Clinician Wellbeing, Efficiency of Practice, Ambulatory Optimization and the Be Wise Approach

Stewart Babbott, MD a UVA Professor in the Department of Medicine researches and writes on clinician well-being.  He is one of the authors in a recent article on physician wellbeing (New England Journal of Medicine on-line journal, Catalyst: April 2017). http://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/

We met with Dr. Babbott recently to ask him more about this:

CMO:  “Your group describes a model which promotes professional fulfillment, addressing stress and promoting wellness. Can you tell us about this?”

SB:  “This model was initially developed by colleagues from Stanford University. There are three domains: efficiency of practice, a culture of wellness, and personal resilience. Each domain has equal weight, as do the interactions and reciprocity between them. Professional fulfillment is at the center of the model. While professional fulfillment is important for all members of the health care team, this work focuses on the physician.

The Stanford model highlights the relative importance and interaction of our clinical practice efficiency, cultures of wellness in our local and institution-wide systems of care and personal resilience. Similarly, adoption of this model offers a broader, balanced view of factors integral to sustainable and successful health systems, and a framework with which to address our common issues and goals.”  

Here is the model:

Professional Fulfillment circle graphic  

The Stanford model reinforces what we have begun at UVA with Be Wise. Similar to the Stanford model, Be Wise has a three pronged approach:
  1. addressing unnecessary stressors in the work environment,
  2. helping team members recognize stress and stress injury and respond effectively, and
  3. enhancing individual and unit-level resilience.

BeWise Approach Graphic

 
So, the approach that we are taking at UVA is congruent with the Stanford approach, and with the growing body of evidence that suggests that this combination of dealing with organizational or systems factors that increase stress unnecessarily, enhancing individual resilience factors, and fostering a culture that is compassionate and respectful of our caregivers.

CMO:  “Optimization of the ambulatory work environment is a priority for fiscal year 2018.  Tell us more about efficiency of practice as a part of the role of the institution.”

SB:  “The ambulatory optimization programs are welcomed and are a good example of the reciprocity and balanced approach of the model.

Efficiency of practice in this model is defined as the value-added clinical work accomplished divided by time and energy spent. One way to tell how things are going is to do a simple equation of expected versus actual – the amount of time needed to do something versus the actual time afforded. Factors that contribute to physicians’ efficiency of practice include workplace systems, processes and practices that help physicians and their teams to provide compassionate, evidence-based care for their patients.  Excessive time pressures and chaotic work environments impair patient care.

The envisioned practice assessments, team approaches and system improvements all contribute to efficiency of practice directly and support a culture of wellness. Similarly, these efforts can decrease physician stress, enhance joy in practice, contribute to positive learning and care environments, and support recruitment and retention of physicians at UVA.

CMO: “What are some of the strategies your group write about that lead to efficiency of practice?”

SB: “There are a number of things that can help to optimize high quality care:  Re-engineering and continuously improving care processes and clinical work flows, optimizing EMRs, providing adequate staffing in both numbers and levels of training (allowing everyone to work at the top of their license & spend more time doing work for which they are uniquely trained), mitigating regulatory and documentation burdens and maximizing user-friendly decision support and facilitating reliable care coordination.

 I suggest considering elements for success in clinical practice to include 5 ‘T’s’: Time for direct and related care, Team composition and function, Technology including EMR tools and training, Top of the License roles for all team members & Temperament for resilience, change and engagement with all stakeholders. These elements can be addressed individually and collectively as the ambulatory optimization project proceeds.

 CMO: Thank you for describing this model. Our ambulatory optimization plans are moving forward, and you’ll be hearing more about this in the coming months.

 * Burnout is defined as a triad of emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment which impacts optimal care.

Reference:  Bohman B, Dyrbye L, Sinsky CA, Linzer M, Olson K, Babbott S, Murphy ML, Purpur deVries P, Hamidi MS, Trockel M. Physician Well-Being: The Reciprocity of Practical Efficiency, Culture of Wellness and Personal Resilience. In New England Journal of Medicine, Catalyst.  April 2017.

