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Leading Through Healthcare Transformation. Agenda. Healthcare Transformation is Upon Us A Systems and Patient-Centric Approach to Practice Improvement Leading Transformation: Leadership Competencies and Derailers A Call to Action: The Patient Journey Group Exercise. 2. - PowerPoint PPT Presentation

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Leading Through Healthcare Transformation1GVA-AAA123-20090708-Healthcare Transformation is Upon UsA Systems and Patient-Centric Approach to Practice ImprovementLeading Transformation: Leadership Competencies and DerailersA Call to Action: The Patient JourneyGroup Exercise

Agenda22Healthcare Transformation is Upon UsLen Fromer, M.D., FAAFPExecutive Medical DirectorThe Group Practice [email protected]

3Healthcare ReformCare Delivery PCMH/ACOHospital ReadmissionsIncreased Patient VolumeReimbursementHospital-Based Revenues (IHSs)P4PReimbursement caps (ASP+6%)MedicareCommercial Payers (Health Plans, PBMs)EmployersConsumersImpact of Economy (especially given consumers are carrying more of the financial burden of HC)More Informed and Engaged through TechnologyChanging Expectations Utilization of Alternative MedicineTechnologyEMR/Meaningful Usee-Rxe-VisitsPatient Portalse-ToolsEvidence-Based DiagnosticsTherapeutic Decision SupportQuality StandardsOutcomes-Based Performance ProgramsProtocols / GuidelinesHEDISNCQAHealthcare StakeholdersKey Drivers Are Influencing Healthcare Stakeholders44GVA-AAA123-20090708-Common Areas of Focus for All Healthcare Stakeholders5Value/Outcomes-DrivenPatient-CentricTeam-Based CarePopulation/Community ManagementSystems-Thinking/Continuity of CareShared SavingsPatient Engagement 5Source: ACP Conference, June 2009. Presentations by Michael Barr, VP, Practice Advocacy and Improvement, ACP, Lawrence Casalino, MD, PhD, Markus Meier, Asst. Dir, FTC, Kelly W. Hall, Executive Director, Strategic Planning at Partners Community HealthCare Inc.Patient-Centered Medical HomeAccountable Care OrganizationsOrganizations that are willing to take responsibility for the overall costs and quality of careHave the size and scope responsibilityClinical Integration System-wide organization (same philosophy as PCMH)Practice levelPatient-centered modelUse of evidence-based medicineReason to expect that it will improve quality and bend the curve on costsPayment models decrease incentive for volume and encourage investment in practice changes to promote qualityFuture of Patient-Centric Care66Todays CareOur patients are those who are registered in our medical homeCare is determined by todays problem and time available todayCare is determined by a proactive plan to meet health needs, with or without visitsCare varies by scheduled time and memory or skill of the doctorCare is standardized according to evidence-based guidelinesPatients are responsible for coordinating their own careA prepared team of professionals coordinates all patients careI know I deliver high quality care because Im well trainedWe measure our quality and make rapid changes to improve itIts up to the patient to tell us what happened to themWe track tests and consultations, and follow-up after ED and hospitalClinic operations center on meeting the doctors needsAn interdisciplinary team works at the top of our licenses to serve patientsMy patients are those who make appointments to see meMedical Home CarePCMH Advocates Enhanced Access to Comprehensive, Coordinated, Evidenced-based, Interdisciplinary Care7Adapted with permission by IBM from Daniel F. Duffy, M.D.Patient Journey Map: A Team based strategic model assessing chronic disease patient care.Impact of chronic care on workflowCoordinated care teamHealth literacyElectronic health recordsPatient empowermentPatient population management

The Patient Journey = The Patient Experience88Resources & PoliciesCommunity DeliverySystemDesignDecisionSupport Self-Management Support ClinicalInformationSystemsHealth SystemHealth Care OrganizationInformed,ActivatedPatientPrepared,ProactivePractice TeamProductiveInteractionsImproved Outcomes

