Navigating to excellence: solutions driving exceptional results.

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AJMXXX10.1177/1062860613511029American Journal of Medical QualityClarke

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Navigating to Excellence: Solutions Driving Exceptional Results

Introduction Steve Miff, PhD, Senior Vice President, Clinical and Care Delivery Solutions, VHA

A Changing Health Care Landscape The rapidly changing health care environment presents health care organizations with new opportunities to advance their organizations and prepare for the demands brought on by new competitive environments and incentives. Health systems are caught balancing the changes that drive 2 contrasting, and at times competing, environments: the current acute-focused care model and the emerging risk-based continuum of care approach. There are several significant and dynamic forces playing out across every market that create challenges for health care executive teams. These forces include the following: •• Pressure on revenue and margins requires health care organizations to work to drive down cost while developing new partnerships and innovative models of care delivery. •• Pressure on hospitals and health care systems to have a more comprehensive, holistic perspective regarding care provision. In particular, “utilization” must evolve as accountability for defined patient populations expands outside the hospital. Building and integrating neighborhood health and virtual visit “sites” will be critical for improving access and engagement. •• Understanding the drivers of consumer behavior and choice will be vital to success. Sophisticated consumer insights research and models are gradually being applied in the health care industry. •• Knowledge gleaned from early adopters of population health management will be essential for organizations seeking to implement new care requirements. •• Big data is becoming a technology burden. Getting to meaningful insights takes time and significant resources and it is becoming an impetus for consolidation and collaboration.

American Journal of Medical Quality 2014, Vol 29(1S) 3S–18S © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613511029 ajmq.sagepub.com

•• Incentives and compensation are changing; health care executive compensation is becoming more performance driven and physician compensation is being redefined. Three fundamental focus platforms are vital for health systems seeking to manage day-to-day operations effectively while planning for future change. First, they must continue to optimize cost and quality in the current model. Second, they must assess, stage, and manage the necessary transformation to deliver integrated care across the continuum. Third, and critical to both previous requirements, they must align and engage physicians to assure the organization’s survival today while navigating the new health care environments. Regardless of where an organization currently stands, the emerging standard calls for increased accountability for managing patient health in a more cost-effective, high-quality manner to create superior value for patients, communities, employers, and payers. There is ample evidence that reducing the wide variation that exists in all aspects of care delivery—physician practice patterns, quality and outcomes, resource utilization, supply choices, processes, and even payment—will result in lower costs and improved quality. Reducing variation in patient care across the system must become a fundamental goal for all organizations. Holistic approaches (rather than narrowly focused efforts) lead to more robust improvements and enable organizations to better identify, quantify, and prioritize performance improvement opportunities and engage with physicians through relevant data-driven research and findings. This comprehensive, integrated method is required in managing the “cause and effect” associated with implementing change. Improving in today’s health care environment is both a journey and a race. It requires insights into national and regional policy, emerging care delivery models, and leading practices, as well as a systematic and integrated Corresponding Author: Janice L. Clarke, RN, BBA, Jefferson School of Population Health, 901 Walnut Street, 10th Floor, Philadelphia, PA 19107. Email: [email protected]

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American Journal of Medical Quality 29(1S)

approach to deploying initiatives and engaging key stakeholders. Among the key actions organizations must take to ensure future success are the following: •• Understand consumer decision making by integrating analysis of consumer insights into the organization’s process and strategic frameworks. •• Evaluate institutional competencies including physician alignment, community infrastructure, postacute infrastructure, behavioral health capabilities, patient access portals, and information integration. •• Cut costs (20%) by reducing variation across the entire patient workflow process to maximize operational, clinical, and financial/supply performance. •• Engage payers and employers by means of a compelling value story. •• Prepare for physician shortages by expanding the roles of other clinicians and ensuring that all clinicians practice at the top of their licenses. •• Develop a 5-year population health strategic plan. •• Analyze the financial impact of new payment models on the organization. •• Build a comprehensive portfolio of services and a local, regional, and national network. •• Implement patient-centered medical neighborhoods and integrate virtual access points. •• Consider new partnerships and networks as a means to grow and accelerate performance.

VHA Inc: An Overview Based in Irving, Texas, VHA Inc, is a national network of not-for-profit health care organizations that work together to drive maximum savings in the supply chain arena, set new levels of clinical performance, and identify and implement best practices to improve operational efficiency and clinical outcomes. Since 1977, VHA has leveraged its expertise in analytics, contracting, consulting, and networks to help member organizations achieve their operational, clinical, and financial objectives. The organization serves more than 1350 hospitals and more than 72 000 non–acute care providers nationwide, coordinating delivery of its programs and services through its 13 regional offices. As the industry transitions toward accountability over the entire continuum of care, clinical outcomes and the supply chain continue to advance as strategic drivers. Integration of all of these into a single platform allows VHA experts and its members’ teams to understand the cause and effect of changes and to pinpoint the most significant opportunities for clinical, financial, and operational improvement.

