05 Dec nly, do not repr oduce. 2020-11 -15 jennifer .naegel [email protected] mail.co m 318 319 Case 21: The Lunchroom: Physician Engagement at a PCMH OBJECTIVES 1. Propose interventions to improve engagement of healthcare providers in quality improvement initiatives. 2. Explain how staying current with healthcare system change can uncover opportunities for improved healthcare quality. 3. Describe how leadership can create a compelling vision for change in the processes that improve healthcare quality, efficiency, and access. 4. Analyze how healthcare staff well-being can impact organizational performance and patient care. 5.
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Case 21: The Lunchroom: Physician Engagement at a PCMH
OBJECTIVES
1. Propose interventions to improve engagement of healthcare providers in quality improvement initiatives. 2. Explain how staying current with healthcare system change can uncover opportunities for improved healthcare quality. 3. Describe how leadership can create a compelling vision for change in the processes that improve healthcare quality, efficiency, and access. 4. Analyze how healthcare staff well-being can impact organizational performance and patient care. 5. Distinguish between positive and negative responses to healthcare quality performance problems.
INTRODUCTION
The U.S. healthcare system lacks effective communication among providers and efficient coordination of patient care leading to higher costs and lower quality (Akinci & Patel, 2014). A new model of healthcare delivery, called the patient-centered medical home (PCMH), incentivizes certain innovations in health service delivery, such as coordinated care, improved access to primary care, and better management of patient chronic conditions (National Center for Quality Assurance [NCQA], 2018). The NCQA certifies PCMH model implementation in healthcare organizations, including the use of analytics to proactively identify patient care needs and the application of a physician-directed team that collectively cares for the patient (NCQA, 2018). The PCMH model of care can reduce clinician burnout and increase overall staff satisfaction (Reid, 2015).
Apollo Medical Clinic is a primary care practice with 40 providers at six locations throughout the Apollo Bay region. Although Apollo is professionally managed by healthcare administrators, the practice is jointly owned by 20 of the practicing physicians, including internal medicine doctor, Jonathan Sanders, MD. After seeing significant change in the U.S. healthcare system, Dr. Sanders perceives that he can no longer practice medicine in his ideal way, an emotional experience that follows a pattern similar to the Kübler-Ross Five Stages of Grief model of personal loss (Kübler-Ross & Kessler, 2005).
CASE SCENARIO
Denial: Reheated Fish Tacos
“None of this makes any sense,” Dr. Jonathan Sanders said to no one in particular. Sanders leaned against the counter next to the lunchroom microwave completely unaware that the smell of yesterday’s fish tacos had wafted into the Apollo Medical Clinic’s Northside Clinic location. Supposedly a refuge for all clinic staff, people rarely joined Sanders in the lunchroom. It was a large space with a round table with seating for eight. Sanders usually ate alone.
At 6 feet, 8 inches tall, people had always asked if Sanders played basketball, but he couldn’t remember how long it had been since someone had asked about his younger playing days. Or asked him anything personal, for that matter. When he began his career as a physician, Sanders spent plenty of time with his patients, educating them, taking the time to understand them, and helping improve their lives. Sanders thought he still provided his patients better care than they could get anywhere. He thought that he did not need to change the way he practiced medicine because the fundamentals had not changed— diagnosis and treatment of illness, coordination of care, and strong professional relationships with patients. These things he could control. The rest? Well, he felt like a hamster on a wheel, constantly behind, and never doing quite well enough.
“I’m sorry, Dr. Sanders. Were you talking to me? What doesn’t make sense?” asked Pam Bukowski, the director of PCMH for the large, multisite, primary care practice of which Sanders was a managing partner. Bukowski breathed through her mouth hoping that whatever Sanders was cooking didn’t cling to her clothes for the rest of the day.
“No, I wasn’t. I’m sorry,” Sanders said absentmindedly. Bukowski grabbed her bagged lunch from the refrigerator and turned to leave. “It’s just that,” Sanders continued, “the productivity-driven practice model does not work. The managers in this practice keep raising productivity targets, with the expectation that physicians will work faster and see more patients. It becomes a mentality for people like you, and you don’t question the wisdom of it. As a physician, my goal is not simply to meet productivity targets, but to take the time to get to know my patients.”
As the director of PCMH, Pam Bukowski knew better. She led the organization’s PCMH certification last year. “Actually, our practices have mostly transitioned to a PCMH model, so productivity is less important than it used to be. Sure, the fee-for-service financing still dominates, but we are moving toward value-based purchasing. I mean, the number of patients we see is still important, but more and more we are paid on the quality of care we deliver.”
“Who are you?” Sanders asked. Bukowski introduced herself again explaining that she wants the PCMH initiative to improve quality of care measures through better coordination of
care, improved access to services, and population health management. “Nice to meet you,” Sanders said. “Actually, we’ve met before. A few times.” Bukowski explained that she had visited his clinic multiple times to explain the PCMH model and her role in
enabling better use of analytics and team-based care processes. She reminded Sanders about the in-service education session in which she explained how diabetes management can be improved by reporting and team-based care.
Sanders could not understand it. He did not remember meeting Bukowski before. He did not know the terms “population health management” or “team-based care.”
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Anger: Five-Alarm Chili
“But that’s my job!” Dr. Sanders yelled with his face reddening. “As I’ve told you before, I control how I practice medicine. And yet you continue to ask me to work with all of these people. I don’t even know what they are supposed to do.”
Vanita Modi, MD, FACP, the chief medical officer of Apollo Medical Clinic, sat with Sanders at the lunchroom table. Sanders was eating his Five- Alarm Chili, a recipe that won him second place at a chili cook-off 10 years ago. (A veggie chili won first place, but Sanders dismissed that competitor because he thought that chili should not be vegetarian.) Modi ate her red lentil curry.
Modi was voted by the other partners to provide clinical leadership to the organization as the chief medical officer. Her job was to meet with the other physicians individually and discuss their performance. “Dr. Sanders, my main focus is to protect physician autonomy, and nobody dislikes productivity targets more than me, but the practice of medicine has changed. Demands required by the PCMH model mean that we have to change how we organize care delivery. Team-based care means leveraging the expertise of many individuals in our practice—case managers, patient educators, medical assistants—to deliver care so that you can provide services that only a physician with your deep expertise can provide.”
“Don’t flatter me,” Sanders scoffed. “No wonder we’re under so much financial pressure. We hire all these people we don’t need.” “I hear what you are saying, Dr. Sanders,” Modi said calmly, “but you are taking on too much by yourself. You are stressed trying to keep up.” “Damn right, I’m stressed!” “And, Dr. Sanders, here’s the thing, you just aren’t keeping up,” Modi said and then let the silence linger between them. Modi continued, “One of the ways that our payers—Medicare included—evaluate our practice is through healthcare performance measures. We became
an NCQA-certified PCMH to help us improve our quality scores. We are making progress, but we still have a long way to go. To keep things simple, I have some of the Diabetic Care Measures to review with you (Table C21.1). As you can see, compared to the national averages as the benchmark, Apollo is underperforming. On each of these measures, your scores are below the Apollo average,” Modi explained.
“Quality indices are the bane of my existence,” Sanders barked. “These measures do not reflect whether I deliver good care or not. These are simply what managers are able to extract from the health record system, and these data often turn out to be wrong,” Sanders said.
“These measures are the nationally recognized standards for diabetic care. These process measures are related to health outcomes, such as mortality and morbidity,” Modi said.
“You say you want to protect physician autonomy, but now you are asking me to spend a good part of my day collecting and reporting data on my performance?” Sanders asked irrationally.
“No, Apollo has a full-time quality director. I am aski
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