Lessons learned from PCHH certification.
For us, PCHH fits into a long history of Quality Improvement. We have been Joint Commission accredited for many years, participated in the IHI and HRSA health disparities and diabetes collaboratives in the early 2000's and were an early adopter of an EMR in 2006. Along the way, we have learned many lessons of Quality Improvement, all of which we apply to our PCHH processes.
"The most important thing is to keep the most important thing the most important thing" (Donald Coduto). While it can be tempting for practices to approach PCHH as an exercise in satisfying NCQA's requirements in order to achieve the desired recognition, we have cleaved to this maxim. For us (as for all health care providers), the most important thing is to provide our patients access to outstanding health care in an environment that recognizes each person's value and dignity and treats each person with respect and compassion. This is a true medical home and we keep this as our guiding aim and focus as we continually work to improve the care we provide.
There is too much for any single medical provider to do. In a landmark study by Yarnall in 2009, she demonstrated that if a medical provider provided appropriate preventive and chronic care for their panel of patients, along with addressing their acute needs, it would take more than 21 hours a day. And that was before PCHH and the additional tasks of outreach and care coordination that it embodies. There is simply too much for a single medical provider to do and so the whole conception and organization of primary care has to change.
A functioning health home has to embrace a team model of care in which everyone works to the "top of their license." Specific team members (other than the medical provider) must carry the responsibilities for referral and test tracking, for outreach and for education as appropriate. Ideally, the team includes "front desk staff and nurses and medical assistants, along with a social worker to address the psychosocial aspects of health and healing, a nutritionist for nutritional counseling, a "patient care partner," "patient advocate" or "navigator" to coordinate and track services and an outreach worker or "health promoter" to help educate patients.
A team that does not meet together as a team is not a team. The team must coordinate with each other in some way. Ideally this is a daily or twice daily "huddle" to review patients to be seen and plan for the day. Lab results, consults, past orders and needed chronic and preventive services are reviewed and tasks are clearly assigned to team members so the necessary aspects of care are provided in an organized, efficient manner.
Good ideas are necessary, but not sufficient. Medical providers do not change because they are told to, taught to, or because it is a good idea. Change requires transformation and transformation must be systemic. It requires multilevel interventions and support. The team benefits from a functionally developed EMR that provides clinical decision support in the way of alerts, templates and order sets. In the midst of a busy practice, these remind the team of needed services and make it easier to provide evidence-based care. Clinicians and clinical teams want to provide excellent care for their patients and our systems should make it as easy as possible for them to do so.
Workflows and systems need attention, design and redesign. We recently gathered representatives of all the different staff in our health centers and presented them with a wall on which we had put cards with every single task needed in a typical office visit (from welcoming and registering the patient to rooming them, asking screening questions, checking vital signs, providing education, tracking and reviewing results, etc.). We gave each person colored stickies with each color representing a different job description and we asked each person to put their stickies on the tasks they performed. The results were fascinating. Some cards had many different colored stickies, implying that we were providing redundant services and other cards had no stickies, implying that no one was doing something we considered an important task. The outcome was dramatic. As we all stood studying the wall, people became animated and engaged and started the process of redesigning the workflows that are needed to assure that someone takes responsibility for everything that needs to get done. This meeting was a great experience for us and one we intend to repeat regularly. This kind of process is never finished--it remains a work in process and constantly evolves.
Once workflows and systems are designed (or redesigned), change must be inspired and spread. This is never easy and is generally somewhat messy. Change is hard and tiring. People and teams cannot change constantly. They must have time to integrate new processes. Not all good ideas should be pursued immediately. Just as we are respectful of our patients, we must be respectful of our staff. Sensitivity and timing are crucial.
Practices need actionable feedback in real time. Each practice needs to see clearly and regularly how it is doing in relation to measurable goals. We provide monthly reports that show each practice its current performance, and trend this data over the prior quarters and year. We also show them how others are doing with the same goals. These reports are neither pejorative, nor punitive. They are designed to give practice leaders helpful information and they often inspire curiosity in leaders who see another practice succeeding in an area they are struggling with. This leads to the sharing of "best practices" and thereby, practice improvement.
Ultimately, our goal is improvement, not change. Our primary goal is to provide our patients access to outstanding health care in an environment that recognizes each person's value and dignity and treats each person with respect and compassion. As we pursue programmatic accreditations and/or recognitions, we must keep this goal always in our vision and hearts. When we do so, transformation and change become meaningful improvements and are most easily embraced by our providers and staff. It is this principal that makes change worthwhile and that makes our medical homes truly patient-centered
Yarnall KSH, Ostbye T, Krause KM, Pollak KI, Gradison M, Mich ener JL. Family physicians as team leaders: "time" to share the care. Preventing Chronic Disease 2009;6(2):A59
By Daniel Miller, MD, Chief Clinical Quality and Training, Hudson River HealthCare