ACP: Practice transformation is more than checking off boxes

A guest column by the American College of Physicians, exclusive to KevinMD.com.

Recently, I was invited to speak at an ACP chapter meeting on the topic of shared vision. In the talk, I used as examples Dr. Martin Luther King Jr., John F. Kennedy, and Steve Jobs, leaders whose visions inspired people and helped them to achieve great things. As I wrote the talk, it occurred to me that developing a shared vision is as important in a medical practice as it is in an industry or an entire country. Across the United States, medical practices are changing the way that they deliver care. Whether those changes are as big as adoption of electronic health records or becoming a patient-centered medical home, or as small as introducing a few new ways of doing things, physician-leaders need to engage and mobilize the members of their teams just as history’s great leaders did.

A common mistake that practice leaders make is that instead of developing a shared vision for the team, they implement policies and procedures without providing a context for them. New tasks are introduced because “we have to do it for” NCQA recognition, HITECH, or HIPAA, not because they improve quality of care, patient satisfaction, or safety. Physicians who practice in some large organizations will recognize this error, since they are often at the receiving end of this excessive focus on process instead of desired outcomes. The less-than-perfect implementation of performance measures, patient satisfaction surveys, and practice guidelines are examples.

Like most of you, I am frequently annoyed by the “concrete thinkers” who worry more about metrics than meaningful outcomes. However, in our roles as team leaders, we are also at risk for thinking the same way and losing the buy in of our medical assistants, receptionists, and nurses when we forget the higher purpose of the changes that we make in our practices or fail to articulate them effectively to our staff.

We can avoid these pitfalls by first making sure that we understand what we are doing and why we are doing it. If we believe that it’s all about checking off boxes and documenting events in order to get paid more, then it is unlikely that we will give our team members the sense of higher purpose that they need to be as successful as possible. Once we have a vision of where we want our practices to go, then we can share that vision with our staff members and move on to other important questions, such as how are we going to get there, how will we know that we succeeded, who will do what, and what will it take for us to get there.

The “Joint Principles” of the Patient-Centered Medical Home, developed several years ago by ACP, AAFP, AAP, and AOA can serve as a vision for what we would like our practices to become. The Joint Principles are a framework that physician leaders can utilize to educate and inspire their team members as they transform their practices. Once we define the guiding principles and goals of the transformation of our practices, we should frame the components of practice transformation in the context of that vision.

That means teaching our medical assistants that medication reconciliation is not all about the NCQA, but it is a way to prevent adverse drug reactions. Fall risk assessments help patients to avoid falls, and do not exist simply to satisfy meaningful use requirements. We track tests and referrals to make sure that our patients follow through with our recommendations, not because we get credit from an insurer for doing so. And so on. The goal of practice transformation is not to go through the motions, but to take better care of patients and achieve the goals defined in the Joint Principles.

This process of educating, communicating, engaging, enlisting, and inspiring is not a one-time event. It is important to reinforce these concepts as often as possible, whether it is at staff meetings, or one-on-one when working with your medical assistant, receptionist, nurse, or even other physicians. While there is a role for extrinsic rewards from meeting targets, improving scores, achieving PCMH recognition, or earning financial incentives, we should not forget the power of the intrinsic rewards that come from achieving a shared vision.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • southerndoc1

    If we pay doctors based on how many boxes they’ve correctly check, we create doctors who see it as their professional goal to develop their box-checking skills to the maximum. If, on the other hand, we want doctors who sit quietly, look their patients in the eye, listen empathetically, and offer their considered medical opinion on the various options the patient faces, we would change course and pay for that.
    I’ve never seen the ACP offer meaningful opposition to any new box-checking task being forced on physicians.

  • southerndoc1

    Would add that it is those doctors who have most clearly developed their vision of what health care can be, who are most acutely aware that box-checking is inimical to making that vision a reality (see Dr. Rob Lamberts).

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