August 16, 2011
Interview with Marty Gabica MD, Chief Medical Officer, Healthwise
THE MOTIVATED AND EMPOWERED PATIENT
It is my belief during my 27 years in practice that a physician’s job has three parts: diagnosis, treatment, and education. When I was training residents and other providers, I would emphasize to them that they need to see themselves as teachers. I emphasized that ensuring that the patient understands his or her diagnosis and treatment plan is a skill set just as important as delivering the diagnosis or determining a treatment plan.
I believe in the power of the patient to transform health care. By engaging patients in taking an active role in their own health and expanding their skills, we can reduce costs and improve the quality of health care. So I view the patient as more than a passive recipient of my care, but as a motivated partner who is willing to do their part in their own health care—and has the potential to make a real difference.
Health care in the United States is in crisis, but a solution lies in the transformation in the role of the average patient. The patient is the only health care resource that has enough potential to make a real difference.
If you look at the various requirements for these new ideas you find lots of rules about how providers should act. You find very little about how to motivate patients to become involved in their own care. Studies have revealed that a patient’s feeling of empowerment is one of the most important factors in motivating behavior change.
We must be willing to discuss the patient’s personal beliefs and preferences when discussing their health issues so that we, as clinicians, can provide the kind of support that helps patients ask for care they should receive and refuse care they do not need.
The solution to the health care crisis is the transformation in the role of the average patient. What is needed is a better understanding of what empowers people. We need more research on what motivates patients. What is also needed is time and training of physicians and a different way to reimburse them.
Time and training for providers to enable them to listen to their patients and guide them is a huge barrier. This means reimbursement for doing so. It also means being paid when a patient chooses to not do a procedure as well as when they decide to do it. Providers need to be willing to accept patient choices that may not be what they want the patient to do. They need to get the training in residency that enables them to counsel, listen, and educate. They need the tools to help them do so without disruption to their work flow. Health education must be included in the standard of care. And the provider must be willing and able to shift some of the control and responsibility back to the patient....Helping patients help themselves will improve the quality of care and reduce the burdens on the provider.
March 1, 2011
Interview with Baptiste Shunatona MD, OMNI Medical Group: Family Practice Doc & Assistant Medical Director for Knowledge Management
IMPLEMENTATION IS A CONTACT SPORT
The Knowing/Doing Gap: What “ought to be” frequently isn’t, and it’s not always easy to go from “ought to” to “is.”
Making it happen involves all the human stuff. Most of the time the answer is to be very creative about implementation. And frequently an important part of the answer is to provide effective feedback. And the feedback has to be actionable with appropriately short feedback loops.
I would advise folks to start by learning some simple principles and methods by reading something like “Quality for Dummies.” Learn about quality by design and quality by inspection. Understand why the system is the problem; not the people. Then do projects starting with plans and pilots.
Reward what you want more of.
with Howard Cohen MD, Neonatologist,
Chair of Quality and Safety for Northwest Newborn Specialists P.C.
primarily at Salem Hospital; Patient Safety Officer, Chair of Pharmacy
and Therapeutics Committee at Salem Hospital, Salem Oregon
AN ORGANIZATIONAL CULTURE OF SAFETY
“ I am
guided by a strong belief that individual caregivers and health
care organizations have three jobs:
highest quality patient care to each individual patient in our care;
2. Improve our systems of care; and,
3. Improve our own competency and capabilities…”
system must allow people to come forward to help improve it…”
care providers, individually and collectively (organizationally)—
- Have expectations
easily understand error science.
- Take a disciplinary
approach to errors and risk.
- Have a history
of accepting disrespectful behaviors so as not to jeopardize finances.
- Have been
risk adverse and secretive.
understand or trust quality improvement methods.
with Joe Schnabel, PharmD, BCPS, Clinical
Salem Hospital, Salem Oregon
YOUR PHARMACIST TO WORK!
advent of “evidence-based medicine” has helped create
a common mission for patient care..."
seem to be more and more non-clinicians pushing “efficiency”
before systems are in place to allow it to happen safely. Clinicians
need to be forceful in their patient advocacy to assure that healthcare
needs are met in the most beneficial way possible...”
