All WWPP RadioWeblogs: P2-Aggregate

Mon, 16 Feb 2004 21:22:50 GMT

We have updated our Frontier/Manila server.


We have updated our Manila Software. This is good for all weblogs because the Manila server actually hosts the Radio Weblogs Radio Community Server, as well as all of the Manila Weblogs.

Thu, 12 Feb 2004 19:33:23 GMT

This is a reposting for todays date. 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.

Thu, 12 Feb 2004 07:13:02 GMT

Just a test of my email publication to a mail list.

Thu, 05 Feb 2004 05:22:51 GMT

Trust as a Verb and Insecurity as a Good Thing.

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.

Thu, 05 Feb 2004 05:22:50 GMT

Clear Leadership.

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.

Thu, 05 Feb 2004 05:22:49 GMT

Which side of the bed?.

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.

Thu, 05 Feb 2004 05:22:49 GMT

A Poem by John Stone.

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.

Thu, 05 Feb 2004 05:22:48 GMT

Dawn Gauthier reports on Shared Care Plan award.

PatientPowered.org wins award!

Thu, 05 Feb 2004 05:22:47 GMT

Narrative in Medicine.

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.

Thu, 05 Feb 2004 05:22:46 GMT

Albert Camus on Community, Hope and Creativity.

"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.

Thu, 05 Feb 2004 05:22:46 GMT

From Programs to Movements.

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.

Thu, 05 Feb 2004 05:22:45 GMT

Advanced Access--a Key to System Improvement.

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%.

Thu, 05 Feb 2004 05:22:45 GMT

Presentation to WA State Medical Society House of Delegates.

Yesterday I had the privilege of talking about our Pursuing Perfection initiative with the house of delegates for the Washington State Medical Society. Below I have included to content of my 11 slides and my notes.

PURSUING PERFECTION in Whatcom County, WA

SLIDE 1, TITLE SLIDE:

PURSUING PERFECTION

WHAT'S IN A NAME?

Perfection? ...when things seem pretty bleak. When the pace and complexity of practicing medicine is at this highest yet. When frustration or even cynicism seems ready to overwhelm many. But in a culture that takes the charge "first do no harm" seriously. A culture where each of us carries the desire and burden for faultless care with us each working moment. I suggest that by admitting to ourselves and to the public that we are all in the pursuit of perfect care may allow each of us to get some help. As the Chasm Report points out, the problem is with the system. The system that should help us do the right thing. The problem is not with the effort of doctors and nurses nor with a lack of desire or to do the right thing. The pursuit of perfect care leads directly into systems thinking.

SLIDE 2, OUR JOURNEY

1990 vision
Persistence
Access for uninsured, level 2 trauma system, seamless care?, Whatcom Integrated Delivery System, Community Health Record, Whatcom Health Information Network, Whatcom Community Health Improvement Consortium, diabetes collaborative, registry system
IOM: To Err is Human & Quality Chasm
Pursuing Perfection, Robert Wood Johnson Foundation & Institute for Healthcare Improvement, +16 others

Like many of your communities, cooperation has a long history in the community. Community wide efforts developed access for under-insured OB patients and others including dental patients. The community developed a common sense, yet bold vision to have seamless care and the best outcomes in the state within 10 years (It will happen but it will take 20 years. Who knew?) A series of large-scale initiatives have occurred in Whatcom County. The most audacious effort may be the current P2 initiative to transform healthcare in our community and in the nation.

SLIDE 3, PARTNERS & FRIENDS LOCAL AND REGIONAL
This P2 initiative has caught the imagination of lots of folks.