VHA has been focused on creating a clinically integrated supply chain approach that enables organizations to address variation across the entire organization and ultimately across the continuum of care. Novation, VHA’s supply contracting company, has developed the nation’s largest repository of health care product and pricing information, which powers the industry’s most robust suite of analytical decision-support tools. The organization has integrated its supply chain expertise, with its clinical, financial, and operational capabilities, to leverage and optimize its expertise across the continuum of care.

VHA 2013 Navigating to Excellence Forum VHA’s 2013 Navigating to Excellence Forum for executive, clinical, quality improvement, performance improvement, and pharmacy leaders was held in Las Vegas, Nevada, from April 30 to May 2, 2013. The Forum was organized around the theme of information integration in the emerging health care environment. VHA professionals and industry experts shared insights and leading practices designed to help organizations deploy key initiatives efficiently and to deliver higher quality, lower cost, patient-centric care. Change in the health care industry is occurring at a pace that requires redefining and redesigning our care delivery models. It requires experimentation, learning, and agility to rapidly deploy modified action plans. Doing it alone produces only incremental change. Success is better attained with a holistic, integrated approach to performance improvement and knowledge transfer through collaboration.

Navigating to Excellence: Solutions Driving Exceptional Results Proceedings of the 6th Annual VHA Clinical Conference Transcribed and adapted for publication by Janice L. Clarke, RN, BBA

Panel Discussion—Navigating the Regulatory, Economic, and Consumer Landscape: Health Care Realities of 2013 Moderator: Steve Miff, PhD, Senior Vice President, Clinical and Care Delivery Solutions, VHA Panel: David Cutler, PhD, Otto Eckstein Professor of Applied Economics, Kennedy School of Government, Harvard University; Marianne Udow-Phillips, Director, Center for


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Clarke Healthcare Research and Transformation; Lecturer, University of Michigan School of Public Health; Dan Wolterman, President and CEO, Memorial Hermann Healthcare System, Houston, Texas; Meredith Rosenthal, PhD, Professor of Health Economics and Policy, Harvard University School of Public Health

Responding to a series of questions designed to promote insightful, interactive, and actionable discussion, the expert panelists shared their experiences and perspectives on the complex and rapidly changing health care landscape. The questions and key discussion points are summarized below. What are the least obvious things that can have a significant impact on hospitals in the foreseeable future? 1. Meeting the need for high-quality patient care while managing increasing labor costs. Because 60% of a hospital’s costs are labor related, there will be increasing tension between hospitals and their nursing staffs. For instance, top nurses in Boston, MA, earn $140 000 to $150 000 per year. 2. Coping with increased antitrust scrutiny from the federal government for hospitals and post-acute care systems. 3. Shifting attention to health care at the community health level. The community is fundamental to the success of health reform and there will be growth in safety net organizations and academic– community collaborations. With 30% of Medicaid patients being told by their clinicians that they have depression, mental health funding will increase and capacity will be expanded via telemedicine. A higher priority will be placed on understanding the connections between social determinants and health and how best to get community health workers involved. 4. Moving hospital systems toward a more integrated approach to providing health care services. This will require addressing workforce issues such as the projected shortage of more than 1 million nurses by 2020; caring for individuals who are not covered under the Affordable Care Act’s (ACA) economic model; and breaking down the existing practice silos among physicians, nurses, pharmacists, and other health care professionals. 5. Addressing the need for internal cost controls. Global payment arrangements will generate discussions about waste reduction and the increased risk associated with providing care. With many empty beds today, hospitals will cease to be profit

centers and become cost centers in the new population health model. Physician groups are likely to replace hospitals in the driver’s seat. Dr Cutler commented that because “health care is a quality industry wherein information is important,” there will be greater consolidation. What do you anticipate the biggest surprises and challenges will be in 2013? 2014? Panelists concurred that, despite earlier predictions of its demise, the reforms set in motion by the ACA will survive. The ACA affects multiple sectors differently: for example, seniors—a very vocal group—will continue to spur action from politicians; the employer-based market will not be affected greatly. Although the private insurance market will be “messy,” individual and small market entities appear to be doing better. Markets will vary depending on which states have health insurance exchanges in place. Costs will spike as sicker individuals enter the system and healthier ones pay $95 to opt out. The variation will taper off as fees and taxes increase after 2 years. Most hospitals will continue to grapple with uncertainty regarding funding and financing for the uninsured. By 2016-2017, reduced Medicare services to the poor may lead to closure of inner-city hospitals. The transformation from fee for service to populationdriven health care will require a major overhaul of information technology systems that is likely to take 5 years or more. Currently, we underutilize technology (eg, effective chronic disease management requires more smart technology in the home). Large employers strongly encourage employee wellness via the use of incentives (eg, coupons, decreased health insurance premiums for participating in wellness programs) and restrictions/penalties (eg, smoking regulations, dropping coverage on employees who smoke). Moving forward, wellness program strategies are likely to assume that people will not participate, and punitive fines for noncompliant employees may help fund the wellness programs. Clearly, cutting health benefits would save employers hundreds of millions of dollars. Patient/family engagement is a complex psychological issue, especially when it comes to getting consumers to help reduce waste and control costs. As a country, how do we hold individuals accountable—and how do we embed this in the system? Just as with any other product, the key may be to have providers compete on the basis of cost with more price transparency. Some organizations are aggressively pushing reference pricing and tiered provider networks (eg, top tier providers associated with a lower co-pay). The challenge will be to get better quality information to consumers.