-cg.

Click to view Positive Comments from January 1 2017 to September 1 2017

Epic Training is Happening Now

Dear Colleagues,

Epic Training is Happening Now

When you think of Epic Phase 2, are you wondering:

  • Will I be impacted?
  • What’s changing as a result of Epic Phase 2?
  • Can I earn continuing education credits by attending Epic training?

Here are the answers:

Online Epic training for all care providers will be available beginning June 1st in NetLearning and are due for completion by June 30. This series of brief, computer-based learnings (CBLs) and Tip Sheets explains the workflow changes happening in areas such as: Lab, Revenue Cycle, Home Health, MyChart, Patient Movement, Surgery and Anesthesiology and Phase of Care orders. Complete the CBLs when it’s convenient for your schedule! Click the link above for details.

In addition, in-depth Epic classroom instruction is available for specific providers in the areas of: Surgery, Procedural, Anesthesiology and Pathology. Click the link above for details.

Classes are available now and are due for completion by June 26. Read the UVA Connect article for more information about how to earn continuing education credits for attending Epic training.

The Training Hotline is available to assist with registration by calling (434) 297-5200 between 8 a.m. to 5 p.m. (Monday – Friday) or by sending an email to the Training Helpdesk.

Visit the For Physicians page of the Epic Phase 2 Project website for updates, links to the physician course catalog, training schedule and more.

Relationships: Interactions Lead to Better Outcomes

Health care is provided through relationships—one on one interactions between the caregiver and the patient. Our nursing colleagues are focusing on evidence based practices that are known to improve the patient experience—Leader Rounding with Patients & Families, Comfort Rounds, Handover of Care using White Boards, and Quiet at Night.

An optimal patient experience can lead to better clinical outcomes.  Here are some tips from our Bush Bell and our Patient Experience team on things we can all do to improve patient experience in the inpatient setting.

  1. When speaking with patients, sit down, make eye contact, and lean in, even if only for 1 minute.  Use the folding chair found in every inpatient room.
  2. Use compassionate touch to connect. Shake hands, touch their shoulder or hand when interacting with patients and their family members.
  3. Introduce yourself every day, explain your role and how you fit in to the team.
  4. Explain their care plan using non-medical and non-jargon language.
  5. Put your name and what will happen today on the whiteboard in your patient’s room.
  6. Ask open ended questions vs. Yes/No questions.
  7. Ensure your patient has an adequate pain management plan and make timely adjustments based on feedback.
  8. Give patients more control by offering choices no matter how simple or small (eg. Does patient want door open or closed when you leave room?)
  9. Share the plan of care with nurses and other members of the care team.
  10. During unit quiet period 2200-0500 daily, check with patient’s RN to cluster care to allow for our patients to sleep and rest.

-cg

Did you ever wonder why the residents order so many labs?

In a 2016 article in the Journal of Hospital Medicine, Sedrak et al. explore why residents order unnecessary labs in inpatient settings. The study is below. We would love to know your thoughts. Tell us what you and your teams think and what changes we could make here at UVA.

The article is in a PDF format here:

Residents’ Self Report on Why They Order Perceived Unnecessary Inpatient Lab Tests – Sedrack et al. J of Hospital Medicine 2016

Take care

– cg

 

 

 

Welcome the Transitionalists – the newest team on the block!

In keeping with the fourfold goals of: improving quality of care,  identifying factors leading to readmission, preventing unnecessary readmissions and improving patient satisfaction, the University of Virginia is piloting a program in partnership with Charlottesville Pointe (a skilled nursing facility).

