Changing Culture to Improve Quality and become a Medical Home

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Changing Culture to Improve Quality and become a
Medical Home

• Timothy J. McCarren, MD
• Mark G. Witte, CEO
• The Family Medical Group
• Cincinnati,OH

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Who are we?
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The Facts

• The Family Medical Group
• 12 physicians largest independent Family
  Practice Group in Greater Cincinnati.
• 5 mid level providers
• 3 locations
• 31,000 patients in our EMR
• 90 employees
• Level 3 certification as a patient centered
  Medical home.
• Top workplaces in Greater Cincinnati, Enquirer
  Media
• Best Doctor Group, CityBeat Magazine

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Practice Profile 1/09-12/09
DX Key DX name Total Units Rank
401.1 Hypertension 16717 1
272.4 Hyperlipidemia 10965 2
V04.81 Need Proph VA 10826 3
250.00 DB w/o complications 8628 4
V70.0 PE, Well Adult 6822 5
427.31 Artrial Fib 3853 6
250.02 Diabetes 2 Uncontrolled 2835 7
V06.5 Need Proph VA 2759 8
311 Depressive disorder 2505 9

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Ancillary Services offered in the office

• Cardiovascular
• Ultrasound
• Coumadin clinic
• Echocardiogram
• Diabetes
• CDE
• Retasure
• Muscular/skeletal
• Bone Density
• Physical Therapy
• MISC
• Minor surgeries
• labs

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Participation

• Primary Care Innovation Group sponsored by
  Aligning Forces for Quality
• IBM/CMS Project participated with HealthBridge
  (HIE)
• Preventive Care Initiative with Ohio KePro (Ohio
  Medicares Quality Improvement Initiative)
• HealthMeasures Public reporting on diabetes
  care in the Greater Cincinnati Region
• Pilot Practice of the PCMH Initiative in Greater
  Cincinnati
• Working with other community stakeholders to
  establish a clinic for the uninsured in a medical
  underserved community in Cincinnati.
• Patient Advisory Board that meets on a quarterly
  basis
• 5 physicians have leadership roles at the Mercy
  Hospital, Western Hills
• Dr. McCarren serves on the physician leadership
  group of the AF4Q project.

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What does it look like?
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Patient Education

•  
• Presents
• Medicare 2011 What you should know
• How do I sign up?  What are the changes?  What if
  I keep working?  What are Medicare advantage
  programs?  Could they be right for me? 
•  
• Select one session to attend
• Wednesday, October 27, 2010-  10 1130 AM
• Thursday, October 28, 2010 -  530 PM
• Friday, November 5, 2010 - 10 1130 AM
•  
• Receptions Banquet Center
• 3302 Westbourne Drive
• Cincinnati, OH 45248
•  
• The Family Medical Group, is offering a free
  service to provide the Patients of TFMG the
  ability to review different options in regards to
  your health plan choices available for you for
  2011.
•   
• How do I register?  One of 3 ways
• Go to our website www.thefamilymedicalgroup.com
  and click on TFMG news to register.
• Or email medicareprogram_at_thefamilymedicalgroup.com
  

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• invites you to celebrate National Diabetes Month
  at the third annual
• The Key Ingredients to Living with Diabetes.
• Thursday, November 11
• 11 AM-1 PM
• This free luncheon will feature
• A panel discussion on diabetes with TFMG
  providers
• Bring a family member or friend.
• Receptions Banquet Center
• 3302 Westbourne Dr.
• How do I register? One of 3 ways
• Go to our website www.thefamilymedicalgroup.com
• and click on TFMG news to register.
• 2. Call 513-389-1400
• 3. diabetescare_at_thefamilymedicalgroup.com
• www.thefamilymedicalgroup.com
• 513-389-1400
•  

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What defines culture

• Stories (SeaBiscuit)
• Language (Florence Yall)
• Food (Burgoo)

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Stories

• Why is there a resurgence of interest among
  today's business and organizational leaders in
  the ancient art of storytelling at a time when
  electronic communications might seem to make it
  obsolete? Human beings have been communicating
  with each other through storytelling since we
  lived in caves and sat around campfires
  exchanging tales. What is new today about the art
  of telling stories is the purposeful use of
  narrative to achieve a practical outcome with an
  individual, a community, or an organization.
• Storytelling, Passport to the 21st Century

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Facts Tell, Stories Sell

• 4 stories

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One doctors Story

• Story 1

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Story 1

• What are some foundational stories to your
  practice?
• If you had to tell one story of how your practice
  began, what would it be?
• Can you name any dominant themes?

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Story 2

• The formation of practice identity

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Storytelling Experience

• We were deciding about our future.
• Partnership meeting in which the founding
  physicians of the practice and administrator told
  the story of their beginning
• Drs. McCarren Bort and Linda Behlmer
• Foundational principles of the practice
• Pre-PCMH we had stories, but not a common
  language.

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Themes

• Confidence
• Ability to deliver quality medicine
• Future
• Physicians
• Adaptation to changing realities
• Working effectively in relation to hospital
  systems
• Relationship with other providers helped in the
  development of practice
• The doctors and the staff created an effective
  partnership in the development of the practice.
• When it was not right fit, there was a
  willingness to make a change.