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Getting individuals to care for themselves is the most difficult problem. Government mandates and broad goals discourage people; a small, attainable, stepped approach is preferable. Some intensive programs (eg, health coaches) with the right combination of technology and “touch” are effective, but giving a person $50 to join a gym does not work. Behavioral economics (ie, giving incentives for behavior change) is a hot topic, and studies are under way to determine which interventions are most effective in bringing about and sustaining positive behavior change. Clinicians must begin to talk to patients in terms that patients understand. If we want patients to stay out of the hospital, we need to work on care transitions. Use what we already know about how people learn. Independent physician offices will continue to decline in number. The common problems for these small enterprises are that they try to “do it all” and that they cannot afford to invest in the level of information technology that enables them to track patients and monitor outcomes. For solutions, it will be helpful to step outside of our own industry and learn from others; for example, navigator services derived from concierge services in other industries. Is there a system solution that is both innovative and practical? •• Integrating clinical care within an organization is essential but not without consequences. For example, organizing physicians to develop integrated clinical protocols for maternal/fetal care led to a decrease in preterm births, a 23% decrease in neonatal care, and a 37% decrease in length of stay at one site. Although these outcomes were better for the patients and the health of the community at large, the facility’s maternal/fetal cost center went from most profitable to operating at a loss. We must move away from the fee-for-service model of reimbursement to assure financial solvency for providers who improve care within their facilities. We must encourage community physicians to participate, perhaps by offering incentive payments in exchange for providing specific metrics. •• Implementing Patient-Centered Medical Homes (PCMHs) inside and outside of integrated systems is part of the solution. Licensed practical nurses and medical assistants function as leaders in this team model with a flattened hierarchy. The largest PCMH includes more than 300 practices, each of which has a care coordinator. Results of external evaluations of the PCMH Medicare/Medicaid demonstration project are promising.

•• The Clinical Quality Collaborative Initiative has published and reported on quality measures since 1996. Starting with the angioplasty procedure, the collaborative has targeted a variety of other areas including end-of-life care. Participating providers use data (eg, registries, claims) effectively and confidentially, share data and best practices, and focus on quality improvement. Positive results in terms of quality improvement and cost savings have been documented, and some payers (eg, Blue Cross/Blue Shield) provide reimbursement to participating providers. What is the biggest gap preventing hospitals and providers from operating more effectively? 1. Information technology (IT). Every hospital and health care system must have functional IT designed to capture the flow of resources to patients and the institution. Consider the following example from one facility: after treating a patient for an acute cancer, the oncologist ordered a magnetic resonance image (MRI) before each of the patient’s follow-up visits. When asked why, the oncologist responded, “So that we have something to talk about.” Is it ethically appropriate (ie, safe) to do an MRI every 3 months? By reviewing data collected in a well-designed IT system, it was determined that the tests were safe. 2. Culture change. Broadening the scope of care from a “rescue care” system to a “health care” system will require changing the views of physicians and other health care professionals. Hospitals in particular must learn to work with the full continuum of care and invest in capabilities and analytics that improve their understanding of where cost savings are to be found. 3. Administrative issues. Changing regulations and the payment model from one based on fee for service to one based on global/bundled payments presents an enormous challenge. 4. Malpractice reform. Data do not support the premise that malpractice reform affects health care spending. Current studies show that fewer patients receive monetary awards than are harmed. Improved communication and saying “I’m sorry” has had a huge positive impact. What new leadership skills are needed at the C-Suite level? Leaders must have the ability to work in and with diverse systems. They must understand how hospitals, payers, and employers think. The ability to develop and maintain


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Clarke interrelationships is critical. Leader apprenticeships would be very helpful. On a broad scale, we need to foster “meta-leadership,” wherein leaders from different organizations work across cultures and systems and think beyond traditional titles and roles. What is your single piece of takeaway advice for hospitals and health systems? •• Dr Cutler—Ask, “Suppose revenue increases at the rate of the economy?” •• Ms Udow-Phillips—Hospitals can lead in bringing communities together. Consider what can be done at the community level and lobby for Medicaid expansion. •• Mr Wolterman—Ask, “Is our health care system sustainable in its current form?” If the answer is “No,” leaders must decide on changes that must be made at local levels. •• Dr Rosenthal—Ask, “What are we doing too much of?”

Games as Tools for Improving Heath and Health Care Presented by Jane McGonigal, PhD, Advisor and Affiliate Researcher, Institute for the Future, and author (Reality Is Broken: Why Games Make Us Better and How They Can Change the World).