Known as the Transitional Care Unit or TCU program, Vishal Jain, a physician on the vanguard of this program notes:

“Our team includes a Hospitalist and a Nurse Practitioner who see the patients when they are admitted to Charlottesville Pointe. The team gets notified a day or two prior to the discharge from the hospital and then gets notified again once the patient arrives at Charlottesville Pointe. Provider team (MD/NP) round 3 times/week, spending about 1-2 hours each visit. Greater attention is paid to the discharge diagnoses, medications (and need for reconciliation thereof), Durable Medical Equipment (DME) needs, follow up testing and appointments with the specialists. All the care elements are coordinated with the primary attending of record in the facility. The expected length of stay for a patient in the TCU is about 4-6 days. We are attempting to develop a robust ancillary testing such as 4 hours turn-around time, 24 hours per day, 7 days per week for lab and imaging studies. As the program gets stronger, we would expect the facility to stock larger supply of emergency medications, including some IV meds, antibiotics, pain meds, and also have 24 hour/day capacity to administer the medications.  Overall, the goal is to provide a rigorous inter-disciplinary care to the patient in the most vulnerable period- transition from acute care to a post-acute care facility.”

Dr. Jain notes: “We are all very excited about the transitional care program.  Health reform measures are leading hospitals to focus more and more on the space beyond the physical hospital facility into post-acute and preventive areas. Several studies suggest that nearly 1 in 4 Medicare beneficiaries are readmitted to the hospital within 30 days of discharge (and the number is higher for patients diagnosed with Congestive Heart Failure).  This is not only financially discouraging but also takes a huge toll on patient’s condition and satisfaction with the healthcare system. For SNFs and other post-acute care facilities, there’s a growing recognition that they need help in managing the increasingly complex patients coming through their doors. Partnering with post-acute care providers to ensure patients continue to recover post-discharge presents a significant opportunity to improve patients’ health and reduce readmissions.”

Beyond offering more seamless transitions, this new group of practitioners also provides personalized care and a sense of continuity. This can be very reassuring for our patients and those who are caring for them.

So, welcome the transitionalists!

-cg

Positive Comments May 1 to December 1, 2016

Positive Comments from our patient satisfaction surveys can be viewed by clicking the link.

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The Impact of Bundled Payments

After seeing this headline in the news: “CMS Announces Bundled Payments for Joint Replacement Surgery”,  my neighbor told me that he was going to need to hurry to have his new knee replacement done now that outpatient rehab was being phased out under Medicare.  I reassured him that outpatient rehab was not going away.  I explained that there were simply changes in the payment model.

CMS began with the Comprehensive Care for Joint Replacement Model.  Historically, hip and knee replacements have been among the most common surgeries for patients with Medicare. These surgeries require “lengthy recovery and rehabilitation periods” and have had a wide range of clinical practice patterns with variable cost and outcomes. (innovation.cms.gov/initiatives)  In response, CMS established a bundled reimbursement model for these total joint replacements.  Of note, UVA is not presently affected by this CMS initiative yet.

Finding the model to be successful within orthopedics so far, the Centers for Medicare & Medicaid Services (CMS) recently announced plans to bundle payments for all care associated with cardiac bypass surgery and heart attacks. This is in addition to an expansion of current bundled payments for total hip and knee replacements.  CMS notes: “Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings” (CMS. gov).

Bundled payments will cover providers and the facilities from admission through 90 days of post-acute/rehab care.  (This is compared to a fee-for-service model, where physician fees and facilities charges are paid for separately.)

According to Dr. James Browne, UVA’s “Guru of Orthopedic Bundle Payments”: “Episode based bundled payment models present opportunities as well as challenges. These models can align incentives around the common goal of coordinating care and improving quality and cost-efficiency.  However, without satisfactory risk adjustment, bundled payment programs can penalize tertiary care centers like UVA that treat more complex patients. The general consensus is that bundled payments are here to stay, so we are working proactively to understand how we can be successful under this new paradigm.”

Dr. Browne refers to an image from the Wall Street Journal below.

WSJ viz

Philosophically, bundle payments uses an approach that minimizes variability and drives quality improvement while lowering the cost of care.  It also fits into the service-line model that UVA is adopting.

For an academic center,  this will requires both supervision and early escalation of issues identified by staff and trainees to ensure safe and efficient care.

That’s where we are now.

 

-cg

 

Thanks to Posy Marzani and Jack Jackson for their help with this blog.

