words real on this journey of Pursuing Perfection.

 

These are the words:  accountability; awareness; advocacy; authenticity; alignment; and action.  I see these words as points on a star.  Right now the star has six points, one for each word.  Iâm certain that there are others and that the star will continue to expand in points and in dimension and depth to become a star that we are all willing to hitch our wagons to.

 

We all must be accountable.  We must take the responsibility to deal with those things that keep us from moving forward, even when that may be uncomfortable for ourselves and for others.  And I do believe, that part of this accountability includes our responsibility to suspend our judgments and confront our own assumptions so that we hear the real message(s).

 

Awareness or self-awareness, so well demonstrated by Annie, is critical.  We first must confront ourselves and reflect on those things that happen in our daily work that may cause us discomfort and build on what causes us joy.  This is the first step; to step back and really discover where we are, what our passions are, what we feel, sense, think, want, and are willing to do. 

 

Advocacy is essential too.  To me, this means not only partnering with others to work together and collaborate, but also to hold forth our expectations and the expectations of others in support of creating even more meaningful partnerships and encouraging team growth toward the same perfection that we want for our health care delivery system.

 

Authenticity has to become an expectation.  To expect it of self is minimal.  To expect it of others is ideal.  What a wonderful opportunity we have to practice this as we Pursue Perfection.  Annie has taken us to the edge of authenticity by becoming self-aware, advocating for a better team, being genuine and real, with good intent, and with willingness to take action. 

 

Alignment can be the result of Annieâs effort.  Iâm thinking that alignment is my personal hot button right now.  If we fail at alignment, we fail to reach our dream.  Alignment comes out of all these other ÎAâ words (accountability, awareness, advocacy, authenticity, and action).  We create balance in people, in systems and processes, in structure, culture, and information and by building on our strengths.  We avoid the potholes that slow us down and cause ruts in the road that ultimately cause us to get stuck.

 

And finally, Action gets us to our end.  We create intent to do, to make things better, to learn from our assumptions, to accept the real meaning of accountability, awareness, advocacy, authenticity, and alignment and to create the new paradigm for our new future in health care. 

 

These words may get us started.  Weâll discover more as we proceed.  We may even create new words.  But we will be even more successful if we add the seventh word ALL meaning it takes everyone to make it happen!

Cindie Becker has the following text in a frame on her office wall.  We have been using it as a starting point in the last month or so to frame the culture that is desired inside different teams and meeting structures.  Iâve been thinking a lot about team agreements of late and have realized that we often go through the exercise of developing agreements with teams.  The problem is that all the teams end up with different rules and the way that these rules play out in cross-functional arenas rarely works.  Iâve decided to take a different approach as I think about helping groups define their agreements.  It has suddenly crossed my mind that we all must share some common statement of ãThe Rules of the Gameä in order to work collaboratively from common understanding.  I wonder if coming to this initial agreement isnât a first step in this ritual of setting agreements.  If we can all agree on a common statement, then our work in individual teams becomes defining those behavioral statements that we need to honor to get us there.  The following is the text that is found on Cindieâs wall.  It is called:

The Rules of the Game

Be willing to support our purpose, games, rules and goals. Speak supportively. Use verbal acknowledgements to express value for each other. Correct supportively.

Acknowledge whatever is being communicated as true for the speaker at that moment. Complete your agreements. Make only agreements that you are willing to ö and intend to keep. Communicate any potential broken agreement at the first appropriate time. Clear up any broken agreement at the first appropriate opportunity.  If a problem arises, first utilize the system for corrections, then communicate the problem with alternative solutions to the person who can do something about it.

Be effective and efficient. Optimize every event. Make more with less. Have the willingness to win and to allow others to win. Focus on what works.  When in doubt, check feelings out.  Agree to disagree until reaching consensus. Tell the truth from a point of view of personal responsibility.

 

With the task of transforming the health care system in Whatcom county and beyond, it is not often when the Pursuing Perfection core team can pause long enough to be in the same place at the same time thought or location wise.  We have staff meetings on a regular basis, but occasionally we need a longer period of time together as a team to update, reflect and dream.  This last week we had a wonderful team retreat where one of the team activities was to share our dreams for the future.  Here are our dreams for one year and beyond· dreams, goals, sustainability and success.