When asked their top 5 regrets, people interviewed on their deathbeds invariably top their lists with things such as: “I wish I hadn’t worked so hard.” “I wish I had stayed in touch with my friends/family.” “I wish I had done more that made me happy.” Why is it so difficult for people to do what makes them happy? If family and health matter most to people, why is it hard to pay sufficient attention to these things? After sustaining a severe concussion several years ago, Dr McGonigal found the answer. In addition to suffering from vertigo, memory loss, and headaches, she was advised to avoid many of the things that made her happy—reading, writing, alcohol, and caffeine. “No wonder suicidal ideation is common with brain injury!” It was during this experience that she began work on her best known project, SuperBetter. This mobile application (app) and Web-based game is designed to help individuals tackle personal health challenges such as depression, anxiety, chronic pain, and stress reduction—by enlisting support from “allies” such as real-life friends and family. To date, the app has been used by more than 250 000 patients.

In our modern world, a billion people play digital games for at least 1 hour a day. Here in the United States, 99% of boys and 94% of girls younger than age 16 play games for 8 hours per week; even among 2 year olds, 92% play games. The average age of game players is 40—and 1 in 40 game players is age 50 or older. Inevitably, we will all be game players because of the positive emotions they elicit—joy, relief, surprise, pride of mastery, excitement, awe, contentment, creativity (license to experiment). Such positive emotions lead to improved resilience and increased likelihood of reaching out to others. In real life, failure leads to feelings of despondency—in games, a person will fail to win 4 to 5 times without feeling negative emotions. Games help players to become empowered, hopeful individuals who approach obstacles and the need for change as a challenge rather than as a threat.

Health Care Industry Applications As the health care industry became aware of game capability, many skeptics began to take games seriously as a means to empower patients to take better care of themselves. According to Dr McGonigal, a decade of research has yielded some surprising results: •• Games are helpful tools for relationship management. •• Game playing for 30 minutes a day outperforms mood-elevating pharmaceutical agents. •• Individuals who play games featuring avatars become more self-confident. PopCap Games. Anxiety and depression prevent people from making positive health behavior changes; games work on anxiety and depression. A randomized study of 60 subjects who met all of the clinical criteria for depression was conducted at Eastern Carolina University. Findings revealed a statistically significant decrease in depression symptoms in the experimental group compared with the control group as well as a 65% improvement in overall mood and a 20% reduction in anxiety on average.1 Re-Mission. A video game for teens and young adults with cancer was designed as a weapon to help them fight the temptation to delay or miss chemotherapy doses because of the unpleasant side effects. A year-long randomized trial involving 375 male and female patients at 34 US medical centers yielded positive results. The patients in the experimental group who played 2 hours per day showed significantly improved treatment adherence and indicators of cancer-related self-efficacy and knowledge.2


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SnowWorld. Designed at Georgia Institute of Technology, this virtual reality video game helps reduce pain for burn victims. It has been used successfully (ie, reduced the need for morphine) by burn patients at Brooke Army Hospital at Fort Sam Houston, Texas.3 Steve Miff, PhD, commented that while individual patient activation is critical, there may be hospital applications as well. One popular idea is to create a US Postal Service–hospital collaboration whereby postal workers would check on high-risk patients while on their daily delivery routes. He envisioned games for use in rehabilitation settings offered on the Web site, Futureofhospitals.org, a SuperBetter game to alleviate anxiety and depression for caregivers, and games for young patients with diabetes offered on external patient portals. The ultimate goal of games is to help the individual absorb information. References 1. East Carolina University. Study: casual video games demonstrate ability to reduce depression and anxiety. www.ecu .edu/cs-admin/news/newsstory.cfm?ID=1906. Accessed August 22, 2013. 2 Kato PM, Cole SW, Bradlyn AS, Pollock BH. A video game improves behavioral outcomes in adolescents and young adults with cancer: a randomized trial. Pediatrics. 2008;122:305-317. 3 Elliott S. Virtual reality helps soldiers deal with real world burn pain. www.army.mil/article/34030. Accessed August 22, 2013.

Panel Discussion—Patient-Centered Partnerships and Processes: Leading Practices for Improving Safety Outcomes Moderator: Lillee Smith Gelinas, MSN, RN, FAAN, Vice President and Chief Nursing Officer, VHA Panel: Cindy DeMotte, MPH, CPHQ, Vice President, Quality, Community Memorial Health System [CMHS]; Martin J. Hatlie, JD, Chief Executive Officer, Project Patient Care; Sue Collier, MSN, RN, FABC, Performance Improvement Specialist, Patient-Family Engagement, North Carolina Quality Center/North Carolina Hospital Association