3000 patients with diabetes & congestive heart failure
Family Care Network
SeaMar Clinic
NorthCascade Cardiology
SJH Center for Senior Health
St. Joseph Hospital/PeaceHealth
Group Health Cooperative
Regence Blue Shield,
Community Health Plans of Washington
Olympic/Sterling/Aon

SLIDE 4, PARTNERS & FRIENDS NATIONAL & INTERNATIONAL

NATIONALLY
Cambridge Health Alliance,
Cincinnati Children?s Medical Center,
Tallahassee Memorial Hospital,
Hackensack University Medical Center,
HealthPartners,
McLeod Medical Center, and
Whatcom County coalition
INTERNATIONALLY
8 communities in Great Britain,
1 in the Netherlands,
1 in Sweden

SLIDE 5, LEARNING

Advanced Access
Patient input into design
We did not have to wait
Collaboration among all sectors
Leadership by physicians for collaboration

So, in this P2 initiative what have we learned to date: a year and a half into it? Doing Advanced Access, in primary care and specialty care, seems to me to be the only thing that can free up people and time to take on the work of redesigning the acute care system into one that provides chronic care. HealthPartners and Jonkoeping County, Sweden point to this conclusion. We have been working with Catherine Tantau, RN. Others have worked with Mark Murray, MD. Patients are of surprising help in redesigning care systems. Their insights are generally lead to simpler and cheaper solutions that we imagine on our own. We could have been doing this 5 years ago. Without working together little will occur. The innovations almost all require cooperation of others beyond your organization. Fortunately the benefits are that diffuse too. Physicians can lead their organizations into cooperation. It will not happen otherwise.

SLIDE 6, 80/20 SYSTEMS THINKING

Baby boomer demographic bulge
Chronic care in acute care system
Winners and losers (modeled)
Collaborators (relationships between parts on behalf of all stakeholders)

There are a lot of things we all consider doing. but which are the most important? The biggest problem and opportunity is heading our way--the aging baby boomers. Chronic care accounts for almost 80% of the healthcare costs and it is going to get higher. If we can effect this dynamic it will have more impact that almost any other change. (Possibly at the same or lower cost for a given population.) We have reviewed the literature on chronic care, we have worked with our patients and our physicians. We have designed a system for patient-centered, community-wide chronic care management. We have modeled the outcomes. We know who the winners and losers are likely to be. Nothing big will happen if the winners don?? help the losers. Medicare, pharmaceutical companies, employers, and taxpayers will need to rethink their roles if the benefits are to be gained and sustained.

SLIDE 7, SOLUTION SPACES

Care management and managers
Navigators and insider advocates for patients
Activated informed patients
Group visits
Shared care plan (electronic and paper versions)
Advanced access
Results based advocacy

Our approach combines community-based care managers (nurses). Improved access to information for patients with DM and CHF and for the members of their care team. There are group visits, web access to tailored information and to a personal medical record called the shared care plan. I now call our previous medical records business medical records, not patient medical records. The shared care plan may be a step toward a real patient medical record. None of the changes are manageable in physician offices or with physician staff until excess capacity for seeing patients and for improvement work is created. Advanced access has this great side effect. Modeling the effects of the changes and getting those affected to participate in the solution is essential. Otherwise it is not sustainable. Medicare (thus Congress), pharmaceutical companies, local businesses and government, and patients as purchasers and voters.

SLIDE 8, INTERESTED PARTIES

Robert Wood Johnson Foundation
Institute for Healthcare Improvement
Medicare (CMS)
Healthcare insurance companies
Our community as well as other communities and healthcare organizations
Other foundations

The work and learning going on in Whatcom County has captured the interest of numerous organizations and communities. Many of whom we are working with. There are now 17 communities or healthcare provider organizations. We are hoping to spread this to Ketchikan, AK. beginning this year. We hope to spread to more of the patients and providers in Whatcom County.

SLIDE 9, COOPERATION

Necessity or preference?
System? ...or only parts?
How? or YES!
Leaders?

Somehow we think this is optional, on an organizational level. We do cooperate as individuals. Our organizations must understand the experience of the patients and design and connect our processes so that they work as a system. Peter Block has written a book called The Answer to How? Is Yes! It is a kind of Nike "Just do it!" attitude. On can delay starting assuming the worst and endlessly asking how, rather than experimenting and working our way forward together, with the patients. A new kind of leader is needed--courageous in collaboration, not in war.

SLIDE 10, MORE?

You may find the details and the tools at these websites. Do feel free to contact me. I put some of what I think on my web log, as do many of the people working in this endeavor.

SLIDE 11, PARTNERS?

Already down this road?
Learn together?
Tipping points?

