I believe that better care that is economically sustainable and available to everyone while producing healthier communities without unacceptable personal sacrifices from individual health professionals is only possible in a professional environment and culture that respects the contributions of all health professionals. When I use the phrase “I to we” I am talking about everyone who is employed in healthcare from the staff that parks cars and cleans the building to the most senior physicians and managers. The optimal use of resources and the best patient and provider experiences require harmony, cooperation and respect across the entire team. The best systems of care are not physician centric. Team performance, not individual performance, is leveraged to efficiently achieve the objectives of the Triple Aim.
When I was employed by an organization that liked to say that it was “physician led” I would tie myself into verbal knots trying to walk the line between promoting harmony and reminding physicians that it was not “all about them.” I believe that one of the greatest challenges to be overcome in the search for the Triple Aim is the redefinition of the role of physicians in the process of care in an environment that needs to have everyone “working at the top of their license” to make their best contributions to the care of the patient. In the posting last week I continued to go light in my treatment of the subject of the harmony and respect that is required from all members of the healthcare team that is foundational to our best efforts. I avoided exploring in detail this most sensitive subject, but Jennifer Gries, a former Atrius manager, called me out in a letter this week which is excerpted below.
Hi Doctor Lindsey,
…Specifically, I wanted to comment to you about [the] key points for a world class health care system. While I heartily support all of the outlined objectives, I was a little disappointed that I did not see more emphasis on collaboration within the entire system of care…
I cannot provide hard evidence, but in my own personal experience the respect that the clinicians showed me when I was a Medical Assistant in Kenmore Pediatrics changed the way we provided care. My dedicated physician treated me like a colleague and like we were a team. It took time to build our relationship, but our mutual trust was evident at every patient interaction.
….respectful and humble inquiry is not commonplace [in the medical workplace] because of fear. Innovating transparency, control and knowledge sharing are based on behavior change as much as process change; change that needs to be embraced by providers as well as by every health care worker at every point in every process. Fear, resentment, ambiguity and a lack of empowerment contribute to the current state. When we emphasize key points for transformation that have no consideration for the multitude of people who provide care for patients outside of providers, we continue to drive inequality and mistrust.
… It is indeed a system that needs input [from everyone] and collaboration to drive higher performance. I suggest we call out more specifically that collaboration is the trust, cooperation and mutual empowerment of every single person who touches a health care process. Not just physicians, not even just professionals (because many may not define themselves as such), but health care employees, workers, contributors and customers…
Jen’s letter put me into a reflective state of mind. “I to we” has been the subject of many of my letters and postings, but I have never had the courage to turn to some of my physician colleagues and say, “We can’t deliver the best care if it’s all about us!”
When I walked through the door for my first day of practice at the old Harvard Community Health Plan (HCHP) I discovered a culture that was egalitarian. The clinicians referred to one another by the non specific term of “provider.” Practices were shared activities between a doctor and a nurse practitioner, coupled with dedicated medical assistants and office support staff. Together the team owned the responsibility to serve our patients. It was a “medical home” with an electronic medical record before the term was in common usage.
I did not know when I was introduced to Barbara Taylor, the nurse practitioner with whom I was paired, how ill prepared for practice I was after my years at Harvard Medical School and my internship, residency and cardiology fellowship at the Brigham. Barbara was very supportive but tough and expected my respect, as she gently altered my worldview and taught me that every person on our team was essential. She demanded a partnership that would be the source of my most important lessons learned in medical practice. Barbara and I “shared” our practice as equals until she died from cancer in 1987. After Barbara died I was at sea until Maxine Stanesa became my partner for the next twenty years until I left the everyday practice of medicine. Maxine is a Physician’s Assistant with great skills in surgery, urology, orthopedics, podiatry and gynecology. Practicing as part of a team was a joy for which I will always be thankful.
What really made the practice at HCHP work were the layers of dyads of clinical and administrative partners that were responsible for the coordination of services between practices, specialties, sites, regions and our various hospital partners. It was all about “I to we.” Initially the system was small scale “Kaiser light.” As it matured it emphasized its own unique innovations and adaptations that were necessary in our environment. The progress was possible because we were focused on continuously improving what we did in a competitive market within the discipline of accountability for the good stewardship of resources that was a natural outcome of capitation.