Gawande’s “The Checklist Manifesto” finally articulated
what I have felt was missing in the healthcare system as I knew
it. We have been willing to allow variability in the system so as
not to “upset” physicians practicing the “art”
with Ward B. Hurlburt, MD, MPH, Chief
Medical Officer & Director, Alaska Division of Public Health
CHALLENGES AMERICA FACES IN HEALTH AND HEALTHCARE
road we are currently on is a detour around being a truly successful
nation because of the massive waste in our healthcare system (non-system)
diseases are our biggest challenges, and they are quite often determined
by life choices—diet and life-style choices …”
I said many years ago, we need to imprint the principles and methods
of EBM into the DNA of clinicians and other healthcare decision-makers…”
Interview with Mark Greenawald MD,
Chair, Department of Family Medicine, Virginia Tech Carilion School
Medical Director, Carilion Clinic Office of Professional Development
Education Director, Carilion Clinic Family Medicine Residency Program
Associate Professor of Family Medicine, Virginia Tech Carilion School
THE “MIRACLE GROW” OF PROFESSIONAL DEVELOPMENT
…an…important process…is the “art and science”
of seeking, receiving and processing feedback…Many people
in positions of leadership…simply don’t ask others about
their own impact….Not doing so creates the potential of our
not being effective, even when our intentions are good…”
… Leaders need to model their own ability to receive feedback.
By asking, “How are we doing?”; by inviting feedback
in a manner that says “I want to learn and do better,”
shows them you are willing to hear and consider. One positive result
of this is when receiving feedback is modeled in a constructive
way, others are more open to feedback from the leader…To take
action takes great courage.”
We see what we look for...”
Interview with Tim Young MD, President,
OMNI Medical Group, President, St. Johns Physicians & President,
Physician Support Services, Inc. Tulsa, Oklahoma
believe that patients aren’t getting enough information…to
allow them to make an informed choice that’s right for them…”
need to carefully lay the groundwork for EBM, have a good understanding
of how to achieve process improvements and people to start doing
the work…Laying of the groundwork in EBM…has made
this much easier… culturally we accepted the premise that
good evidence is required to ensure effective treatment. For us,
EBM is truly a big piece of 'the' answer…
the organization needs to know how to do it and just start doing
it — I think it’s just that simple.…”
“ I’d like to create a culture where, when physicians
want something, they have to figure out how to justify it generally
via cost and patient benefit and to measure it.…”
have used a lot of group process activities to implement EBM in
our group…. Beyond evidence-based QI activities, the small
groups are great forums for new ideas and discussions…one
of the groups is specifically charged with doing new stuff.…”
Interview with Karen Ching MD, EBM
Director & Nephrologist, Kaiser Permanente Hawaii
OF SUCCESS FOR AN EVIDENCE-BASED GUIDELINE AND CLINICAL QUALITY
Permanente Hawaii (KPHI): Prevention of Venous Thromboemobolism
(VTE) in Total Hip and Total Knee Replacement — Including
Guideline & Decision Support
VTE prophylaxis project was started because there was so much
variation in way VTE prophylaxis was administered, even within
a department of a single hospital. This variation and controversy
was in part fueled by a body of medical evidence that does not
provide conclusive answers...This project was a perfect opportunity
to gather surgeons, hospitalists and allied health personnel in
a room to go through the work of reviewing the evidence collaboratively
and in detail. The common goal was to make an evidence-based guideline
that everyone could endorse. It also was a terrific educational
opportunity to teach evidence-based medicine principles and to
illustrate that even published guidelines on this subject have
readiness as well as recruiting engaged participants are very
important. It took persistence as well as the support of leadership..."
was an important project, and it was successful because each of
the members of the workgroup was engaged in the process and participated
fully. It was also helpful to have group leaders representing
orthopedic surgery and hospital medicine to represent differing
viewpoints....It also can be intimidating to approach a vast body
of medical literature, especially one that is controversial. Having
facilitators like Mike and Sheri really made the difference; they
did an incredible amount of work behind the scenes. They guided
the group through the process and made the work of EBM easy and
project was an important investment to our institution. At the
most fundamental level, the project encourages evidence-based
practice and thinking. For the hospital, it means a focus on quality
and patient-related outcomes."
