Planning Care Well Exemplary Clinical Microsystems

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In this section we provide a brief description of several microsystems that excel at planning care. In planning care the Dartmouth-Hitchcock Spine Center, in Lebanon, New Hampshire, uses a computer with a touch-screen monitor to collect information on each patient's general and disease-specific health status; this information then provides a sound basis on which the patient and the clinicians can engage in shared decision making to best match the patient's changing needs with

FIGURE 7.1. SCHEMATIC OF THE PLANNED (CHRONIC) CARE MODEL.

Community

Resources and Policies

Health

Organization of Health Care

5ps Nursing Assessment
Source: Wagner, 1998.

the preferred treatment plan. At the Intermountain Health Care Shock Trauma Intensive Care Unit (IHC STRICU), in Salt Lake City (Nelson et al., 2003), predetermined protocols, data collection, and feedback among all care staff help staff tailor the planned services into unique, patient-centered planned care. (These two organizations are also discussed in Chapter Nine.)

A patient who visits the Dartmouth-Hitchcock Spine Center uses a touch-screen computer that inquires about his or her symptoms, functional status, expectations for care results, and results of past treatment. Clinical staff use a summary of this information to guide the patient's evaluation and treatment. When possible, clinical staff employ additional technology to guide the evaluation and management of the patient's concerns. Most of the care is preplanned for the most common types of spine patient problems. For example, if the patient has low back pain, the clinician will ask the patient to view shared decision-making video programs that customize clinical management of the patient's condition to the individual patient's needs (Barry, 2003). Effective and safe care is designed so that little of the evaluation and management work is left to chance. A patient receives phone follow-up to ensure that the information and management plan are understood and are in place. At subsequent office visits the patient's symptoms, function, and response to treatment are reassessed, again using the touch-screen computer.

Any patient sent to the twelve-bed IHC STRICU is critically ill; about 15 percent of the time, she or he may not survive. Many standard protocols are used. Computers are at the bedside of every patient, and the staff have developed several long (two-hour) and short (ten-minute) reporting formats to augment the information contained in the bedside electronic medical record. Data elements tracked over time for improvement purposes include the usual physiological measures (for example, vital signs, blood gases, intake-output), thirty types of errors, eleven distinct bacterial infections, and administrative information (diagnoses, treatments, costs, staffing). The information flow ensures that everyone knows which particular management plan has been chosen for each patient and what each staff member must do to deliver the planned care. Staff also have the ability to complete shift reports on unstable patients within minutes. Despite all the activity and technology, the STRICU preserves a very close and caring interaction with family members, who can visit the patient at any time.

A patient calling the Norumbega Evergreen Woods primary care office, in Bangor, Maine, is interviewed by a patient representative who uses a software program called the Problem-Knowledge Coupler (PKC; http://www.pkc.com)' to guide the interview. This program uses protocols that address everything from a simple cough to complex chest pains and prompt staff to order needed diagnostic tests before the patient comes to the office. The program also helps staff schedule patients in time slots according to the severity of their conditions. Patients complete standard, program-based questions that inquire about the mental and physical components of their problem. The software also displays an evidence-guided list of possible diagnoses for the problem, organized for easy review, and suggests possible courses of action.

Each examination room contains a computer that is used for patient records, scheduling patient visits, telephone triage, and decision support and also for displaying patient education programs. Staff use the patient education software to manage patient concerns and generate information for the patient about his or her problems. Statistical process control charts of clinic performance are posted, and measures of preventive interventions are available automatically from the PKC. (This microsystem is also discussed in Chapter Six.)

On Lok SeniorHealth, which is located in San Francisco, provides a program of all-inclusive care for the elderly that is intended to optimize each patient's quality of life, sense of independence, and physical and cognitive function and to maintain the patients in their communities and homes. (On lok means "place of peace and happiness" in Cantonese.) A standard assessment of physical and mental health and social functioning is completed on enrollment to determine the services best suited to meet patient and family needs. All patient information is entered into a computer system, where it can be accessed by interdisciplinary staff. The information system is used to document care, transmit medication orders to local pharmacies, and ensure feedback of performance measures to staff members.

These four exemplary microsystems know their 5 P's. They have the information and knowledge needed to plan efficient services for the benefit of both patients and staff. They have rejected many of the common myths that underlie much of current clinical practice (Table 7.1).