The Institute for Halthcare Improvement is attempting to spread the learning from Pursuing Perfection communities.
We have time for those who want to transform healthcare locally, in their communities.

Thank you for your time and attention.

Thu, 05 Feb 2004 05:22:43 GMT

Community meets leaders of its EMR venders.

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.

Thu, 05 Feb 2004 05:22:42 GMT

Health system innovation, ORGANIC or MECHANICAL?.

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.

Thu, 05 Feb 2004 05:22:41 GMT

"...program is so simple, it's brilliant, "Bellingham Herald editorial board.

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?

Thu, 05 Feb 2004 05:22:40 GMT

Local paper covers Pursuing Perfection.

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

Mark Porter, The Bellingham Herald

Keith Robinson doesn't sugarcoat his cost to America's health care system.

The no-nonsense ex-Marine with chronic ailments, including diabetes and a congenital heart defect, remembers seeing a physician bill after his five-month stay at the University of Washington Medical Center four years ago.

The tab: $500,000 - and that didn't include the cost of his hospital stay. He's never seen the bill for room and board and shudders to think how much that cost his insurer, which ultimately reaches into John Q. Public's pocketbook through higher premiums.

Heart failure

Nearly five million Americans suffer from heart failure, a blanket term that means the heart isn't pumping as well as it should. An estimated 2,000 Whatcom County residents have heart failure.

Usually, the heart has been weakened over time by an underlying problem, such as clogged arteries, high blood pressure, a defect in the heart walls or valves, or some other medical condition, according to American Heart Association. People with heart failure don't get enough oxygen, so they feel weak, fatigued or short of breath.

More than 500,000 new cases are diagnosed each year in the United States, including children and young adults, but most commonly older people.

"People with chronic illnesses end up using more quantities of health care than other people," said Robinson, 54, a lifelong county resident. "And there's more than one person in the same fix I'm in."

Robinson is one of about 60 chronically ill county residents taking part in a community project aimed at helping people with heart failure and diabetes to improve their health, and ultimately save money for themselves and others. Pursuing Perfection, a $1.9 million grant from the Robert Wood Johnson Foundation, is an attempt to spread the gospel of patient-centered care with a three-pronged focus:

[>] Patients get to help make decisions about their own care.

[>] Coordinators help patients through the maze-like health-care system.

[>] Patients gain greater access to health information sharing through the Internet.

Robinson sees himself as a living example of the need for a new approach that could help him stay out of the hospital, lead a longer and healthier life, and avoid overtaxing the health-care system.

It's easy to second-guess the current system, but Robinson wonders if he could have avoided the five-month hospital stay if he had been a Pursuing Perfection patient back in 1999.

"If you ignore these chronically ill people, one day you have a hospital filled with chronically ill people who need help," he said. "If we follow those people more closely, maybe we can keep them from getting so sick."

History of ailments

Robinson was born with a heart defect that was discovered during an eighth-grade school physical. As a 12-year-old, doctors repaired his aorta, the artery that feeds blood from the heart to every part of the body except the lungs. His aorta should have been the size of a quarter, but was the size of the head of a safety pin, he said.

That didn't stop him from having a life. He wrestled for Bellingham High School, reaching the state tournament. He then spent four years in the U.S. Marine Corps, where doctors discovered a heart problem during an insurance physical, he said.

Diabetes

Seventeen million Americans - including an estimated 6,713 Whatcom County residents - have diabetes, a shortage of insulin that allows fats to increase in the blood, eventually damaging vital organs.

Diabetes kills more than 200,000 Americans a year, and can cause heart disease, stroke, blindness, kidney failure, leg and foot amputations, pregnancy complications and death related to flu and pneumonia. The economic impact of diabetes totals nearly $100 billion a year, according the federal Centers for Disease Control and Prevention.

That led him to a cardiologist who decided he was just fine, and he went on to train on flight director radar for aircraft. But looking back, he said, he ignored subtle warning signs, such as shortness of breath.

He returned to the Bellingham area after the service and worked several jobs until he became sick in 1979. An infection from an abscessed tooth spread to his previously repaired aortic valve. The result: surgeons gave him an artificial valve.