 

Patient involvement ö patient initiates, clinic follows

 

Website: more info to the right person at the right time ö patients control info that goes to them

 

Education process through community - electronic, standardized, color printed

 

Inter-team communication through web or tool such as groove

 

Primary docs routinely meet to discuss patient needs

 

All clinical staff fill out shared care plans as primary priority

 

Spread patient centered care as norm beyond county

 

Bulleto used for migrant community as focus of their care

 

Ease in access to electronic information

 

Support groups across community

 

Any healthcare professional will know how to define/use SCP and P2

 

Process established to support creation of SCP for anyone in community

 

SCP easily connected across organizations without duplicated effort and automatically

 

National healthcare program, like Sweden, or transformed healthcare

 

Reimbursement for email, group visits to prove economic sustainability for chronic care

 

Motivational interviewing takes hold among all clinicians

 

Electronic guidelines, always current, user friendly and always available

 

Healthcare professionals feel balanced in their practice, with patient centeredness and sufficient time to work

 

Patients experience is empowered, feeling like part of collaborative team

 

Awareness of need for transformation and belief in our approach among total community ö spreading the awareness

 

Sustainable, automated system to continue data collection/analysis

 

All FCN clinics, Lummi, Interfaith and Mt Baker family as P2 sites

 

More CCSâs

 

Patient outreach coordinator

 

More diseases that are better managed

 

Network of 13 P2 sites all following P2 community model

 

Integrated SAFE electronic med list

 

System is patient driven

 

Management of chronic conditions resemble one another to ease provider adoption

 

Forum for patient and others involved to discuss complex issues

 

Options for care located in a place called Chronic Urgent Care

 

Include all who share work on patient care in the center ö not just patient-centered

 

Support and sustained balanced lives for heath care transformers

 

P2 patients being advocates of transformation among providers and other patients

 

Other fundamental aspects of healthcare, IE profit, are examined for transformation

 

Examine incentives in system to reinforce those that benefit patient

 

Spread beyond Whatcom county

 

Improvements so apparent and recognized that people demand them

 

Cross clinic team on going

 

More efficient change through systems dynamics modeling

 

Bi-directional, transparent med list

Clinicians and patients work together, caring for entire patient care team integrated into excellent, satisfying care

 

Sense of alone-ness, of being a disease rather than a whole person, disappears

 

More prevention and support for behavior change

 

Patients with chronic diseases support one another in prevention

 

Whatcom community knows what health indicators are and uses them and existing assets to support P2 and pool resources for prevention

 

Community takes responsibility for sustainability

 

Spread to OR, WA and non peace heath communities through leaders connecting and learning how to transform chronic care

 

More CCSâs, solid value-added, lean, effective structure

 

Patients advocating effectively to promote and sustain change at local, state and national levels

 

Patients feel strong and effective

 

World Peace

 

Computer in every exam room

 

All payors pay for P2 aspects and assure that healthcare pays for itself

 

Have Olympic take over Medicare payment for P2

 

Immediate feedback (money) for providers/payors doing the right thing

 

P2 at center of international transformation

 

P2 Whatcom county as case study of sociology of collaborative community

 

Company that does P2 as a service in any community

 

Physicians will want to stay in our brand of healthcare

 

All medical records tied together and patient can access through shared care plan all info on the condition

 

All Whatcom county patients supported by P2 process

E-SCP available nation öwide

 

Patients continue central role in design

 

Communities will use web-logs; stated personal values, to form virtual communities with free, easy access to information

 

Local systems dynamics modelers

 

Pharmaceutical companies fund electronic updates and spread to more communities

 

Patients show increased relationships, self-management and communication

 

Idealized design of clinic process solves all access problems in Whatcom county

 

Models expand to 5 diseases

 

Communities learn that they can transform their own health care

This is a test of FM Radio

; This chart will be transitioned into a SPC chart once we have enough data points to do so.  Thanks to Sarah Jane Satre of the PeaceHealth MOMS Team for her strong knowledge of SPSS and continued help with this analysis.

2)  Later this week we will begin the first analysis of the Clinic PSAT Touchscreen Survey data.  We currently have >250 completed surveys in the hopper which is a perfect amount to create the necessary anchor file.  In addition to the creation of the anchor file we will also be able to provide the clinics with actual PSAT scores.  With the feedback gathered from the most recent Implementation meeting we will hope to reformat the clinic specific PSAT report into a more user friendly manner.  The PeaceHealth Survey Subteam of Aaron Ignac, Sarah Jane and of course Bill Mahoney will be instrumental in making this analysis a reality.

