Recently, the Pacific Business Group on Health (PBGH), L.A. Care Health Plan, and the Southwest Pediatric Practice Transformation Network (a partnership of CHOC Children’s Hospital and Rady Children’s Hospital) came together to announce some incredible news and set the table for the future. With support from CMMI, over the course of the last four years, our organizations collaborated on a major quality improvement program for both primary and specialty care. This combined effort averted over $345 million in medical costs by avoiding 67,000 emergency department visits and 59,000 hospitalizations, while improving objective clinical outcomes. We worked with 9,800 California physicians and touched the lives of 5.9 million patients, making this one of the largest quality improvement effort ever undertaken in California.
These results are nothing short of remarkable. But they are also the kind of headline-grabbing results that strike many physicians working on the frontlines of medicine as “pie in the sky.” Quality improvement work is onerous, and it can be expensive. Often, it doesn’t strike smaller practices as affordable, doable, or even realistic. But it doesn’t have to be that way.
The other “triple aim”
When I talk to frontline physicians working outside of large, well-resourced systems, I often engage them with the following mantra: You have your own “triple aim.” You want to provide the highest quality care, while earning a living, and trying to have some semblance of work-life balance. So how can this type of engagement make this happen? If you work outside of the well-organized systems, it is overwhelming trying to figure out these new-fangled payment arrangements while you’re trying to figure out when you will next be on call and when you will have time to hire that much needed new receptionist. But even juggling the day-to-day running of a practice, you can still change the way you deliver care, and the results will not only help you reach the IHI Triple Aim but also your personal “triple aim.”
Take a step back
Often, the first step to practice improvement is to just find the time to take a step back and ask, “Who in my office is doing what?” The literature supports the fact that early half of the work performed by frontline physicians can be performed by someone else on the care team, and the data shows this approach is not only efficient and cost-effective, but also leads to improved quality outcomes. For example, who on your team calls patients back to inform them about the results of their lab work? If lab results or x-rays come back normal, trained care team staff can be the ones making these phone calls. Patients will welcome this as long as they are familiar with the team. Any practice can start small, with a pilot to test one or two small changes that can make a big difference in clinical outcomes and/or office efficiency. Changing something as simple as who makes these phone calls can save you time and money while actually improving patient satisfaction as well.
Know your resources
In some ways it was easy for our organizations to work with CMMI on wide-scale quality improvement efforts – we were recipients of this large CMMI Award, and we had high-level leadership engagement in the process of transformation. For smaller scale improvement efforts, something as simple as the websites for the American Academy of Family Physicians or the American Academy of Pediatrics can be a wonderful resource. NCQA also has some excellent resources about how to you can focus on practice changes that help support a patient-centered medical home. Check out NCQA.org for more information. One need not go through the recognition process to achieve “quick wins” in the office setting.
Relationships, relationships, relationships
To truly improve the way you practice medicine, it is hard to operate in a bubble. To achieve more widespread, systematic changes, you have to partner with people and organizations beyond your office walls. This requires the delicate work of building relationships and establishing trust. When I talk to smaller practices I also give this advice: find an aggregator. For example, for pediatricians, your local American Academy of Pediatrics Chapter can be a great place to begin these relationships. IPA’s can also help you meet like-minded people in your area.
In a state like California, value-based payment isn’t foreign to many providers who largely practice in a capitated environment. Nonetheless, the value-based payment changes coming to Medicare and Medicaid are very foreign to many of us — especially pediatricians. We have to get used to practicing medicine in a world where greater efficiency is a requirement.
If we focus on starting small, using the resources available to us, and growing our relationships, we find just about any practice can improve their efficiency and quality. And the results are great for everyone’s triple aim.
Michael A. Weiss is vice-president of population health, CHOC Children’s, Orange, CA.
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