"I felt pretty good for quite a few years," Robinson said.

But the area by the valve began leaking blood. He lost energy. Even mowing the lawn became a monumental task.

Robinson became sick again in January 1999, spending three days at St. Joseph Hospital, then off to the University of Washington Medical Center for five months, in part, waiting for a new heart.

Doctors then decided to replace the valve again, in May 1999, and later implanted a defibrillator to kick-start his heart if it beats irregularly.

A postal worker at the time, Robinson retired in June 2000 because of his chronic health condition, which is considered a disability. Along with his heart problems and adult-onset diabetes, he also suffers from restless leg syndrome, which causes an irresistible urge to move the legs. The urge worsens at night, causing sleeplessness. Robinson also suffers from sleep apnea, meaning he repeatedly stops breathing for short periods while asleep.

Getting help

Before becoming part of Pursuing Perfection, Robinson got help through Family Care Network, a group of family-care physicians. Family Care employee Nancy Stothart, who now works for St. Joseph, helped Robinson negotiate the tangled medical system, and continues to do so now with Pursuing Perfection.

Before, Robinson said nobody helped him keep track of his condition and symptoms - such as his blood-sugar level, weight gain and energy level - that might portend problems. Now, Stothart calls him every other week.

Just managing his 14 daily medications is a chore. Stothart helps him make sure than none of the medications conflict with another one or with new ones he might need.

"If I have concerns, I can just call her up; she can get the doctor's ear faster than I can," Robinson said. "She's pretty easy to work with, and she seems concerned."

Like many people battling chronic illness, Robinson gets help from family. In his case it's his wife, Debbie, whom he started going out with 1983 and married in 1990. She spent the entire time he was in Seattle at his bedside, reading and playing gin rummy to battle the boredom and uncertainty.

"We call her Nurse Debbie because she watched and learned everything," Robinson said.

Robinson still carries a special beeper so he can rush to Seattle if he is called for a heart transplant. He doesn't expect to be high on the list, because he's stable now.

That's fine with him. Modern medicine is the reason he's alive, with or without Pursuing Perfection. He works in his yard and around the house. He's refinishing antiques and cabinets.

"In five to 10 years I will need a transplant or another valve," he said. "But from how sick I was in '99, then 10 years down the road is quite a life extension."

-----------------------

POWER TO THE PATIENT

(Photo not available at this time)

MAKING PROGRAM WORK: Nancy Stothart (left) and Connie Golas work for the Pursuing Perfection Project in Bellingham. MAME BURNS HERALD PHOTO

Local trial program gives sick people more responsibility for their treatment

Mark Porter, The Bellingham Herald

Ask any average Joe about a Whatcom County effort to make medical care more cost-effective and patient-centered. Odds are, he'll roll his eyes in disbelief.

Pursuing perfection?

The Pursuing Perfection project is funded by the Robert Wood Johnson Foundation, a philanthropy which works to improve health care. Whatcom County is one of seven areas across the nation that are giving the program a practical test. Health-care providers involved in the local trial are: Family Care Network, Sea Mar Community Health Center, North Cascade Cardiology, and St. Joseph Hospital with the Center for Senior Health, which is part of the hospital. Participating health-care payers are Group Health Cooperative and Regence Blue Shield. The $1.9 million local grant expires in March. Local advocates hope to continue with new grants.

After all, America is the land of disjointed health care - with government, doctors, insurance companies and hospitals all fighting for a share of the trillion-dollar health-care industry.

That longtime approach is exactly what the Whatcom Community Health Improvement Consortium is trying to change.

The community group was one of seven across the nation last year to receive part of a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement.

The program is called Pursuing Perfection: Raising the Bar for Health Care Performance.

The idea is simple to understand but tough to carry out: Reduce the need for expensive hospital visits by helping people do more to manage their own health care.

The result, organizers hope, is a more-efficient and less-expensive approach to health care that will spread throughout the medical world.