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Themes

• Confidence
• Aligning forces in the community
• Impact of the financial demands of the practice
  to guide strategy
• New systems within the healthcare environment
• Challenge of personnel issues
• Ability to make changes within a larger
  organization.
• Responsive to the direction of every group of
  physicians loosely organized as a clinic without
  walls.

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Stage 1

• Identity

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Story 3

• The formation of team based care

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Turning Doctors into Leaders of a Team

• The cultural barriers to change in health
  caredoctors resistance to being measured, their
  need to be perfect, their reluctance to
  criticize colleagues, their resistance to
  teamworkreflect a deep-seated belief that
  physician autonomy is crucial to quality in
  health care. Doctors have historically seen
  themselves as their patients sole advocates, with
  the rest of the world divided into those who are
  helping and those who are in the way.

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Turning Doctors into Leaders of a Team

• Precious as this passion for patients interests
  might be, physician autonomy is not synonymous
  with quality. For the needed structural and
  operational changesperformance measurement,
  process improvement, teamworkto become
  mainstream, doctors must accept that to
  all-caring is different from being all knowing or
  all-controlling. Thomas H. Lee, MD Harvard
  Business Review, April 2010.

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Coumadin Clinic

• Pro-time clinic within the office
• Managed by a Physician Assistant
• Patient experiences a team within a doctors
  office.
• Diabetes
• Osteoporosis
• Physical Therapy

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Stage 2 Development

• Team Based Care
• Pre-PCMH

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Name a story of team based care practice.

• Who was involved in the story?
• How did you measure the success?
• How did you celebrate it?
• Do you know your practice?
• of patients?
• 10 diagnostic Codes?
• Daily, weekly, monthly, annual visits?
• How do you perform on Clinical measures?

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Story 4

• Language as a key strategy

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• The First challenge in creating a performance
  measurement system is getting everyone across an
  organization to use the same languagethat is,
  to measure the same thing in the same way.
  Otherwise its easy, and understandable, for
  resisters to challenge the validity of apparent
  differences. But once providers believe that
  apples are being accurately compared with apples,
  peer pressure and other incentives will help
  spread best practices. Thomas H. Lee, MD,
  Harvard Business Review, April 2010

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The theme for this project is

• TFMG EPIC Launch To Meaningful Use and Beyond!

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Launch of a new EMR

• Not just an EMR
• Process Improvement
• Identifying waste
• 5-S system
• Standardization
• Change Management

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Launch of a new EMR

• Present EMR is being sunsetted
• Meaningful use. What is Meanginful use?
• Established a partnership with a hospital
• Senior Process Improvement Consultant
• IT Implementation Team
• Established a schedule on 15 minute huddles with
  all of our staff over the next four weeks to give
  them a common language

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Language School

• Patient Centered Medical give a context to the
  language of the care of patients.

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Language of your practice

• Do you share a common language?
• Have you instructed your staff on a common
  language?
• Doctors speak a common language?
• Patients speak a common language?

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Examples

• Physician and staff meetings
• Weekly email newsletter
• Doctor Newsletter
• Information system
• Clinical review project Senior Process
  Improvement consultant

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Stage 3

• Language and context of a Patient Centered
  Medical Home

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Why PCMH is important
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Section II

• The PCMH Journey

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Important Foundations

• PCMH is not about the doctor doing more, but the
  organization becoming more effective.
• PCMH teaches us that effective/outcome
  driven/patient centered Healthcare requires a
  commitment to data management
• PCMH challenges us to find a common language. A
  language that providers, staff and, most
  importantly, patients speak.

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Why is it important?

• National certifications will do the following
• Force you to look at your own practice from
  another perspective.
• Challenge staff to new competencies
• Put you in position for possibilities around
  payment reform
• Open you to new possibilities within your
  practice.

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What is Patient Centered Medical Home?

• The Patient Centered Medical Home is a health
  care setting that facilitates partnerships
  between individual patients, and their personal
  physicians, and when appropriate, the patients
  family. Care is facilitated by registries,
  information technology, health information
  exchange and other means to assure that patients
  get the indicated care when and where they need
  and want it in a culturally and linguistically
  appropriate manner.

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PCMH

• There are nine PPC standards, including 10 must
  pass elements, which can result in one of three
  levels of recognition. Practices seeking
  PPC-PCMH complete a Web-based data collection
  tool and provide documentation that validates
  responses.
• NCQA.org

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PCMH

• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access
• Payment

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Patient Centered Medical Home

• On March 30 we submitted a 250 page document to
  NCQA
• www.ncqa.org
• Part of a pilot project
• Formed a team around the application. Met every
  week at a set time.
• One person was administrative person for the
  project
• Donna Hedrick facilitator

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Patient Centered Medical Home

• On March 30 we submitted a 250 page document to
  NCQA.
• Developed a Policy and Procedure Manual for our
  entire organization.
• Established a program of care coordination

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One Guidebook

• Understand where you are at this point in
  relation to the journey of recognition.
• Access the online tool of NCQA
• Internally, what can your system handle.
• A change readiness assessment.

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Find a partner

• Local Collaborative
• Health System
• Partnership
• Donna Hedrick

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Technology

• Technology is an important tool.
• Have to leverage that investment with the long
  term goals.