The realities and discipline of capitation, a mission that makes a difference, and competition all drive the need to continuously improve and innovate. The improvements and innovations required the input and acceptance of everyone in any process that we changed. We frequently said that we were “physician led”, but that was misleading. Progress required the eventual acceptance of change by our physicians, but minus the ideas and energy of the other members of the team there would have been much less accomplished.
In 1975 HCHP was developing an ambulatory model of care that was unusual for its day. We were providing telephone advice after usual office hours, walk in urgent care services until late in the evening, and if needed, access to be seen by a physician twenty four hours a day. We were operating with the objective of reducing unnecessary emergency room visits and hospitalizations in a day when most office based practices would direct patients to the hospital for convenience as well as need. We were a prepaid practice and interested in eliminating wasteful use of resources even before the industry began to talk about being paid for “value.” We did not have Lean, but we intuitively practiced many of the principles that we would later call Lean.
Throughout the eighties HCHP pushed forward against the resistance of a local market that wanted choice as competitors diminished the reputation of “managed care” by denying care or making it difficult to obtain. The goal and ethic of HCHP had always been to provide the right care, the care that was needed, in the right place at the right time.
The nineties were a decade of decline from which we can harvest great learning. By then the original culture had been diluted by substantial expansion driven by employers requesting single source coverage. Traditional insurers could easily expand their networks to cover wide geographies. Our network was both our competitive advantage for quality and cost and our disadvantage in a world that wanted single source coverage with a wide choice of providers over a large area. By the end of the decade the practice found it necessary to exit an exclusive insurance relationship. We began to accept patients from most payers through a variety of contracts including fee for service. The reversal of fortune was accelerated by the financial collapse of Harvard Pilgrim and by January 2000 we were faced with abandoning most of our managed care infrastructure which did not add as much value when the majority of our patients were seeing us through FFS contracts.
Fee for service revenue and practice is antithetical to the environment of respect and collaboration that Jen advocates. In a FFS practice every department and every clinician is rewarded as a function of their earnings from doing “things.” In a churning environment people who once were creating value or were themselves valued for their function in the total process of care often become just an expense to be eliminated to maintain a positive short term financial outcome.
It is a harsh reality that most physicians who have been trained since the mid nineties have only known healthcare in a fee for service environment. Atrius Health was an organizational response for survival in a fee for service world. Several groups with a past history in managed care came together to better leverage their infrastructure expenses and improve their fee for service contracting. By 2006 with the passage of chapter 58 (Romneycare) in Massachusetts it was possible to imagine that things might change again. In 2008 Massachusetts passed chapter 305 which sought to abolish FFS practice in Massachusetts in five years. That did not happen, but since 2008 the strategy of Atrius Health has been to prepare for the ultimate return of value based reimbursement. That return has been dependent on two things.
First, there was the need to have an operating system that would educate and move current staff back toward the general principles of managed care. To move in the right direction we needed to work together and reacquire the means of “managing by processes of care” across a fully engaged and collaborative staff to produce value for our patients, improve the work life of all of our staff, and eliminate waste to lower our cost of care. To accomplish that task we adopted Lean. Lean was a sophisticated codification of many of Dr. Ebert’s thoughts and consistent with our own appreciation of continuous improvement.
Secondly, we realized that we needed to improve the professional satisfaction of all staff but realized that the pressure of “today’s work” and the FFS compensation system had become the equivalent of a self administered drug for our physicians that was a barrier to all the “adaptive change” necessary to “get back to the future.” Our hope was that the respect and collaborative focus of Lean would drive the changes we wanted. Later we realized that the process of change might be accelerated by a “compact” conversation with physicians.
Getting doctors to recognize the need to change both for the benefit of their patients and the community is an enormous and daunting task that is complicated by the fact that each day’s work in the current dysfunctional environment leaves them so exhausted that they have no energy “for improvement.” The other professionals of the organization become anxious that their future is dependent upon physicians who are naturally concerned about their own survival and do not have the energy or insight to recognize that their salvation lies in better systems that they can not create alone but do have the professional leverage to ignore or resist. Jen’s letter nicely articulates the feeling of those who want to get on with the journey to better care and often must do the work without evidence that their physician colleagues “get it.”
Organizations like Atrius and others like Kaiser that influenced the evolution of Atrius are proof that despite the fact that “healthcare is complicated”, it can be better. Competition does drive innovation and I have seen it lower the cost of care as it improved access, quality and the professional experience of every team member.