"Whatcom County is the focus of the nation," said Nancy Stothart, a registered nurse and clinical care coordinator for the local Pursuing Perfection project. "How can we transform health care within a community, and not just an organization?" A Rand Corp. study published Thursday highlights the lack of coordination in the health care system. According to the study in the New England Journal of Medicine, doctors fail to take nearly half of the recommended steps for treating such common illnesses as diabetes and high blood pressure. Further, patients in the study did not receive a third of the standard medicines for heart disease or half of the recommended care for diabetes.

Patient's diary

Patient's diary The Pursuing Perfection effort includes a high-tech and low-tech version of a "shared-care plan" available on paper and the Internet. It's a booklet that chronically ill patients can share with their doctors. The booklet includes a personal profile, goals, and a list of caregivers, allergies, medications and diagnoses. The goal is to have information on hand so there's no confusion about the patient's condition and medications.

"Health care now is very disjointed," said Marc Pierson, a St. Joseph Hospital vice president and a leader of the Pursuing Perfection project in Whatcom County.

"Without question, the model of an integrated plan ... is a model that makes sense," he said. "The question is, 'Can we get it to work?'"

Giving guidance

Leaders at Robert Wood Johnson Foundation, a health-care philanthropy in Princeton, N.J., want to see statistically provable improvement in patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors. Such measurable improvements could have a huge effect if applied nationwide.

Caring for chronically ill people consumes up 70 percent of the nation's health-care dollars.

Fifteen million of the 77 million baby boomers are expected to develop congestive heart failure in the coming years, and diabetes cases in the United States doubled from six million to 12 million over the past 20 years.

In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure.

To bring those numbers down, Stothart and Connie Golas are coordinating the care of about 60 chronically ill county residents participating in the Pursuing Perfection project. They're using computers, the Internet and the plain old telephone to track the residents' health and guide them through the medical maze of doctors, hospitals and insurers.

"The person who is managing chronic illness is the person with chronic illness," Stothart said. "We've expected them to do it without support or self-management."Before Pursuing Perfection, there was no standard way to get information to and from such patients. With the project, patients are at the center of the equation, and they like it.

"They don't feel like they are going to the principal's office," Pierson said. "They feel like they are partners."

Golas said she and Stothart are supposed to be interim helpers. The Pursuing Perfection model calls for training workers in medical offices to become more aware of the needs of chronically ill patients.

"We don't want to displace the cardiologists or primary-care doctors, but to help the person self-manage," Stothart said. "I do a fair amount of checking in on the phone, more frequently with heart failure, just doing some monitoring.

"I can't think of anyone who hasn't said, 'My life has been better since this started,'" she said. "Sometimes I can tell, just by phone and how they are talking, how they are doing. We are having relationships with people."

The fact that Stothart and Golas operate independently of insurance companies and health-care providers is a plus, Pierson said, because they can follow the patient even if he or she changes insurers.

Calculating benefits

Preliminary results from the project are encouraging, said Mary Minniti, a St. Joseph employee and program manager of the project.

Diabetes patients in the program have shown marked improvement in their blood-sugar control, she said. While many haven't reached their long-term targets of near-normal levels, they are moving closer to a target that some had thought was out of reach, she said.

In an inefficient care system, patients must repeat medical stories and medical information, then wait for helpful treatment or information, she said. That can eat up work time for patients and their employers, she said.

To get a handle on the benefit of Pursuing Perfection, the local consortium asked experts to figure the cost and the savings from a proactive approach to caring for diabetes and heart failure patients.

Their conclusion: It would cost $9.8 million to run a local Pursuing Perfection program for the next five years, but would save an estimated $26 million in worker disability expenses.

Even with such savings, there still must be insurance reforms if Pursuing Perfection is to succeed, said Mark Donaldson, Group Health Cooperative administrator and a member of the local project's leadership board.

There aren't any natural rewards for changes in the current payment system, he said. For example: It's known that group visits and e-mail exchanges help patients, but insurers and the government don't currently cover those, he said.

"What is attractive to Group Health about this is we aren't talking about a vertical (company) integration," he said. "We are getting separate business entities trying to get together to benefit the entire community."

Doctors say that if Pursuing Perfection works, they will have more time to spend with people who need traditional office visits, and people won't have to wait as long for appointments.