Chronic Care Model (CCM)9Slide from E. Wagner TrackingPatient-Centric ApproachClinical FocusPatient Self ManagementEmphasize patient role in managing illnessPersonal goalsTools to change behavior1-1 and group educationCultural sensitivity and family involvementMeasurement & feedbackImprove patient communication withhealth care providersEducation curriculum supported by evidence based guidelinesCare team works to maximize cooperation and application of best clinical expertisePatient Registry to identify patient populationAnticipate problems and provide quality-of-life serviceCare team works together with patientOffice task chartAccessible office hours/ same-day apptsOrganized patient visitsCare team meets to review patient population workSystems for communication and follow-upPatient follow-up calls and informationPatient censusEMR/paper recordReminder system for patient and case teamFeedback loopCare planningEmpowering motivated and activated patients Evidence-based clinical decisionsCollaborative, team-based carePatient tracking and information sharingChronic Care Model an evidence- based framework for health care that delivers safe, effective, and collaborative careWagner Chronic Care Model: The Foundation of the Patient Journey1010

10 Year Projection of Prescriber % by Size SettingCMS movement / mandates for bundled payments/ACO modelDRG payment rolled out over a 6-10 year period before hospitals became comfortableLeaning a new world of bundled payments will force a wave of change on hospitals and their local provider baseCare transitionsIncreased home care utilization...This could also result in ACOs expanding into new geographies to manage bundled payments (because local players are not capable)Pace of Change: Bundled Payments Will Be a Disruptive Factor That Accelerates Health Reform11

On the Path Toward Accountability12Uncertainty of timing, not direction, our principal strategic challengeSource: The Advisory Board, 201012One year data from payer pilots has demonstrated that individual practices can provide the equivalent of higher quality at lower cost as published data from large integrated systems.The Value of Primary Care and PCMH13A Systems & Patient Centric Approach to Practice Improvement

Diane Cardwell, MPA, ARNP, PA-CDirector of Practice TransformationTransforMED

14Building Learning Organizations15Healthcare delivery as a complex adaptive systemUtilizing a systems approach to changeAligning individual goals with practice/system goalsContinuous quality improvement that is driven by metrics15

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Access to Care & Information Health care for all Same-day appointments After-hours access coverage Accessible patient and lab information Online patient services Electronic visits Group visitsPractice Management Disciplined financial management Cost-Benefit decision-making Revenue enhancement Optimized coding & billing Personnel/HR management Facilities management Optimized office design/redesign Change managementPractice-Based Services Comprehensive care for both acute and chronic conditions Prevention screening and services Surgical procedures Ancillary therapeutic & support services Ancillary diagnostic servicesCare Management Population management Wellness promotion Disease prevention Chronic disease management Patient engagement and education Leverages automated technologiesCare Coordination Community-based services Collaborative relationships Emergency room Hospital care Behavioral health care Maternity care Specialist care Pharmacy Physical Therapy Case Management Care transitionPractice-Based Care Team Provider leadership Shared mission and vision Effective communication Task designation by skill set Nurse Practitioner / Physician Assistant Patient participation Family involvement optionsQuality and Safety Evidence-based best practices Medication management Patient satisfaction feedback Clinical outcomes analysis Quality improvement Risk management Regulatory complianceHealth Information Technology Electronic medical record Electronic orders and reporting Electronic prescribing Evidence-based decision support Population management registry Practice Web site Patient portal1718

Care Management Population management Wellness promotion & Disease prevention Chronic disease management Patient engagement and education Leverages automated technologies Quality metrics & outcomes Practice-Based Care Team Provider leadership Effective communication Task designation by skill set Defined roles & responsibilities Workflows to ensure accountability Patient & family participation Process metrics - accountability19

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Practice ManagementDisciplined financial managementCost-Benefit decision-makingPersonnel/HR managementOptimized office design/redesignChange management50 Reasons Not to Change21

It is too expensive We dont have the staff for thatWhat is in it for me?They wont pay for it 21Change ManagementTeamworkLeadershipCommunicationPCMH Transformation22

22Team Work

2323Change Is Not Easy, It Takes a Team Effort!24

24Leading Transformation: Leadership Competencies and DerailersTracy L. Duberman, PhDPresident & CEO The Leadership Development Group, Inc.

