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Four Habits You Might Want to Develop

Earlier this month, the New England Journal of Medicine (NEJM) published a Perspective article by Richard Bohmer entitled, “The Four Habits of High-Value Health Care Organizations.” The full text is available online.

The premise is that while successful organizations may vary in structure, resources, and culture, there are key similarities in approaches to care management. Though the article pertains more to large institutions, the four habits identified are likely to be helpful to even the smallest of practices:

  1. Specification & Planning
  2. Infrastructure Design with a Focus on Microsystems (see Dartmouth microsystem academy)
  3. Measurement & Oversight
  4. Self-Study

How can you apply these habits to small practices implementing/optimizing health IT? For specification/planning, does your practice incorporate standardized workflow processes including intake of patients by staff, algorithm-based screening, and order sets for common clinical situations? How about use of clinical decision support? Standard referral processes and policies regarding information sharing for transitions in care? Does your practice analyze the patient population served to identify groups who might benefit from standard interventions (i.e. vaccinations) or management (i.e. depression screening)?

What about infrastructure design? Does your office make sure that staff are practicing to the highest level of their license, skill, and knowledge (including the clinicians)? Do you ensure that all of the necessary supplies, equipment, and technology are readily available when needed? Does the leadership of the practice set overall objectives (clinical and operational) and then plan accordingly to make certain that there is alignment across the practice, that staff are advised and trained to help achieve those goals, and that the office budget reflects these priorities?

Bohmer points out that measurement and oversight is often driven by external factors and organizations. However, high-value practices use measurement to support internal evaluation of processes and performance management according to the goals set by the team. In many cases, these metrics go well beyond those required for external entities — and since they are aligned with the goals/objectives of the practice, they are often (and should be) more meaningful.

Finally, if a practice doesn’t engage in self-study how can it be sure that the processes set in place are achieving the ends desired? For example, if evaluate of adherence to a condition-focused practice guideline demonstrates that Physician A is doing better than Physician B, the team should determine why the difference exists to help the entire practice deliver higher quality, more cost-efficient and patient-centered care.

Be sure to read the article for more details and add your comments below.

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.


2 responses to "Four Habits You Might Want to Develop"
  • December 28, 2011
    Arvind Cavale

    These four ideas seem self-evident. However, real life usually gets in the way, especially in small practices. First, it is almost impossible to get staff with an appropriate mindset (whether MA/PA/NP/Physician). Second, algorithm-based approaches are truly applicable to very few processes. Third,physicians are seldom adequately trained or experienced in objective measurement methods, and hiring professionals is just too expensive (without our ability to pass on such costs to our customers-patients/payers). Fourth, what is the financial value of all these efforts to a small practice, since there is no recognition of such efforts? A higher performing small, independent practice generally receives a lower reimbursement rate than a poorer performing university-based practice (mainly based on ability to negotiate based on size).

    So, none of these efforts are worth talking about until there is a true free-market business model for medical practice. Any takers?

  • January 12, 2012
    Carol Stryker

    I feel a bit like Daniel heading into the lion’s den, but couldn’t resist. First, there are numerous reasons staff lack an appropriate mindset. The most common one is that the physician has not clearly communicated expectations, modeled the desired mindset, and held staff accountable. Second, algorithms can be appropriate to anything, simple tasks with little or no variability (taking a message or rooming a patient) and complex tasks if there are avenues for exception handling built in. Algorithms save a tremendous amount of time and avoid errors by not requiring everything to be figured out again at every iteration. Third, physicians are seldom adequately trained or experienced in objective measurement methods. That’s why they need professionals. Focus on expense is short-sighted. What is the net value, e.g, the benefits gained from the expenditures? Fourth, the financial values can be huge. If a practice’s operating costs can be reduced by 20-35%, which is typical because the physicians haven’t invested in effective process design, those savings in real dollars drop straight to the bottom line: more income. The idea is to run the business more effectively. That increases capacity, reduces costs and mitigates risk. Each has significant impacts on finances, independent of reimbursement schedules.
    Carol Stryker, Symbiotic Solutions, Houston, TX

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