When seeking reasons for “poor care,” health professionals often point to patients’ pursuit of short-term gratification and lack of adherence to medical treatment regimens. New initiatives suggest that the real problem may lie in how health care professionals interact with patients. Engaging consumers in care partnerships is essential to achieving health care quality and safety. Hospitals that engage patients and their families report reduced lengths

of stay, lower costs of care per case, decreased adverse events, and higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Panelists shared their experiences with patient-focused interventions that enhance quality and safety. Cindy DeMotte—A recent study suggested that, when a doctor is seated during a visit, the patient perceives that the doctor has spent more time on the visit and is more “genuine”—both of which lead to greater trust. As part of a collaborative sponsored by the Institute for Healthcare Improvement and the West Coast VHA, a physician communication bundle was developed. CMHS piloted an intervention in which physicians were asked to incorporate 4 simple things in their visit to hospitalized patients: 1. Offer a warm greeting; introduce himself or herself and provide a business card 2. Sit down 3. Ask a “worry question” (eg, “Is there anything you’re worried about?”) rather than “How are you?” 4. Write the key elements of the care plan on a white board Via a brief skit, Ms DeMotte demonstrated the process using a “cane chair.” After a successful pilot on 1 unit, every unit is now equipped with 2 cane seats/chairs. Recognizing that physician engagement leads to patient engagement, CMHS devised a learning session that uses stories and evidence as the basis for engaging physicians and patients. Patients complete a 1-page feedback form (available in English and Spanish) and the information is given to physicians for tracking. Certain elements in this process have been written into physician contracts. Martin J. Hatlie discussed several initiatives: •• After experiencing hospital-acquired infections spanning 3 family members in 3 different hospitals within the space of a single year, Victoria and Armando Nahum cofounded the Safe Care Campaign in 2006. The Nahums teamed with Mr Hatlie and the Healthcare and Patient Partnership Institute to create the Patients as Partners Training Guide for Hospitals.1 •• The importance of transparency around patient safety events with potential liability was reinforced by an incident involving the anesthetic-related death of the young mother of 2 children during a routine procedure at the University of Illinois Medical Center. Listening and telling were equally weighted in the open, honest communications


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Clarke about the event, which were initiated within 30 minutes of the event. Early in the communication, the patient’s father requested that his daughter’s kidney be donated to a close friend in desperate need of one. The family and hospital worked together to donate the patient’s kidney to this man, which was very meaningful to the family. The hospital assumed all related medical costs for the kidney donation, and all hospital and physician bills relating to the care wherein the adverse event occurred were waived. As a result of the foregoing, the legal case settled quickly. Although the family was appropriately compensated, substantial overall savings were realized by the hospital because legal fees and litigation costs were minimal. Other positive outcomes included retaining the family as trusting future customers, culture change within the hospital through the family’s continued involvement in hospital safety work, valuable learning that led to a change in the national anesthesia standard of care for monitoring patients, and favorable publicity.

corporate policy to help identify advisors. A good patient advisor is an individual who can translate personal experience into a broader perspective and who is willing to be part of the solution. Four years ago, at a typical executive committee meeting, a physical therapist shared the story of a young man who was shot and later died in the intensive care unit (ICU). Although the family was present in the hospital, they were not permitted to be at his bedside. After determining that existing ICU policy prevented patients and families from being engaged, “family presence hours” were put into effect. The valuable lesson learned is that the patient’s family, health care workers, and visitors have important roles to play in the lives of patients. They must be considered as part of the team. Leaders must be held accountable for effective patient engagement. After committing to the best possible patient outcomes, leader rounds with staff members and a weekly board-level quality meeting with patient experience reports were instituted. Vidant’s newly created “leader bundle” includes (a) daily, ongoing, leader-staff “huddles,” conversations, and look-backs and (b) leaders scorecard review.

It is clear that good and timely communication improves patient engagement and that organizations can learn from their failures. Early reporting, expedited communication with patient and family, support for caregivers involved in an event, and apology and remedy when subsequent investigation shows the standard of care was breached are all essential to achieve improved outcomes and liability savings, both of which drive overall cost savings. Are the cost savings and culture change real? Funded by the Agency for Healthcare Research and Quality, a demonstration project to evaluate the implementation of the University of Illinois approach in 10 other hospitals is demonstrating similar liability and cost savings. Sue Collier—Vidant, a 9-hospital system in North Carolina, is committed to engaging the patient. After surviving a dissecting aneurysm following the birth of her first child, a young woman has worked with health care professionals to help them understand how to engage patients. Engagement of patients in all aspects of quality and safety has resulted in a 17% improvement in care. From the bedside to the boardroom, patients sit at the table and on steering committees. Patient advisors serve on the Quality Improvement Committee at the patientcentered medical home level and on community advisory councils. Patient advisors serve on a volunteer basis and receive training by means of a structured process. There is a

How does one approach patients—and providers— who do not want to be engaged? Panelists agreed that health care systems must take ownership of “noncompliance.” Consider redesigning processes to create opportunities to develop the skills, knowledge, and confidence necessary for engagement. The Health Research and Educational Trust tool indicates opportunities for wellness and choosing wisely. Patient engagement approaches must be tailored to the particular patient; for example, a patient who suffered harm may want to know how she or he can help keep someone else from similar harm. Consider something fun and creative to get the message out (eg, a video clip) to providers and share results of initiatives; for example: •• Improved scores on the HCAHPS (particularly with respect to patient-centeredness) •• Decreases in hospital-acquired infections and associated impact on the bottom line •• Decreases in the number of lawyers engaged and time for legal processes to be resolved •• Communications for patient advisors and grateful patients In summary, panelists commented that broad involvement of patients and families is vital to transforming


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systems and sustaining positive change. The physical plant is not a barrier and there is clear evidence that community hospitals are engaging and involving patients in meaningful systems change.

physician leaders at both the group practice and hospital levels, particularly those with expertise in governance and management.