The foundation grant runs out in November, but groups in the consortium are committed to funding the effort until spring, and hope more grants follow, Pierson said.

The automobile industry improved after learning from Toyota's teamwork and flexible approach to manufacturing, said Andrea Kabcenell, deputy director of the Pursuing Perfection program for the Institute for Healthcare Improvement, in Boston. While health care is not a pure product line, "we can learn from those industries," she said.

"The average Joe should care because Pursuing Perfection is an attempt to know what one hand is doing with the other," she said. "That doesn't happen very often in care in the U.S.

"If it doesn't work," she said, "health care is in a lot more trouble than we thought."Reach Mark Porter at mark.porter@bellinghamherald.com or call 715-2263.

Reach Mark Porter at mark.porter@ bellingham herald.com or call 715-2263.

Thu, 05 Feb 2004 05:22:36 GMT

Patients & Physicians.

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.

Thu, 05 Feb 2004 05:22:36 GMT

Reductionism vs. 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.

Thu, 05 Feb 2004 05:22:35 GMT

Pursuing Perfection Doctor Honored.

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.)

Thu, 05 Feb 2004 05:22:35 GMT

Group Visits grow in Whatcom County.

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]

Thu, 05 Feb 2004 05:22:35 GMT

You too can have a public voice in health care improvement..

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/

Thu, 05 Feb 2004 05:22:34 GMT

Our weblogs, with others, mentioned in American Medical News.

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.

Thu, 05 Feb 2004 05:22:34 GMT

IHI reports on our Purusing Perfection Efforts and Progress.

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."

Thu, 05 Feb 2004 05:22:33 GMT

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.

Thu, 05 Feb 2004 05:22:33 GMT

Streaming Stories Sooner than Later. 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.

Thu, 05 Feb 2004 05:19:17 GMT

Patient powered indeed!.

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]

Thu, 05 Feb 2004 05:19:16 GMT

Patientpowered.org and Shared Care Plan honor.

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]

Thu, 05 Feb 2004 05:19:15 GMT

Early disease managemnet.

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.

Thu, 05 Feb 2004 05:19:15 GMT

Care Models - how do you practice?.

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.

Thu, 05 Feb 2004 05:19:15 GMT

Whatcom update continued - July August 2003.

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

Thu, 05 Feb 2004 05:19:14 GMT

Whatcom Pilot Activities - July - August 2003.

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

Thu, 05 Feb 2004 05:19:13 GMT

Who needs a Shared Care Plan?.

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.

Thu, 05 Feb 2004 05:19:12 GMT

1st Year Technical Achievements Whatcom P2.

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

Thu, 05 Feb 2004 05:19:05 GMT

Shared Care Plan.

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

Thu, 05 Feb 2004 05:18:49 GMT

Hot Button Lexicon.

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.

Thu, 05 Feb 2004 05:18:49 GMT

Richness in Diversity.

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........

Thu, 05 Feb 2004 05:18:48 GMT

What Commitment Means on the Ground.

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.

[Marc's Weblog]

Thu, 05 Feb 2004 05:18:48 GMT

Dialogue.

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.

Thu, 05 Feb 2004 05:18:47 GMT

Successes fuel continued efforts.

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!

Thu, 05 Feb 2004 05:18:47 GMT

Dialogue on Organizational Culture - December 2002..

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.

Thu, 05 Feb 2004 05:18:46 GMT

Join the Team.

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!

Thu, 05 Feb 2004 05:18:46 GMT

Canine Care.

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.

Thu, 05 Feb 2004 05:18:46 GMT

The P2 Forest Crew. 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.

Thu, 05 Feb 2004 05:18:45 GMT

One system connecting many.

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.

Thu, 05 Feb 2004 05:18:45 GMT

Conference on Dialogue.

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]

Thu, 05 Feb 2004 05:18:45 GMT

Comfort in uncertainty.

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"

Thu, 05 Feb 2004 05:18:44 GMT

A gift from Annie.

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]

Thu, 05 Feb 2004 05:18:44 GMT

Shared vision.

"...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?

Thu, 05 Feb 2004 05:18:15 GMT

The Journey Continues- Building on Community Assets.

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.