 

Service Lines: Putting Patients at the Center of Their Care

Nationally, we are observing that many major medical centers are using service lines to manage their clinical operations.   The American Association of Medical College’s Advisory Panel on Health Care has recommended service lines as a best practice for providing “integrated, high quality, patient centered care with efficiencies gained from reducing/duplicative administrative cost and from centralizing support functions”. 1

The patient is at the center of the story and the service line is the path in which they will travel.

Our Cancer Center already operates in the management model of a service line. When a patient is referred for a suspicious mammogram, for example, multiple distinct disciplines engage with each other to coordinate her care – from radiology and pathology to surgical and radiation oncology. LIPs from different disciplines are involved. Because of geographic proximity, interdisciplinary discussions ensue for a plan of care.  Of course, there are many others who may be involved in this patient’s care – respiratory therapists, physical therapists, occupational therapists, nutrition services, etc.   This happens at the Emily Couric Cancer Center, although there might be an admission to the 8th floor for concerns or complications as they arise.

These providers, all who work with cancer patients, may have more in common with each other than with members within their own Departments.  This is the premise of the service line – to link groups which are connected by the patient or disease, and their spaces, to each other.  The providers in the Cancer Center know each other, and use protocols and best practices to inform decision making. They share resources, and harness each other’s ideas to grow.  They belong to departments, but work within a service line.

SL

We envision eleven services lines at the University of Virginia with some support lines (such as Radiology, Laboratory Medicine and Pathology).  Each service line will have a lead physician (or 2 physicians co-leading) and an administrative lead from the Medical Center (a manager or a director).   These leads will be dyads (physician/administrator) with collaborative decision making (resource allocation, sharing and growth).

You might ask yourself how this might impact you.  For some of you, it will feel no different.  You will still be in a School of Medicine Department, and you will report to a Chair.  You may already be in a service line.  For others, you will remain in your Department, but your Department will now work with one or a number of service lines (for example, you work exclusively with one population – such as neuro-oncologists do). However, for everyone, there will be more resources to share and an ability to grow.

We are really looking forward to building up these service line teams and to focusing all of our resources on patient centered care. – cg

  1. Enders T, Conroy J. Advancing the Academic Health System for the Future. A Report from the AAMC Advisory Panel on Health Care. American Association of Medical Colleges. Available at www.aamc.org/download/370550/data/advancing.pdf

(Thanks to Posy Marzani and Jack Jackson for their help with this blog).

Becoming Our Patient’s “Pharmacy Home”

We’ve had a lot of interest in our most recent blog post and wanted to share some additional thoughts from the Director of Pharmacy, Rafael Saenz.

One writer acknowledged that this change is impressive and represents great progress, but wondered aloud how we are going to compete with the CVS across the street (and their other stores), noting that although they are the most expensive pharmacy in town, they give great service and are convenient for our faculty and staff?

In response, Rafael notes:  “I can appreciate this perspective and can authentically say that it is the core reason why we needed to do a better job for our patients”.  He provides additional updates to help reshape this perspective:

Increased convenience while you work:

  • A new UTEAM Connection window for employees and their families for faster turn-around and less wait time.
  • The meds-to-beds program is designed to reduce nursing and patient time traveling to our pharmacy. Meds will be brought to the bedside for patients who are being discharged. And soon, patients receiving infusions at the Couric Cancer Center will be able to fill their prescriptions from their infusion chair.
  • An upgrade to the fulfilment system and our clinical staff functions. We are completely integrated with the IP and Ambulatory EMR.
  • UVA clinical pharmacists are trained to provide patients with the safest and most comprehensive clinical care in the Commonwealth.
  • You can get most of your vaccinations from our pharmacists.

Benefits for all patients, regardless of their ability to pay:

  • Our indigent care services are comprehensive.
  • We assist patients in receiving their meds free from the manufacturer and walk them through logistics of subsidy programs.
  • We cover those who have been rejected by other pharmacies.

Savings for patients:

  • In many cases, UVA Pharmacies provide patients, with drugs at a cheaper price point.
  • We’ve been able to do this while maintaining a healthy bottom line.

Access through a mail delivery process:

  • Meds can be delivered any prescription straight to a patient’s home at their request.
  • No need to even come to our pharmacy.