about the project: Kaiser Permanente Hawaii (KPHI): Prevention of
Venous Thromboemobolism (VTE) in Total Hip and Total Knee Replacement
and access the Clinical Guideline & Decision Support
Interview with Pieter Cohen MD, Associate
Program Director at Cambridge Health Alliance and Harvard Medical
School Tutorial Course Director
CARE PHYSICIANS AS EXPERTS AND HEALTH ADVOCATES
to motivate future generations of clinicians to pursue expertise
in primary care is a passion of mine...I
would like to address the importance of encouraging primary care
clinicians to pursue expertise and debunking the common myth that
only subspecialists can become experts."
must find special areas that particularly interest them and develop
those interests to create a balanced career. One area in which
many clinicians might find unexpected satisfaction is learning
to become health advocates and applying lessons learned caring
for individual patients to the larger community."
coming years we are likely to move to a system of healthcare in
the US in which primary care will take center stage. It will be
important to capture this moment to make sure that we reinvigorate
the practice of primary care at the same time...I could envision
a national organization emerging that incorporates the best of
family practice, pediatrics and primary care internal medicine
into one strong organization focused on academic primary care."
to reinvigorating medical education, I think no group is more
innovate in this respect than the Consortium of Longitudinal Integrated
Clerkships....One extremely creative model which has been used
in parts of the country for years and has begun to be used in
major medical centers is the concept of longitudinal integrated
really want to show the students the power of being connected
with patients. This can really drive change and should really
drive system changes. We want students to see the patient plus
the illness, not just the illness abstractly. Our goal is to be
keeping patients in the center."
To read more
about reivigorating primary care, about longitudinal integrated
clerkships and more stories from Pieter, read the full interview.
Interview with Joseph Eichenholz, Executive
Director, The Pharmacy and Therapeutics Society
nation's economic, social and political priorities are being rebalanced.
There are unique exogenous factors affecting healthcare. I think
we are facing a 'perfect storm' in healthcare right now, and I
don’t think the healthcare system is ever going to forget
the period that began with 2009. Addressing many such issues in
health care is like solving a simultaneous equation model. Solutions
must simultaneously satisfy all of the equations."
a framework that is useful and robust—one that will stand
up to scrutiny by any stakeholder, be accepted by the public,
policymakers and health care providers as being in their best
interest and is versatile enough to allow modification as needed.
It is an evidence-based framework for successfully developing
and implementing clinical and economic policies and generating
and utilizing clinical information to the greatest advantage."
leadership needs to support the organizational infrastructure
and processes necessary to collect, evaluate and communicate evidence
to physicians and other health care practitioners in a way they
can apply it in patient care and translate the implications of
healthcare decisions to patients in a way that maximizes their
ability to make choices consistent with their values where there
are choices to be made."
Pharmacy and Therapeutics (P&T) process should be a key focal
point for future decision-making regarding many aspects of health
care coverage and payment. The committee needs to be the fulcrum
for the balance between rigorous analysis of issues and the human
factors inherent in employers’ health care coverage or a
public-sector benefit program to achieve a delicate balance of
the evidence and the true needs of the patient....greater consideration
of outcomes is an issue for P&T committees. They need to be
able to move across traditional benefit 'silos' so that both medical
benefits and pharmacy benefits are addressed..."
committees must be able to synthesize the evidence, establish
clear priorities and put forward choices for patients to make
with their physicians and other health care providers. The P&T
process should stand between us and making those choices in ignorance."
Note: For more information on the Pharmacy and Therapeutics Society,
please contact Joe at firstname.lastname@example.org, 201-923-4534,
or visit their web site at www.pandtsociety.org.
Interview with Paul Wallace MD, Medical
Director, Health and Productivity Management Programs; Senior Advisor,
The Care Management Institute and Avivia Health, The Permanente
Federation, Kaiser Permanente
2.0: HIT & CHANGES IN THE RULES AND ROLES FOR PROVIDERS AND
are changing faster than we are currently set up to manage —
it is necessary to know with validity and precision what works
for which patient, and the number of considerations are exploding.
In other words, the rate of knowledge-generation is changing rapidly.