Requisite Tools for Creating the Enterprise

Reference 1. Healthcare and Patient Partnership Institute. Patients as partners training guide for hospitals. http://h2pi.org. Accessed August 26, 2013.

The Enterprise: Including Physicians at the Decision Table for Both Economic and Clinical Outcomes Presented by Don Hicks, JD, and Jim Doty, Physician Services and Strategies, Senior Principal, VHA

With regulatory pressures intensifying, health care organizations are involving physicians in decisions beyond the clinical sphere. The key to successful engagement of physicians in making necessary changes is sharing robust, reliable data with them. The VHA Physician Services and Strategies Team shared new models and success stories highlighting effective approaches to physician engagement and accountability, organizational structures that help address clinical quality issues and operational efficiency, and the need to manage resource utilization and financial risk. Presenters reported that Richard Umbdenstock, President and CEO of the American Hospital Association, believes that it will be very difficult for stand-alone hospitals to have economies of scale. He expects that nurse practitioners will play a larger role as primary care practitioners become scarce, and he anticipates that there will be licensing skirmishes at the state level. He sees mid-level professionals taking on more important roles while hospitals shift from “doing more with less” to “doing better with less.”1 Stuart Altman, PhD, Professor of National Health Policy at Brandeis University, views today’s health reforms as smarter and less aggressive than the “managed care” reforms of the 1980s and 1990s. Consequently, he foresees less of a backlash from the public and the press.2 In light of payment reform, previously “siloed” teams must be consolidated as an enterprise—a “team of teams.” The enterprise is a family of organizations (eg, hospital, aligned medical group(s), home health agencies, freestanding ancillaries, provider-owned health plans) that is exposed to collective risk and that reaps collective benefits as a team. The survival of all elements depends on the enterprise. Given the dual goals of providing “cradle-to-grave care” and moving toward population management, the enterprise’s chief weakness is a significant lack of skilled

1. Start immediately on physician leadership training. It takes physician leadership to transform culture, and today’s physicians are far behind the curve. The American College of Physician Executives offers a number of programs to help physicians develop leadership skills. Mentoring is critical, as is having a senior leader who recognizes the importance of physician leadership. Avoid the common pitfall of assigning physician leaders rather than seeking out good leaders. Like a new graduate, expect a new physician leader to go through a learning curve; in particular, physicians must be retrained to understand that it is safe to fail. The goal is to develop a culture based on trust, mutual respect, and transparency, a culture in which physician leaders and physician groups are at the table making decisions rather than infighting. 2. Be prepared to spend money. Whether the necessary changes are effected internally or by means of an external entity, it will be expensive for organizations to create an enterprise. 3. Find “early adopter” physicians and board members. The enterprise requires executive leadership style and culture that leverages influence rather than issues edicts. Seek smooth, nonconfrontational, strong individuals. 4. Upgrade the information technology (IT) system(s). All data are driven by integrated IT systems (eg, national data, hospital data, physician-level data). Clinical data IT systems must bridge both the hospital’s and the physicians’ practices. A consolidated system to integrate outpatient and inpatient (financial and clinical) data is essential. Clinical integration cannot be done without physician input; therefore, the enterprise requires physicians in true decision-making management roles. An organization’s IT system must be able to create from its data warehouse an “enterprise-wide” set of comprehensive reports that accurately assesses the economic value of the medical groups’ operations and hospital throughput. Once in possession of the data, shortcomings can be identified and the value of changes can be assessed.


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Clarke The following are “real-world” examples of organizations that have moved in the direction of integration: •• Southern California’s PIH Health, a large community hospital with a medical foundation and integration focus driven by common values and principles. Under the current chief executive officer, PIH Health has acquired a large primary care group, built the primary care practitioner base, and created an IPA with equal, nonpreferential contracts. Specialist care is contracted out, and the results of integration have been very positive. •• Regional West Health Services, a Midwestern (Nebraska) medium-sized community hospital in a rural market, employed 95% of its medical staff. All were in one boat, but not rowing in the same direction. After integration, there is a single board with representation from the hospital and physicians, and the cultural orientation has changed from “my patient” to “our patient.” •• Kaiser Permanente—Like it or not, these are the leaders in integrated systems. With transparency, they have invested $4 billion in IT and manage risk wisely and effectively. They are doing what the government requires (ie, squeezing out waste in a consolidated way) and putting pressure on the rest of the industry to emulate them.