He adds:  There are many more changes that we have embarked on in the past 3 years. These are just some highlights. We welcome the opportunity to earn everyone’s business. We not only want to be the pharmacy services provider of choice for our patients, but strive to be all of our patients’ “Pharmacy Home.” I know it will be difficult to regain lost business after years of perceived poor service, but we are truly making an effort to rebrand, re-image and become the best pharmacy possible.

I’d be happy to take any questions or address any comments in person if desired.

Professionally,
Rafael

Rafael Saenz, PharmD, MS, FASHP
Administrator, Pharmacy Services

Barringer Pharmacy: Past, Present and Future

Change is Good

Before our eyes, an amazing transformation has occurred in our outpatient pharmacies within 2 years.

Item In 2014 In 2016
Average Wait Times 50 mins or more Less than 16 mins
Percentage of calls answered (300-400/day) 40%  answered daily 90% answered daily
Hours open M-F 8 hours (8:30-5:30), Sat/Sun for discharge pts only M-F 12 hrs (8 am-9pm), 7:30-3 pm Sat/Sun
E-prescriptions & preparing meds in advance Not ready for pick up, prepared when patient presented to the pharmacy Ready for pick up, prepared in advance
Waiting Room Waiting room full, patients frustrated and waiting around Waiting room near empty – pts sometimes think that the pharmacy is closed! (it’s not…)
Other No time to talk Individualized time for quality patient education

 

And, all this while filling more prescriptions daily…

What changed?

  • A new Call Center –  staffed by 4 technicians – to answer phones and to and move prescription requests further “downstream” so that a higher percentage are ready to pick up when the patient arrives.
  • Effective e-prescribing and new communication between electronic pharmacy component (known as Willow) and rest of EPIC – allows for triage – now correct work is in front of correct team member.
  • Increased hours with better access.

And, there are new services which have come on-line, including:

  1. Discharge Delivery:  The pharmacy has successfully implemented a pilot program which provides delivery of discharge medications (bedside delivery) to an inpatient unit with plans to expand.
  2. Specialty Pharmacy Services: This area is the highest area of growth in the industry, and UVA is expanding quickly. The Hepatitis C program alone has resulted in the successful treatment of more than 500 patients.
  3. High Alert Medication Counseling: Pharmacists now provide comprehensive counseling for anticoagulants, inhalers and insulins.  More than 500 education sessions have been provided.
  4. Immunizations: Out-Patient pharmacists provided 1,800 immunizations to patients, family members and employees last year.
  5. Be Well Program: Employees enrolled in the program get a personal call from one of our pharmacists who performs a complete medication reconciliation and assists with cost and adherence issues.  More than 400 consultations have occurred, and 80% had discrepancies in the EMR that were addressed by our team.

What can you expect to see in the future?

  • Relocation: Barringer will move in early 2017 to the first floor of the Educational Resource Center building (photo below) located across from the University Hospital and become UVA Pharmacy. This central location will further allow us to improve efficiency, increase access to a pharmacist, and increase convenience for patients and team members.
  • 24 hour/ 7 days access: By January 2017, we will be the only pharmacy within 50 miles that a patient can access 24 hours daily.
  • Discharge Delivery:  Expansion to one new unit is scheduled for June 2016, with a goal of providing bedside delivery to the entire Medical Center in the near future.
  • Over the counter medications  – ERC pharmacy will have an expanded OTC selection available for patients.

Our pharmacy colleagues deserve a huge round of applause!  A comprehensive, multi-phase plan was designed, and through creative solutions, thoughtful and targeted allocation of resources and team-wide dedication to providing superlative patient care.  Barringer Pharmacy is becoming a model of pharmacy services.  They encourage you to give them a try and note; “If you haven’t come to see the new UVA Pharmacy Experience, give us a chance to exceed your and your patients’ expectations.”

–cg

pharmacy pic

(Thanks to Rafael Saenz, Michael Palkimas, Justin Vesser, Posy Marzani and Jack Jackson for helping me with the blog.)