Listening to patients and staff
A large physicians’ group practice in Massachusetts is improving the experience of patients and staff by breaking down the organizational hierarchy and encouraging process improvement from the bottom up.
"Listening is a political act," says Zeev Neuwirth, the vice president of clinical effectiveness and physician affairs at Atrius Health, a nonprofit alliance of five medical groups in Massachusetts. In leading an effort to remake healthcare within his organization, Neuwirth has discovered that "listening breaks down the barriers of power and hierarchy — the engagement that comes when people are listened to can produce profound changes."
In 1997 Neuwirth published a survey of research showing that doctors who are empathetic communicators produce better healthcare outcomes. He spent the first part of his career training physicians in how to listen to their patients. One approach he used was arranging improvisation workshops for doctors to hone their communication skills. Looking back, he says, "The doctors are excited for a day or two, but they fall back into old habits. If you haven't changed the environment, the changes won't last."
Now Atrius Health has begun a pilot program to change the healthcare environment, starting with two offices of Harvard Vanguard Medical Associates, the largest of its five affiliated group practices with 500 physicians providing primary and specialty care to 350,000 patients.
The effort draws on an eclectic variety of management techniques, including elements of Toyota's Lean system that show up in rapid prototyping and empowering frontline clinicians and staff to make process improvements and innovations.
In the first test office, a group that included representatives from every patient touchpoint and every administrative function was tasked with designing the ideal healthcare experience. It isn't uncommon to take years to design and implement healthcare initiatives. But in just six weeks, this group clarified and reorganized work duties, restructured the patient's experience, and increased usage of Harvard Vanguard's web portal, which allows patients to securely access their personal health information and request appointments.
Karen DaSilva, a physician with Harvard Vanguard, explains that this far-reaching change happened in part because the process broke down the organizational hierarchy. "We were getting 20 to 30 people in a room — medical secretaries, main desk registration staff, lab people, pharmacy people, clinicians, nurse practitioners, nurses — all saying, 'Okay, this is the problem that we need to solve,' and then having a discussion about how to solve it. Through that we were building an environment where a medical assistant can turn to a doctor and say, 'That's not the best way to do it,' which we've never had before."
According to Neuwirth, in one session, a physician, who is a former chair of the Atrius Health board, described a streamlined referral system. The medical secretary sitting next to him responded. "She said, 'That sounds pretty good, but let me tell you how I think it should be done.' And she just started to outline the workflow. He scribbled down exactly what she said."
Neuwirth says that rather than seeking solutions to a discrete problem the group made a decision to invest up-front in trying to establish a self-generative culture of continuous learning, improvement, and innovation. "To create cultural change, you don't focus on cultural change. You focus on the goal of outstanding, respectful patient and family care. You support the frontline folks who are working to achieve that goal. And in the process of getting there, it's necessary to create a respectful and collaborative work environment. People are happier because they are doing meaningful, creative, empowering, partnering work."
Thad Schilling, another Harvard Vanguard physician, says, "My patients' experience is as dependent on my medical assistant as it is on me." As part of the new program, medical assistants take a more active role in patient care, including meeting with patients to get complete lists of medicines, in order to minimize errors. Having people work to the top of their training keeps them engaged and challenged — and frees doctors to do what only they are trained to do.
"The conversations that I'm having with the patient are much more proactive and much more effective," DaSilva says. "A year ago, if I saw a patient who was obese, I would tell them they should lose weight, and I would tell them to think about Weight Watchers." Now lab work and other pre-visit work is arranged by medical assistants and completed before visits, so the results can be the focus of the conversation. "I understand my patient's life better because of the new screening assessments we're doing. And I'm coming up with a plan with them."
The new system aims to ensure that patients leave each appointment with a written "after-visit summary." Research shows that patients remember the details of a visit poorly, resulting in their not taking medications appropriately or completing necessary follow-up steps. The summary creates a few minutes of work for physicians and other members of the team, but may pay off with patients better able to follow care plans. In another effort to increase communication, patients can use the web portal to contact their doctors with questions that they might otherwise be hesitant to ask or that don't seem to merit a visit.
But even at a nonprofit like Atrius Health, changes need to pay for themselves, something they haven't yet done. The effort is being underwritten with a grant from Blue Cross and Blue Shield, a sign that while many elements of the healthcare system recognize the need for improvement, the kinds of changes Atrius Health is instituting would be difficult to maintain under the current encounter/procedure-based fee-for-service payment regime.
DaSilva points out that when she sends emails to patients, it may be convenient for the patients and increase their engagement with their own health, but it reduces billable, if unnecessary, office visits. Along the same line, "medical assistants spend time doing chart review, getting people in for pre-visit labs, and looking through rosters to see who is overdue for monitoring tests. None of that work is compensated," DaSilva said.
Neuwirth adds, "There is a tremendous amount of collaborative work, coordination, and basic preventive care that is required on the part of primary care physicians and specialists — very little of which is recognized or paid for in our system. In essence, the system punishes physicians and staff who spend time collaborating with their patients and with one another. As a result, you get a payment system that drives us increasingly towards higher cost, non-preventative care."
