10

Leading and Managing a Successful Practice Transformation

The primary goal in reengineering care and implementing ProvenHealth Navigator (PHN) was enhancing patient care. That’s the first question we always explore. PHN and other Geisinger innovations also have made things better for providers, an important consideration and benefit for any healthcare organization looking to innovate.

BEFORE PROVENHEALTH NAVIGATOR

The professional life of a physician 15 years ago and prior to PHN was controlled chaos. Doctors sort of had a budget, mostly dependent on the goals and ambition of the individual provider and how many patients he or she was willing to see in a day. Schedules frequently were uncontrolled, with patients added on or double-booked indiscriminately. It was difficult and stressful to spend appropriate time with each patient knowing that other patients, scheduled for the same time, were waiting.

Patient communication predominantly was via the telephone, which was overwhelming, and sometimes by fax or snail mail, which was slow and inefficient. Just imagine the mechanics of writing and mailing a note to your doctor and waiting for a response. Documentation of care was via paper chart, which served as notes for the physician to keep and review during subsequent episodes of care for the individual patient: a series of scribbles or perhaps checklists with no ability for flow charts or meaningful care plans unless manually produced and, in general, lacking organization. Office-based care then was mostly a cash business, and there was no oversight or need to review the memorialization of an office visit by outside agencies or insurance reviewers. The flow of information from inpatient to outpatient environments and vice versa was slow, inefficient, and inadequately managed, setting the stage for poor transitions of care, missed opportunities, errors, and overall care that was not as good as it could and should be.

When Geisinger implemented its electronic health record (EHR), it was used primarily as a typewriter or word processer for the first five years. Notes became more legible, accurate, and comprehensive as time passed, and we began to take advantage of additional EHR features such as prompts to ensure various tests were completed at appropriate intervals, prescription reminders, electronic referrals, and more.

But that wasn’t the case in the beginning, when even the scheduling of patient appointments was uncontrolled. Paper-based schedule books commonly were used, but individual physicians had the ability to design their own templates. So doctors would have many different appointment types: 5 minutes for one, 20 minutes for another, or 60 minutes for an annual visit. There was no ability to assess or analyze the value of time spent for each of the various appointment lengths or time lost by not filling the schedule completely. There also was less control because physicians thought the phone staff and other schedulers would just add patients between the lines as needed to satisfy patient or physician requests for return visits. Due to the inability to establish firm scheduling guidelines, physicians often felt like they were running on a nonstop treadmill, trying to do the right thing, but knowing that there was always someone waiting in the next exam room.

There really was no unified direction as we attempted to provide the best evidence-based, comprehensive care. Individual doctors had their own repertoire of evidence-based care depending on the latest journal article read or educational conference attended. We all thought our unique care models were the best, but there was no ideal method to measure outcomes to provide evidence to alter practice styles or reduce variation in recommended treatment for patients with chronic conditions.

The delivery of care was laid directly on the shoulders of physicians. Support staff members answered phones, placed names on schedules, escorted patients to exam rooms, and perhaps took blood pressures, but were responsible for few other clinical interventions. That was accepted practice. The physician was expected to be in charge and in control. In many cases, the doctors didn’t even want others to intervene clinically. That was their job.

There also was no accountability for quality or efficiency. No one knew outcomes, either intermediate, such as blood pressure control or diabetes management control across a practice, or endpoint, such as diabetes patients with retinal, renal, or vascular complications. Paid for volume, hospitals loved the big admitters. Pharmaceutical utilization went unchecked; for example, polypharmacy had no checks and balances and off-label use was not challenged or monitored. But we did our best, given the available tools and resources at the time. (See Figure 10.1.)

FIGURE 10.1   Life as a Family Doctor Before ProvenHealth Navigator

Despite these challenges, everyone thought the quality of the care they provided was superb, until our first internal chronic disease bundled care metrics were revealed in March 2006. That’s when we learned that as a system we were performing dismally with only 2.4 percent (or about 450) of 20,000 diabetes patients meeting all of the agreed-upon nationally recognized measures. The care bundle is a group of evidence-based, internationally recognized treatment goals that all patients with diabetes should attain, for example, control of blood glucose, blood pressure, and lipids; periodic blood and urine testing; regular flu and pneumonia vaccination to reduce the risk of severe infection; and smoking cessation.

Before PHN, physicians often were overwhelmed, running in circles as fast as possible with no guidance, direction, or goals except to get on to the patient in the next exam room and make it through the day. All the existing responsibility and accountability for care was placed squarely on the physician’s shoulders with no expectation of assistance. There was no effective methodology to measure outcomes in a meaningful, actionable way.

As we rolled out further metrics, we learned that we were equally deficient in other areas of care. But we also learned from our insurance company’s Healthcare Effectiveness Data and Information Set scores that American medicine in general was no better, and often worse, than we were on many individual measures both regionally and nationally.

AFTER PROVENHEALTH NAVIGATOR

The doctor’s professional life is much improved since the development and implementation of PHN. Now there are tools and actionable reports from multiple clinical quality and resource utilization sources, which give real meaning to the differences in doctors’ practice styles and help to determine whether care actually is helping patients. PHN allows us to measure and reduce unnecessary variation in care, and our team-based approach permits us to distribute functions of care delivery appropriately across all members of the team, even back-office functions, so all can contribute to high-quality evidence-based care.