And with that comes a need for a change in roles…. This
is a fundamental change and leaders need to be aware that new
role models are needed to help manage this change… A challenge
to senior leaders in academia is to listen carefully to new ideas
brought forth by younger faculty and others …”
“ A key issue
for leaders is to retool to a mode of working to manage the “rate
of change” to help make it tolerable and to have an awareness
of the need for managing change over time as compared to a thinking
of it as managing a single change and then we are done…”
“ We are now
moving into an era of real accountability and having meaningful
monetary impact through their effective use. This has only come
about because of a greater understanding of, and focus on, EBM.
This area is another in which I think it’s important to
see a vision, keep the faith and continue to work in this area
presuming that eventually all will have this view of the importance
of valid science and its appropriate application. Again, I think
it is important to think of science as one contributing factor
to healthcare decision-making along with a host of other considerations…”
“ We are now
moving to an era much more typical of ‘farming,’ where
data, generated as a by-product of care delivery, will be abundant
— perhaps overwhelmingly so — and potentially widely
accessible. Harvesting knowledge in this new context will require
no less of a transformation in infrastructure, roles and ‘rules’
than it took for hunters to adapt to the plow…. If we are
successful in doing this type of by-product-knowledge, it can
complement and substantially extend the data generated from well-done
“ Our approach
to learning and knowledge-generation has been an elite and separate
process parallel to mainstream delivery of care and also quite
distant and opaque to the key object of that care — the
patient…. It’s important to step back and really listen
to the patient….to involve consumers to look at things through
a different lens. It’s...about reconciling points of view…”
Interview with David L Clark, RPh,
MBA, Senior Vice President Health Care Services, Regence
DO EVIDENCE AND OUTCOMES FIT IN HEALTH CARE DELIVERY?
have seen that motivated health care practitioners can really
make a difference in the delivery of care and improving outcomes
for individuals and populations.…”
“ … Evidence
should only be counted if it has passed a critical appraisal.…”
“ … Quality
evidence can tell us what the outcome can be, and what it takes
to achieve that outcome.… studies need to be well-designed
and carried out to provide the evidence…The evidence should
then be critically appraised, and the results of valid and clinically
useful studies made available, quickly, to those make treatment
decisions, or to the individuals that may have those treatments…
Then focus on actually improving care and outcomes. It does not
matter how many individually are started on appropriate therapies
unless those treatments are completed and a successful outcome
Interview with Michael E. Stuart, MD
President & Medical Director, Delfini Group
NEED FOR CRITICAL APPRAISAL SKILLS FOR ALL...ESPECIALLY FOR MEDICAL
“ Leaders universally
need to take critical appraisal seriously and act on it locally…
Teachers need to understand these principles and apply them in
ways ranging from just-in-time with patients at point-of-care
to participating in evidence evaluation and teaching activities…”
“I want change
in which 1) quality research is performed and reported well enough
to evaluate its validity and usefulness, 2) health care professionals
can tell the difference between the good and the bad to know what
is valid and clinically useful and what is not, and 3) patients
are provided with clinically useful information that helps them
make decisions based on their own values and preferences…”
Full Interview »
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to be considered for an interview, please
email your answers to our questions here
or contact us at delfini (at)
04/01/2009: Interview with Sheri Ann Strite
Principal & Managing Partner, Delfini Group
VALUE OF CLINICAL PHARMACISTS IN EVIDENCE-BASED PRACTICE
are in crisis. And almost know one knows this. Most research is
unreliable irrespective of source. Most health care professionals
do not know this nor do they have skills to evaluate the medical
literature. This includes faculty, researchers, editors and peer-reviewers.
Bias tends to inflate results up to a relative 50 percent. I believe
clinical pharmacists can be an effective solution to this critical
information problem that harms patients and causes waste …”
Full Interview »
If you'd like
to be considered for an interview, please
email your answers to our questions here
or contact us at delfini (at)
go to delfini.org
interviewees by last name
Karen: Kaiser Permanente
The Pharmacy & Therapeutics Society
- Gabica, Martin: Healthwise
Mark: Virginia Tech Carilion
Ward: State of Alaska
Joe: Salem Hospital
- Shunatona, Bat: OMNI Medical Group & St. John Medical Center
Paul: Kaiser Permanente
Young, Tim: OMNI Medical Group & St Johns Health System