3) Began work on the Systems Dynamics data pull for Congestive Heart Failure.  This has proven to be a bit confusing and more complex than the Diabetes data pull.  At the very least it looks like an impressive challenge that we look forward to tackling.

One of the main challenges is staying in compliance with the patient confidentiality rules and regs, especially the new HIPAA regs that go into effect April 2003.  While all of us truly have patients at the center and have an enormously high regard for patient confidentiality the new HIPAA regs are creating some challenges not previously experienced.  Simply relying on our self judgment of what is "reasonable" doesn't cut it anymore.  The HIPAA regs are very specific and have teeth.  Violating these regs, even inadvertently, could sink our efforts, on a personal level as well as community level.

The first step of the Systems Dynamics pull is fairly straight forward and we should be able to submit "Phase I" data to the consultants in the very near future.  The phase I data does not involve the release or sharing of any pt identified data so we will be able to move quickly on completing this request.

Many thanks to Dori Robart from SJH and Sarah Donelson of the MOMS Team for providing their continued support and guidance with the security and confidentiality rules and regs.

4)  We created a database to assist us in tracking the rate of completion of the clinic PSAT survey.  This has proved useful in providing the clinics with immediate (daily) feedback on the # of surveys completed at their offices.  Run charts are faxed or emailed to each pilot site on a weekly and/or daily basis depending on their preference.

5)  Data collection for the measure: 3rd Next Available Appt was conducted and completed.  This is the second month of data collection for this measure.  The processes, established last month, created a very useful and efficient template for this month's data collection.  We hit a few barriers with contact folks being out of the office but in each instance the specific clinics responded positively and quickly to getting the issues resolved and helping us complete the data collection.  A big thanks to all of the pilot sites!!

information from meetings with systems dynamics people. Diabetes model explained.

3) Updated queries and macros with new provider info for new care providers at clinics.

4) Researching CHF community statistics through the CDC to attain a percentage of CHF patients in this community.

5) Systems dynamics meeting with consultants to discuss CHF measures and data to use for model.

6) Starting month end IHI and clinic reports.

Learned SPSS and process from Sarah Jane Satre on MOMS team. Distributed report to Marc P. and Mary M. via email.

2) Installed SPSS and started tutorials for processing of info for both frequency reports and upcoming initial RASCH analysis data for clinic PSAT reports.

3) Created Macros in Statit to improve efficiency of monthly reporting needs.

4) Added new CHF queries for additional CHF reporting needs brought up in Implementaion meeting for info relating to patients taking beta blockers, ACE inhibitors or both. Integrated these measures into the IHI-CHF report.

5) Working on P2 storyboard for upcoming HID university.

6) Continued to assist in adjusting the clinic PSAT survey.

created.

4) Further adjustments and tweaking of Clinic Pt Satisfaction Survey.
     -Bolded some text to provide more emphasis to key words
     -Changed the response categories for the following questions: Can I email my provider· and There are group visits at my clinic· to Yes, No, I donât know.  This change was approved by Bill.
     -Discovered some errors in the Spanish translation.  Working through those now and should have them fixed shortly.

5) Contact made with the Bellingham Fire Dept for gaining access to their data.  Need to report to IHI: # of pts with known CHF that called 911.  Will hope to set up a meeting with them and the necessary members of the P2 team as soon as possible.

6) Agreed on an initial reporting template for the PSAT reports as well as identified the process to create those reports.  Will look for continued support from the MOMS Team, specifically Sara Jane and Aaron Ignac, to get Brian and I up and running.

as is, without the financial numbers and when Dan Philpot is able to complete the financial portion of the pull we will then fwd on to Gary.

2)     Clinic specific IHI reports completed and presented at Implementation meeting.
Gathered some great feedback and clarification on the CHF and Diabetes measures.  Clinics seemed please to be able to receive clinic specific reporting.

3)     CHF registry and scratch pad retreat with MOMS team members for design and implementation of new CHF scratch pad.  CHF scratch pad area almost complete.
This ãscratch padä will mimic the DWAP scratch pad and allow us to report CHF clinical measures over time.  Further more, we feel that it eventually should be usable for other regions that implement the CHF registry.

4)     Meeting with Erez Gordon and Adam Miller to discuss survey input and processing.
Plan to touch base every other week for review of needs and update on any barriers around survey data storage.

5)     Meeting set up with MOMS team members to coordinate survey data reporting.
Will hope to produce a draft proposal that will cover all of the P2 Survey related reporting needs.  Looking forward to working with and learning from Aaron and Sarah Jane!