A critical change in the office-based team has been the embedding of nurse care managers in all of our primary care practices. These nurses have been a godsend. Their responsibilities include a number of services all aimed at keeping patients healthier and at home rather than in the hospital.

They provide care for the frail and those with multiple chronic conditions. They review all hospital and nursing home discharges for completeness, a process called transitions of care, and they focus on answering such questions as whether resources are in place at home to continue appropriate care, whether durable medical equipment such as oxygen, a walker, or a hospital bed arrived on time, and whether the patient is taking medications correctly. They follow patients with certain conditions longitudinally as well. Those with heart failure, chronic obstructive pulmonary disease, and end-stage renal disease, for example, are known to be admitted to the hospital frequently. With appropriate access to information and medications, they can be kept healthier and out of the hospital. We developed protocols for treatment of exacerbations of these conditions that by agreement of all medical staff can be implemented by the care managers, thereby limiting the exacerbation and keeping patients at home. These nurses also monitor certain patient vital signs, such as daily weight in the case of heart failure, to provide advance notice of an upcoming problem.

In many ways, care managers are similar to health coaches. They intervene earlier in the course of many chronic conditions to provide education and access to self-care resources to provide better control of a patient’s condition at a stage before complications develop. For example, newly diagnosed diabetes or hypertensive patients who need education about their condition, diet, lifestyle changes, or medication may be referred to care managers. They may provide medication reviews, community resources, telephonic monitoring, and coaching to instill good health habits in those who are early in the development of a potentially serious chronic condition; for those who need coaching in preventative health such as tobacco cessation; or for patients with chronic conditions that are not life threatening, but lifelong, such as migraines.

Another tremendous adjunct to our practice has been embedded pharmacists who provide clinical consultations to patients about medications through a medication therapeutic management (MTM) program. These pharmacists spend a greater amount of time with patients educating them about the purpose, potential side effects, and expectations of medications. A good example is the initiation of insulin for diabetes. It may take several sessions for a layperson to learn the proper technique of injecting insulin under the skin. Likewise, the use of statins for treatment of high cholesterol is fraught with rumors and hearsay about complications. Embedded pharmacists are allocated appropriate time to provide the necessary education and counseling so these medications are understood and used properly. Similarly, chronic pain management has become a specialty, and the MTM program has pharmacists devoted to this as well.

Our care gaps program that assists us in attaining the most current, recommended patient care is a good example of the value added by back-office functions. A nursing team works in the background analyzing care plans to determine whether certain evidence-based care has been completed. This may include preventative services such as cancer screening, chronic disease follow-up, or identification of patients in need of follow-up care or disease surveillance. We search for patients over age 50 who never had a colon cancer screening and females over age 50 who never had a mammogram, as well as patients on certain medications including statins for cholesterol control who require monitoring and have had no recent lab testing.

In our post-PHN world, scheduling and access have improved with the ability to spread provision of care to appropriate team partners, and templates have become more manageable and flexible to serve patient needs. Communication has been simplified to some extent, as it now is incorporated into the EHR; however, some challenges remain regarding information overload. Patient communication is more contained and streamlined because phone messages and MyGeisinger electronic messages all are contained in one place. Specialty and imaging reports also are contained and more streamlined.

The physicians, rather than being alone in responsibility for patients, serve as leaders of the care team and don’t have to remember and do everything by themselves. Physician confidence in the process and willingness to let go is key to success. Some physicians initially were unwilling to relinquish control of all aspects of care, but gradually have seen the advantages, and the EHR has become a partner in care and a valuable tool to extract information that allows providers to excel. This innovation provides patients superb care for many conditions without an office visit or relying solely on the memory of their personal physician to provide needed service. (See Figure 10.2.)

FIGURE 10.2   Life as a Family Doctor After PHN

Even as providers remain somewhat overwhelmed with access, communication, and sheer volume of patients, finally, there is a measurable, improved sense of pride and professional satisfaction in the care we provide. We now see measurable aspects of quality and endpoint clinical outcomes improvement, which truly is what PHN and all of Geisinger’s innovations are designed to accomplish.

THE FORESIGHT OF DR. BILL NEWMAN

Dr. William (Bill) Newman practiced family medicine near Scranton, Pennsylvania, for decades. As the senior partner of a three-physician group that joined Geisinger, he knew that care had to become more efficient with greater support for the physician. One of his rationales for leaving the traditional small group practice model and taking the leap of faith as a pioneer in the evolving integrated health system model was that he clearly recognized his model of care delivery was essentially the same, fundamentally, as that of his grandfather, who founded his practice almost 100 years previously.

Dr. Newman and his colleagues saw patients one at a time, listened to their stories, performed physical exams to assimilate the findings into a list of differential diagnoses, and then narrowed the list down to the most likely etiology. He recognized that the available tools certainly were different.