25Identifying and communicating metrics to define physician "value to patients and health partnersUnderstanding clinical systems thinking and applying the concepts to new models of care deliveryCommunicating effectively to engage physicians and other healthcare providers to work as a high performance teamImplementing patient-centered clinical integrationLeading culture change rooted in trust between physicians and the health systems they supportChallenges for Physician Leaders 2626Partnership based upon synergistic expertise in leadership assessment and development and organizational need identificationStudy designed to elicit success model for physician leaders given todays challengesStudy results combined with GPFs research and knowledge on health systems challenges/priorities can be used as a framework to position future and current leaders for successThe Leadership Development Group (TLD Group) & Group Practice Forum (GPF) Exploratory Study2727Designed to Focus on Three Areas:Physician Executive Core Leadership Competencies Pivotal ExperiencesDerailers that may inhibit successConducted Phone Interviews & Administered Psychometric Tests with Key Leaders Participant organizations:Austin Regional ClinicClinical Care Group of the University of Pennsylvania Health SystemDean Health System Healthcare Partners Medical GroupHolston Medical GroupMedical Edge Healthcare GroupSt. Vincent Physician GroupAdvisors from Group Practice ForumThe Iowa ClinicTransforMEDLeadership Study Methodology2828Results MD Leadership Competency Model29

29MBTIENTJ (Extraversion, Intuition, Thinking, Judging) Typically logical, analytical and objectively criticalNatural leaders, ENTJs prefer to be in charge and like long-range planning and strategic thinkingCharacteristics:High Tolerance for StressLess likely than the general population to show their feelings and emotions in stressful situationsHigh problem- solving abilityStrong Analytical Skills (Methodical Approach)Bar On EQ-i ResultsBalance of Independence and CollaborationAbility to balance desire to act independently with a willingness to work in collaboration with others, which is critical in the new environment where close collaboration and coordination are requiredHighly Self-ActualizedDrawn to pursuing meaningful work that is consistent with own sense of purpose, which enhances their ability to inspire and rally others around a shared visionResults Psychometric Assessments3030Early managerial/administrative experiencesFormal Leadership training boot camp & fellowship programsFirst-hand experiences that fueled the passion for making a differenceLosing a key position and learning from mistakes along the wayMentoring by a respected physician or non- physician leaderCoaching by an external coach

Results Pivotal Experiences3131Being risk averseLimited self-awarenessInability to manage changeBeing inflexible and/or impatientBeing too self-involved and individualisticBeing nave about the importance of politicsInability to persuade groups towards a common goalAllowing the tactical to take the place of more strategic workUnwilling to give up instant gratification for longer term successUnclear role expectations for self and inability to communicate expectations to othersResults Derailers 3232Best Practice Development Programs Integrate Organizational, Individual, and Job Factors to Attain Optimal Performance33IndividualBest FitCulture and ClimateStructure and SystemsMaturity of the industry and strategic position of the organizationCore competenceLarger context