Exemplary microsystems reject the notion that they must have an advanced information system before they can provide great care and service. In fact, an inappropriate information system can make inefficient processes more difficult to change. It is best to learn how to optimally match work to patient needs before committing to an information system. The information systems of the exemplary microsystems described here resulted from months and years of doing tests, so that each microsystem was sure it understood its 5 P's.

As described in detail in Chapter Six, exploring the 5 P's deepens a clinical microsystem's knowledge of the patients who are the beneficiaries of care, the professionals providing care, the processes used to provide services, and the patterns of social interactions, health outcomes, and process measures. This knowledge positions the microsystem to engage in meaningful improvements. The microsystem becomes informed, aware of its identity as a system, and curious to try out improvements based on this new information.

Exemplary microsystems reject the notion that factors such as educational level will automatically affect a patient's ability to absorb information or to act on information. They know that patient self-management is critical to effective planned care (Bodenheimer, Lorig, Holman, & Grumbach, 2002). The belief that particular types of patients (or their families) are "too limited" to self-manage their problems is a myth.

Exemplary microsystems reject the notion that new approaches will not work for a particular setting or for certain types of patients. Self-management support and monitoring of progress is increasingly facilitated by the telephone, patient registries, e-mail, and Web-based technologies. Technology facilitates the extension of care beyond the office. Innovative microsystems learn that electronics are right

TABLE 7.1. COMMON MYTHS REJECTED BY EFFECTIVE CLINICAL MICROSYSTEMS.

Negative Attitude or Myth

Advanced information systems are needed before services and care can be improved.

Patient self-management skills are dependent on education, income, language, and so on.

"Electronics are not right for my patients." Many practices assume that they have to spend money for hardware and software and the space and personnel to maintain this technology.

Ambulatory care is visit based. Fee-forservice practices most often build patient flow around visits because that is how they are paid.

All paths lead to a doctor. When patients need help, they need a doctor.

Demand is patient driven. When patients need help, they go and get it.

Resources are needed to help patients develop their self-management skills.

A designated person to plan care (for example, the care manager) will correct a practice's deficiencies.

All resources and capacity to support patient care exists within the four walls of the practice.

More Useful Reality

Better to understand purpose, patients, professionals, processes, and patterns; test changes; retest changes; then build information systems to make the best processes more efficient.

Better to realize that patient self-management skills can be learned and that the microsystem has a central role in supporting these skills. Better to realize that a rapidly increasing number of patients will welcome patient-centered electronic methods for getting information and engaging in self-management. Because the patients can do a lot of the data entry, the practice flow immediately benefits.

Better to think about what each patient needs to attain high levels of self-management, so inefficient rework is minimized. Many revisits "clog" the system with low reimbursement care. Better to think about what has to be done to serve patient needs and deliver efficient effective care. Once the what is answered, the who often turns out not to be the doctor.

Better to realize that many demands are caused by professional habits and rework. Once rework is reduced and demand is managed, the microsystem will have enough time to plan how to do the right thing at the right time.

Better to have planned services; the efficiencies will result in more resources and capacity to plan care. Better to make planned care part of planned service (for example, involves all roles and all "work").

Better to explore resources within the practice and outside the four walls, in the community.

for many of their patients; that patient-centered technology can build patient self-management support into everyday practice. And for those patients who may not be able to use electronics, family members and community organizations can be encouraged to offer assistance.

Exemplary microsystems reject the notion that all care must be visit based. They know there are many ways to provide planned care; it is seldom confined to an office visit, nor is it confined to the care provided by a physician. Physician-centered care often results in bottlenecks, but these can be minimized by the use of other professionals, peers, and community services. Providing only physician-dominant, visit-based care is often more costly and less complete for patients, and it may, paradoxically, reduce net practice revenue.

Exemplary microsystems also reject the notion that aiming to care for patients when patients want to receive care will overwhelm an ambulatory care practice. They know that current patient demand largely results from the way the microsystem has operated in the recent past; demand will change to match the way services and care are planned in the future (Schwartz, Woloshin, Wasson, Renfrew, & Welch, 1999; Wasson et al., 1992).

Finally, exemplary microsystems use the efficiencies of their planned services to improve their capacity to provide care. This capacity is spread across microsystem staff as they develop the new roles and tasks needed to help patients become better self-managers.

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