Physician Engagement in the Enterprise To change physicians’ clinical behavior, we must first do away with the “us versus them” mentality and work toward developing a more common language. Second, we must empower physicians on all substantive issues. Physicians must be presented with their own data that focus on their performance. By comparing their own data with in-market peers (eg, via VHA IMPERATIV Advantage), physicians become more engaged in changing their clinical processes. “Physicians are very smart and very competitive—they will work to get to the top of the game.” Key areas of focus for physician behavior change include the following: reducing variation in physician use of equipment and devices, reducing variation in physician clinical processes, and physician-centric collaboration. Ideally, required changes in clinical processes should be paired with changes in compensation based on nonproductivity measurements. For example, couple the physician’s own outcomes data versus peers’ data with 2 other factors: (a) change the physicians’ reimbursement/compensation model to one in which their pay is based on clinical outcomes compared to their peers and (b) institute a peer or “collegial confrontation process.” When a challenge of “Show me the data!” is met with

comprehensive, accurate clinical outcomes, physician behavior is more likely to change.

Summary With health reform a reality and payment reform at the doorstep, the physician has become part of the hospital enterprise and, as such, sits at the decision table for both economic and clinical outcomes. The lack of sustainable physician leadership is the biggest deficit. Macro health economics are needed in the boardroom. The hands-on skill of clinical collegial confrontation using actionable data is helpful in persuading physicians to change the way they practice medicine. Most health care leaders agree that these problems must be solved to trim the required 20% of clinical costs from their organizations. Start immediately, find fervent early adopter physicians, and adopt a clinical data information system that bridges inpatient and outpatient data and the physician practices. References 1. Bresnick J. AHA on Medicare cuts: don’t do more with less, just do better. http://ehrintelligence.com/2013/02/28/ aha-on-medicare-cuts-don%E2%80%99t-do-more-withless-just-do-better/. Accessed August 21, 2013. 2. Bebinger M. Altman to chair board of new cost control health policy commission. http://commonhealth.wbur .org/2012/11/stuart-altman-to-chair-board-of-new-costcontrol-health-policy-commission. Accessed September 11, 2013.

Linking Fiction, Science, and Gaming Strategy for Safety Leadership Skill Building Led by faculty of The Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD: Christine Goeschel, ScD, MPA, MPS, RN, FAAN, Director, Strategic Development for Research Initiatives, Assistant Professor of Medicine, Nursing and Public Health; Michael Rosen, PhD, Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Human Factors Psychologist; and Sallie J. Weaver, PhD, Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Organizational Psychologist

The largest federal hospital initiative to tackle patient safety and quality of care, Hospital Engagement Networks (HEN) are funded by the Centers for Medicare and Medicaid Services (CMS) as part of the national Partnership for Patients initiative. Using its Rapid Adoption Network methodology, VHA’s HEN helps its hospitals achieve improvement goals while helping CMS learn which performance methods are most effective, scalable, sustainable, and applicable across the industry.


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The leaders of this session acquainted participants (health care organization executives) with a new model of accountability by means of 4 lean, cognitive simulation exercises.

Scenario 1: Cardiac Stents A high-volume cardiologist is observed inserting stents in patients who do not need them. A nurse is overheard stating this. Her perception is labeled “accusation” and “hearsay.” Group discussion centered on perceptions of risk, decisions, and actions. Risk: Nurse’s conversation inappropriate, potential revenue loss to the hospital. Immediate level of concern: Moderate to high. Decisions: •• As chief executive officer (CEO), the first person you want to speak with: Nurse who made the allegation •• As CEO, what next?—61% said meet with chief nursing officer (CNO) and chief medical officer (CMO) to discuss •• As Director of Invasive Cardiology, who would you expect to hear from first? CNO or CMO Actions: •• Involve physician early rather than late. •• Analyze each cardiologist’s cardiac stent placement data (eg, patient histories, diagnostic tests) and compare with evidence-based recommendations. Investigate by interviewing appropriate staff and send cases out for peer review to avoid perceived threat from insiders. •• Reinforce mechanism for anonymous and straightforward reporting process. •• Present facts to the Board if substantiated and discuss with staff. Work to rebuild a culture of trust between nurses and physicians, thereby rebuilding the team. Actual case. In May 2009, an employee lodged a complaint that a leading cardiologist was performing inappropriate medical procedures. In December 2009, a total of 585 patients were notified that they might have undergone an unneeded procedure. In May 2010, state regulatory documents suggested that the physician avoided the hospital’s peer review process. In June 2012, it was verified that the physician had a suspiciously high rate for placing stents.

Scenario 2: Infection Control Following the integration of an ambulatory services organization, a hospital received a number of new claims indicating poor infection control in the acquired facility (ie, potential exposure to hepatitis B). Group discussion centered on perceptions of risk, decisions, and actions. Risk: Risk to patients and to organizational reputation. Immediate level of concern: high threat. There is risk in not doing something. Decisions: •• As CEO, what do you want to know initially? Is an infection control practice in place? •• As Director of Risk Management, what do you want to know? Determine why staff believed that they were doing things in the correct manner, and help them understand the need for change. Actions: •• When acquiring or affiliating with an organization, be certain that appropriate quality standards are in place and regularly monitored. •• Work toward a consistent, system-wide infection control policy and plan with regular audits to assure compliance with measures. Refer to national benchmarks and identify areas of vulnerability. •• Disclose to all affected patients, even at the risk of organizational reputation. Actual case. An oncology patient on chemotherapy became reinfected with hepatitis C. A total of 99 patients contracted the disease before it was discovered that health care workers were not following safe injection practices. Such infections can occur in primary care and other practice settings when staff members are unaware of the inherent risk of using the same injectable medication vial for multiple patients.