Organizational EnvironmentVision, values, philosophyKnowledgeCompetencies or abilitiesLife career stagesStyle InterestsTasksFunctionsRolesJob DemandsBoyatzis (1982) Contingency Theory of Action and Job Performance3370:20:10 Development Model34Experience: Developmental tasks and challenges in current job and stretch assignmentsEducation: Structured training courses, e-learning, speakers, reading, etc.Exposure and Exchange: Mentoring and networking; assessments, coaching and feedback3470% Experience20% Exposure & Exchange10% EducationFacilitate a meetingRepresent your department at a cross-functional meetingTrain a team memberIntegrate a plan across unitsDelegate and empower others to do assignmentsBring multiple approaches together and combine them in creative waysGain support and commitment from others for idea or projectBring conflict/disagreements into the open and work to resolve them collaborativelyProvide clear direction and prioritiesComplete self-assessmentsGain insights from 3600 assessmentsGather performance feedback from manager/stakeholdersAttend networking eventsParticipate in mentoring program as both protege and mentorContract with coachInternal training coursesExternal seminars and conferencesCollege coursesAdditional degreesAdditional credential(s)Read a book or paperSubscribe to journalsE-learningBecome an active volunteer in professional organizations70:20:10 Development Examples3535EXPERIENCE (70%)Promote provider leadership developmentCoordinate and share Information Organize Teams Around Skill SetsEncourage Peer Pressure for Good PerformanceDevelop workflows to ensure patient & family participationDetermine process metrics and accountabilityEXPOSURE (20%):Complete self-assessmentsGain insights from 3600 assessments Gather performance feedback from manager/care teamAttend networking eventsParticipate in mentoring program as both protg and mentorContract with a coachEDUCATION (10%):Mainstream Article: Turning Doctors into Leaders Thomas Lee, HBRCreating a Coaching Culture Anderson, et alCase StudiesBecoming a Provider of Choice/Practice-Based Care TeamsCourse Work:CCL, Becoming a Conflict Competent LeaderSample Process for Building Effective Practice-Based Care Teams3636The Patient JourneyLen Fromer, M.D., FAAFPExecutive Medical DirectorThe Group Practice [email protected]

37Patient Journey Creates a Map of the Patient Experience through the Healthcare System38

Coordinated care teamPatient empowermentHealth literacyPatient population managementElectronic medical records38Sample Patient Journeys39Osteoporosis

Asthma

DiabetesCOPD

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Sampling of Tools Supporting the Patient Journey40

40The Patient Dashboard: A Means to Assess, Monitor, and Modify41Initial VisitPatient DashboardTestDataHeight56"Weight160 lbsBMI25.8 kg/m2 (overweight)Average of 3 office BP measurements140/89 mm HgTreatmentHTN management: ACE inhibitor (ramipril 10 mg qd); (second medication of choice)Diabetes management: metformin 850 mg bid6-Week VisitPatient DashboardTestDataHeight56"Weight155 lbsBMI25.0 kg/m2 (slightly overweight)Fasting blood glucose110 mg/dLAverage of 3 office BP measurements127/78 mm HgTreatmentNo change to medsContinue nonpharmacologic interventionsFocus on lifestyle changes to control blood glucoseThe information presented in this case is a hypothetical example and not based on an actual patient41The Patient Journey Highlights Team-Based Care Models: Every Member Plays A Part42Patient RegistryMotivational interviewChecked medication adherenceUpdated EMRDistributed educational toolsLifestyle SMBG (diet/exercise)Outreach to patient after appointmentMD date dateNurse/NP/PA date date date dateOffice Staff date date date datePharmacyCDE date date date date

Shared Responsibilities to Reach a Common Goal42Quality / CostMaximize the numerator Decrease the denominatorThe Bottom Line: Value434344

44Tennis Ball ExerciseRapid cycle improvementCompeting teamsChange can feel good

Group Exercise4545Methodology for achieving team consensus quicklyBenefitsWorks with small and large groupsEveryone participates from all levels of the group organizational structureSupports rapid cycle change and quality improvementNominal Group Process for Decision Making4646Present the question or issue and give the group a few minutes to silently reflect and come up with their individual ideas.Group members share ideas, each of which is recorded on a flip chart.The group discusses the ideas, clarifying and combining similar ideas as needed.The group reviews the ideas silently and each member ranks the ideas by preference.A preliminary vote is taken.After viewing one anothers rankings, group members vote again.Nominal Group Process4747In teams, use nominal group process technique to determine the top 3 barriers to engaging your physicians to embrace change and the PCMH.

Nominal Group Process Exercise #14848In teams, use nominal group process technique to choose the top 5 solutions to each barrier.Nominal Group Process Exercise #24949