I had a bad river-rafting trip once.  Actually, it was my last river rafting trip and it took place a few years ago on the McKenzie River, near Eugene, Oregon.  I'd been on that river before with a trusted friend and skilled river guide. We worked as a team, with his expert guidance.  This time the person directing the raft was someone else with less skill and less judgment, and who did all the paddling.   Have I mentioned that I am a proponent of teamwork?

To make a long story short, the climax of the trip was getting caught in Brown's Hole.  Picture this... three desperate mice clinging onto an inflated soap dish in a washing machine set in the spin cycle.  I think you get the drift... While we did provide some captivating, and apparently humorous entertainment to some kids standing on the near-by boulders, my only thought at the time was... well, I actually had two thoughts - "I'm going to die"; and "How do I get out of this situation?".  Creativity went the way of the broken paddle.  We clung on to our increasingly damaged raft with all our might, throwing ourselves from side to side, trying to stabilize things.  Eventually, the river tired of us, and my next awareness was that of being tossed into the air (and out of the raft).  In the brief moment before hitting the water, I remember thinking one thing, OK, two things... "Iâm going to die", and "Get back into that raft as soon as possible."

   When I surfaced in the VERY COLD water, I gratefully realized that the raft was within reach.  Obviously, I lived to tell the story... and if I hadn't been so scared, and so cold, this could have been a thrilling ride. When I related the story to my sons later, they were almost envious.  All I can say is thank goodness for lifejackets.

The memory popped into my head tonight for some reason, and I reflected that sometimes working in health care feels a little like being in that raft in Brown's Hole... spinning around and around, and being tossed from side to side, desperately trying to hold on.  In these types of situations, creativity is abruptly replaced with an intense focus on survival. 

In his book, "The Consultant's Journey"  Roger Harrison, makes the point that organizations are so inundated with non-stop change, and people are so change weary, that what is needed instead of change agents are "facilitators of healing".  I think he makes a good point.  What I'm realizing once again is the incredible importance of relationship building in any change effort.  Relationship building and breathing.  We need to find ways to acknowledge and appreciate each other and breathe and reflect upon the work that is being done. We also need to find ways to reduce anxiety whenever possible.  These things seem like luxuries sometimes, but they are just as essential as efficient processes.

 

 

Charon's description of the use of narrative in her medical practice  is registering with some thinking I've been doing lately.  I've been wondering what truly transformed medical practice looks like for the patient, the family, and the health care clinicians.  It has seemed to me that time for the patient's story is an integral part of this practice.

 I'm recalling working with Dr. Andrew Elliott, ND, a physician in Eugene, Oregon. This man has been one of my greatest teachers in the field of healthcare.  One thing that was integral part of Dr. Elliott's practice was listening compassionately, non judgmentally and intently to patient's stories.  Being a classical homeopath, gleaning the small details about symptoms, reactions, even states of mind was an essential part of his effective practice.  Andrew's compassionate and quiet listening approach almost always drew out very complete pictures of the patient's current state and also built a trusting relationship.  Part of the reason he was able to do this (and still does, in a thriving practice), is that he also respected and cared for his own physical, mental, and spiritual needs.

So how does a practice with established production demands take the time to listen to patients' stories? Isn't part of efficiency, trying to get just what you need out of a patient to make an accurate diagnosis, and move on to the next patient as quickly as possible?  How does one balance this with taking a comprehensive approach to patient care?

I certainly don't have the answers and I've never practiced medicine.  I keep coming back to the wisdom of another teacher:  David Cooperrider at Case Western University. http://connection.cwru.edu/ai/ David's quote, "We are made and imagined in each other's eyes." comes to me at least once a day.  

When I reflect upon my experience as a patient, I realize what matters more to me than the amount of time spent with me in the exam room, is how present the care provider is. Is she/he really there - really listening?  And, what are they doing with their judgments?  How is this person's belief about me impact how they imagine me, their presence with me, and, my response or reaction.    How does the image I hold about my care providers impact my presence and response to them?  How can we really see each other?

  Once my medical record got confused with someone else's at an office.  The other patient has a very complicated and challenging social history.  The assistant , thinking I was actually someone else, approached with an aura of suspicion, caution and judgment.  It wasn't until she began asking me questions that didn't make sense, that we identified the source of the confusion and her demeanor changed entirely.  As she shifted in her approach, my defenses began to drop and my responsiveness to her shifted back to what is normal for me.