By Ted O’Callahan
Photograph by Tony Rinaldo
Vice President of Clinical Effectiveness and Physician Affairs, Harvard Vanguard Medical Associates/Atrius Health
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Additional comments on creating and managing change in a healthcare setting from Zeev Neuwirth, a physician and the vice president of clinical effectiveness and physician affairs for Atrius Health, a nonprofit alliance of five medical groups in Massachusetts. Harvard Vanguard Medical Associates, the largest of Atrius Health’s groups, has a pilot program funded with a grant from Blue Cross Blue Shield to overhaul how it delivers healthcare.
On management approach
My firm belief is that there is no technology, no electronic medical record system, and no process improvement approach that’s going to create a safe, effective, and efficient healthcare delivery system without us also taking a social perspective — that is, without the integrated social engagement of the people involved in healthcare delivery. Healthcare is as much a social and communal process as it is technical. I think that anthropology, sociology, and community organizing have as much to teach us as does continuous quality improvement and quantitative population health techniques. Leaders in healthcare all over the country don’t seem to understand this — really smart people. There seems to be this belief that technology, quantitative metrics, standardization, and resource allocation are going to solve our healthcare problems. It’s clearly essential to have these components, but it still can’t be done without the people part.
One other thing that’s made our approach so exciting and engaging is the diversity of clinicians and staff participating in the process improvement and innovation process. In particular, we’ve made sure to have a fair number of medical assistants and secretaries involved. Because you have these different perspectives in the room, all of a sudden, there are solutions generated that people in the higher echelons of the organization couldn’t have come up with on their own because they’re thinking strategy, they’re thinking bigger picture, they’re thinking budgets. They don’t know the work in the same way as people who do it every day.
We went from sitting down in a room introducing ourselves to “go-live” implementation in six weeks. In doing this, we discovered that a lot of healthcare managers haven’t had practice in making things happen quickly. Healthcare is a very conservative business. It takes, on average, 15 to 17 years before a research-proven medical intervention actually becomes adopted practice among doctors. Can you imagine that? Other industries come and go in those timeframes, but in healthcare people aren’t skilled at rapid management and rapid prototyping. They aren’t skilled in how to dialogue in a goal-oriented way that leads, not just to maintenance, but also to continuous improvement and innovation. We’re working on getting them those skills.
One of the profound benefits of our approach was creating great working relationships across the functional and departmental siloes that exist even within one site. Many of the folks we brought together in this room had worked in the same building for years and had taken care of the same patients, but had never spoken to one another. My gosh — we had people on the same clinical team who didn’t even know what their team members were doing. How can we expect to deliver seamless and coordinated care without internal networking?
On flexibility
Regardless of the system, once you’ve created a template for change, the template itself often can become an obstacle or barrier to change. Maybe an approach works well in one place, at one point in time, but even if it’s a system that has a human process built into it, I worry, because it’s taking people through a sort of machinery. Once you say this is the way we do it, you’ve taken away people’s ability to see reality, to think creatively, and to adapt to new situations which occur continuously. Essentially, you’re creating a new box — perhaps a better box — but it’s still a box which defines how people are supposed to think and behave.
What I think we’re trying to build is an approach that is highly reflective and open to change. It’s a somewhat chaotic, iterative, and network-based process — definitely messier than the more rigidly defined, spreadsheet-based approaches others have taken. Over the past couple of decades, the organizational gurus have begun writing about learning organizations, complex adaptive change, and chaos theory; and books like The Wisdom of Crowds and Group Genius are teaching us about the power of social networks.
There’s this wonderful movement away from “organizations as machines” to organizations as biologic/social entities or even ecosystems. I have to say that I have been heavily influenced by these writings. And it’s fun to talk about these ideas. but the practical application, the day to day follow-through, is not easy and it’s not always fun — in part because it’s driven by uncertainty and tension and failure. It’s less about knowledge and technical skill, and more about learning, asking questions, and engaging people. So, we are constantly asking our folks, “Does what we’re doing make sense? Is this the best way we can go about it? Is there another way?” And so we’re actually continuously changing how we are working together.
Here’s a very concrete example: We were doing this site-based approach, working with all the specialties and departments within a practice site, but then the administrators from the specialty departments that go horizontally across all the sites — like cardiology, orthopedics, pediatrics, radiology — turned to us and said, “Maybe we should be looking at it horizontally as opposed to vertically.”
It made sense. For example, the pediatrics department within a site is dealing with different issues than the adult-based internal medicine within that site. But pediatrics is dealing with very similar issues across sites. A specialty-specific horizontal approach can get really detailed about workflows. Standardization can get the workflows down, get staffing ratios down, and be applied across the sites within a specialty much easier than across all specialties within a site. We can figure out how to make the job more doable and more efficient within that specialty. But it’s something that is hard to do if you’ve got all the specialties together. There’s too much diversity.
So I asked the specialty administrators and clinical leaders, “Maybe we should just abandon this site-based approach all together and just go with the horizontal specialty-based approach?.” They said, “No, no, no. The site-based approach is great because we’re building this internal community within each practice site and creating a coordinated integrated delivery system. And the different specialties within a site can borrow learnings and best practices from one another.
We want that kind of cross-fertilization.” So we took their suggestion and now we’re using the vertical and horizontal approach — they both add value and they’re synergistic.
If we had a system that was concretized, it wouldn’t allow for that kind of engagement, creativity, and adaptation.