Dr. Newman expressed confidence that Geisinger, as an integrated system, would help him develop a more efficient practice style, provide greater support for physicians, offer linkages to medical and surgical specialists, and reduce duplication of services and waste. He spoke of the technology that Geisinger offered as a huge improvement in his practice style and ability to serve patients better. What we originally offered him related more to electronic registration, billing, and revenue cycle services rather than true clinical support, but we ultimately supported him with team-based care that includes physicians, advanced practitioners, nurses, pharmacists, and the EHR, which allows us to provide excellence in care.

THE COMPLEXITIES OF PRACTICE TRANSFORMATION

There are numerous moving parts in any medical practice, and they must move in conjunction with one another to truly change patient care, improve work flows, and enhance the overall patient experience. There was significant tactical planning at the outset of PHN, and with no one to show us the way as plans evolved, we needed to work collaboratively to determine how work flows and clinic operations could support new ideas. We vetted ideas clinically to gain understanding of whether they truly were doable. If they passed this test, ideas then were vetted at the site where the care was actually provided for a reality check. Finally, ideas were vetted even further at a site PHN meeting before they were adopted. See Figure 10.3 for information on managing a ProvenHealth network.

FIGURE 10.3   Managing a ProvenHealth Network

Early on, we learned to pilot all of our initiatives at one or two sites, selected based on the adaptability and change management style of lead physicians, and often one large site and one small site to assess scalability. We learned that physicians may fall into the category of early adopter for one change process and late adopter for another.

Once a concept was proven clinically, we addressed work flows, both clinically and electronically. Because the EHR was a necessary partner in practice transformation and successful PHN implementation, information technology (IT) support and optimization were imperative. We had a full-time IT optimization team focused on getting the EHR to think like a doctor, rather than asking doctors to think like IT professionals.

Our nurse care managers were another critical partner; it’s important to engage nurses throughout the improvement process. Additional fundamental partners include our “SNFists,” advanced practice providers who work in skilled nursing facilities (SNFs) to optimize care provided to our patients who require skilled nursing services. These important team members understand that while post-acute patients years ago would stay in the hospital until their disease improved and they were able to ambulate safely and conduct their activities of daily living in a safe environment, this is not the case today. Most inpatient stays now are approximately three to four days, then patients are transferred to a post-acute care facility for the remainder of convalescence.

Last, we put together what we called a Delta Team to ensure ongoing support for innovation efforts and to continue developing ideas to help outpatients. This team consists of doctors and advanced practitioners, nurses, operations managers, representatives from public affairs, and financial and regional managers from both the clinical enterprise and health plan.

We stay on top of how we are doing with a monthly 90-minute meeting at every site that focuses on ensuring that processes are effective. These meetings, which are attended by as many of the practice staff as possible, include case presentations by physicians and care managers so the team can continually review and learn. We strive to discuss saves as well as misses to learn about better patient centricity. A steady flow of utilization measures also is studied, including health plan membership, admissions, readmissions, length of stay, high-end imaging, and generic prescriptions. As a result of the discussion and inquiries about the basic data, these efforts ultimately have evolved into a comprehensive report with many levels of detail about each practice.

LEADERSHIP ISSUES

We understood early that PHN is critically dependent on the partnership between the clinical enterprise and our health plan, which meant we had another layer of leadership to consider in planning and implementation. For example, executive leaders in our community practice service line and health plan, including our population health leader, had to unite in the common goal of making things better for patients. This involved not only partnering for accountability, but also a command of change management skills and the ability to interact and relate well with the service line leads and health plan managers. Our service line structure includes regional medical directors and geographically dispersed operations managers, clinic supervisors, and managers. This ensures geographic support to the site medical leads and staff, an important factor in confirming that PHN is working at each individual site.

As the practice transformation occurs, the nonclinical management staff effect the changes in terms of facility space, staffing, phones, and other front desk services, so it is imperative that they are involved in the planning and management of the overall program. They also must assist the physician leaders, as there inevitably is some pushback from less innovative physicians and late adopters.

Strong physician leadership is critical at all levels, from systemwide to geographic regions to the office sites themselves. The site lead physicians must buy in to the concept of improved patient outcomes, decreased unnecessary or hurtful costs, and improved patient satisfaction (our Geisinger version of the Institute for Healthcare Improvement Triple Aim),¹ be local thought leaders, and have effective people skills and good relationships with the office staff (medical, nursing, and support) to effect the necessary change. On the payer side, there must be an engaged medical director to lead and mediate clinical issues. The care managers and regional managers must interact with clinic staff at several levels including physicians, advanced practitioners, nurses, and support team members. They must clearly represent the payer and their employer and relate closely to the physician leads.

LESSONS LEARNED

•   Recognize that the physician can’t do it alone and needs team members to support effective patient care and office operations.

•   Use technology to its fullest capabilities.

•   Pilot programs at one or two sites to determine scalability.

•   Expand the role of each care team member.

•   Remove as much care as possible from the hospital, emergency department, and doctors’ offices.

•   Ensure that new care pathways are easier than old care pathways for both patients and providers.

•   Benefit to patients always increases both patient and provider satisfaction.

•   Continual performance data feedback drives results and enables ongoing reengineering to achieve best results for patients.