So, it seems to me, if we believe that patient stories are a vital part of healing care, then we must help ourselves be in a state of mind in which patients feel comfortable sharing them.  Self awareness can help here.. recognizing one's own internal reactions,  keeping our intent and desire towards healing at the foremost of our approach, and therefore enhance our responsiveness.   And, remember healers need to take care of themselves, too!

The Center For Senior Health has done it again.  Their team development score has surpassed all others.  This, while integrating a new director, welcoming new staff and saying goodbye to others, adding new clinicans, working through major reorganizational efforts and being involved in P2!   A great deal of the credit goes to Erin Baumgart, Nurse Practitioner, who makes it her business to pay attention to the dynamics in this fine clinic.  At the recent Guidance Team meeting, I asked the members what contributed to the success of this team.  This is what they told me:

 

• Communication is open and people can say what they think and be heard.  Also, they can talk about their feelings. Everybody is allowed to share their feelings and is validated for having them.  Communication is open and honest. People feel secure, knowing their jobs arenât threatened if they make a mistake, "we just try and fix it".  Itâs the job thatâs the issue, not the person.  Erin has a basic belief (modeled by her mother) in trusting in the good of a person.  Also, modeling the way, rather than telling people the way to behave.
• Denise Fischer contributes by supporting Matt Groenig (Director of the Clinic). She is responsible for recruitment and selecting finalists for positions.  She take the culture of CSH into consideration when choosing candidates.
• Kathy Higgerson, front office team-lead, helps by keeping people aware that they are begin heard and something is being done about their requests. Even if the process is slow ö she keeps people abreast of progress. 
• Matt Groenig helps by doing the same thing. He responds quickly to staffâs need to hear information from him, or for him to listen to them.
• There are no white elephants among the group.

Our former process facilitator, Terry Wagner has contributed by just being herself and building relationships while working on P2 projects in the clinics.  Bringing chocolate was a big plus.  Terry also tried to just "be present" with the with staff and connecting on a person-to-person level.

Once again,, it just isn't rocket science.  Paying attention to relationship is the key to good teamwork.

 

Met today with FHA's leadership team, which is composed of the clinicians and manager.  Stacey and I have recognized the value of staying in close touch with leadership as the clinic traverses all the changes ahead.  Late yesterday afternoon, we got wind that staff were reporting high stress levels at FHA.  Stacey and I charted out the projects currently, or soon to be  in process for the clinic. This list includes: 

Open Access, Planned Care, Idealized Office Design Efficiency, Shared Care Plan, Alternative visits, HF and DM registries, Patient Centeredness, EMR, Millbrook upgrade, transcription changes, recovery from docu-scan and Millbrook implementations, a remodel on the horizon, and HIPAA regulatory remodeling. Phew!  No wonder people were getting a little frantic!

This morning, we asked the clinicians what they've noticed as far as staff behavior.  Their observations were that staff were expressing increased fragility, frustration, anger, sarcasm, fear, shock and anxiety.

Here's what the clinicians identified that seems to be helping:

Relationship building that is happening in the redesign teams

Quick fixes being addressed and attended to

Cross-function mixing of staff on teams

Adhering to team agreements up front

Role modeling

Everyone together in a room hearing the same thing at the same time (the most recent all-staff meeting)

Acknowledging the situation and the magnitude of the changes, regularly

Expressing gratitude to the staff

We agreed to schedule another all-staff information/sharing meeting in the next few weeks. 

What I know from William Bridges excellent work, Managing Transitions, Making the Most of Change is that people benefit from the following in times of change and transition:

• knowing why this is happening -- and the benefits
• understanding the problem with the old way
• focus on the future rather than on the past
• keeping communication lines open
• sharing feelings and plans
• ceremonies to "let go" of the old
• defining what is over and what isn't
• support/caring
• gleaning ideas/ sharing ideas and support
• acknowledgment of the fear and chaos
• understanding that chaos is normal
• focusing on short-term goals
• rewarding small successes
• promoting personal responsibility
• converting complaints to action
• modeling new behaviors
• slowing down and enjoying the newness as much as possible
• mark the arrival of new beginnings with a celebration
• choosing new patterns before routines set in
• noticing the difference.

In addition, I believe this journey is a survivable one if we can just keep our eyes focused on the vision of excellent, patient-centered care and appreciate each other along the way.  

The Access, Planned Care, Patient Flow, and Culture teams at FHA have now created their mission statements and group agreements. The mission statement creation process

I have created a special category to post information about Appreciative Inquiry or similar approaches.