Scenario 3: Accountable but Powerless A nurse sent a letter to a CEO alleging that a kidney infection, misdiagnosed as a pulled muscle, resulted in a 3-day hospitalization and left the patient with a $35 000 debt. Summary of group discussions Decisions: •• As CEO, what is your immediate level of concern?—Highest


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Clarke •• As CEO, who do you want to talk with for clearer understanding? The source nurse and/or the Director of Nursing. Actions: •• Acknowledge preliminary findings to the Board and frontline staff (ie, be transparent about what is working well). If the allegations are legitimate, address concerns related to the specific unit. Share details and advise the Board regarding plans. •• Does the culture support employees who raise concerns? There is high turnover when employees are unhappy. Set up a call line to see if there are additional issues. •• Nurses: Schedule an open forum with the CNO to air good and bad news. Assemble nursing focus groups to address issues up front. Initiate nursingfocused leadership rounds to share information and concerns. Discussion points: •• It is important that the chain of accountability in the organization be documented and understood by the staff. •• Tools are available for building capacity (eg, VHA tools such as Building Capacity: Competencies Across the Organization and the Quality Improvement/Patient Safety Inventory; the Institute of Medicine Checklist for High-Value Care). •• Important questions to consider: What data do you collect? What data are required? By whom? Who reviews the data and responds? It is difficult to raise the types of issues represented by the scenarios. Discussing such topics in theoretical terms helps identify gaps and build efficiencies into the system. Patient and family engagement must be considered in all such discussions. When the chain of accountability is fully activated, great things happen. For example, having made quality and safety a priority, the President of Johns Hopkins University Hospital engages staff throughout the organization—from physicians to housekeeping. Quality must be integrated into the curriculum and safety competencies must be drafted and adopted. We must think boldly, be more courageous, and collaborate more readily. Making safety a priority rather than an assumption is a challenge we all face.

Making Value-Driven Health Care Real: Linking Supply and Pharmaceutical Data With Clinical Outcomes and Operational Data Presented by Allen Johnson, PhD, Senior Vice President and Upper Midwest Executive Officer, VHA, and Rob Welch, MD, Vice President, Upper Midwest, VHA

For decades, decision science has helped economists, social scientists, analysts, and others in the academic and business sectors to evaluate vast amounts of data to improve the quality of decision making. Decision science is a discipline that is concerned with identifying the values, uncertainties, and other issues relevant to a particular decision, and applying advanced analytical methods to arrive at a more optimal decision. Main concepts include reliability, uncertainty (unexplained variance), validity, and statistical sufficiency. Sufficiency is reached when, regardless of further understanding, the same conclusion would be drawn. The challenge lies in identifying the minimal data sets and analytics from which a statistically accurate conclusion can be drawn. A basic model to evaluate the “production function” of a process can be expressed as follows: Total Cost = function of (inputs + defects + other relevant items [eg, unexplained variance]) To evaluate the production function of a process within a hospital or health system, the equation would be the following: Total Cost of Care = function of (use of inputs [eg, patient, physician, protocols, supplies] + defects [eg, hospital-acquired infections, readmissions] + other items) Key concepts to be addressed include issues of reliability (eg, differences in coding and definitions), uncertainty (eg, unexplained differences among patient outcomes), validity (eg, the use of cost proxies), and sufficiency (eg, achieving the necessary level of detail). Applying such models and concepts in hospitals and health systems can be especially challenging. A key question for health care evaluations is, “What analytics are sufficient to improve performance?” Consider the following examples: •• Grocery store receipt: “Sufficiency” is achieved with the level of detail provided on a grocery store


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receipt. Items on the receipt are grouped and subtotaled by type (eg, bakery, produce), and the price per item and quantity purchased is clearly displayed. Because claims, clinical, and supply/purchasing data generally are stored separately in hospitals and health systems, there is no data sufficiency. Databases similar to those used by grocery stores would be very helpful to hospitals. •• Deli sandwich-making process: The cost of making the same sandwich varies among chefs. The business question is, “Which chef produces the greatest profit?” A model for evaluating the production function of each chef might be expressed as follows: Profit = Total revenue minus (cost of inputs [sandwich ingredients] + defects [eg, product waste, returned orders] plus other items [eg, customer volume, ingredient inventory, customer choice of bread])

By comparing the production functions of individual chefs, it is possible to define the optimal combination of ingredients. Again, because health care data typically are siloed, sufficient analytics are extremely difficult to achieve.

Merging clinical data with pharmaceutical and supply data can provide a deeper understanding of the actual cost of care and reveal opportunities to identify variations in utilization. New ideas are emerging with respect to performance improvement by integrating supply chain and pharmaceutical data with clinical data. The VHA Upper Midwest Region has engaged several member organizations in a pilot to analyze the link between the price paid for supplies and the transaction-level activity or procedure performed. This data link will drive informed conversations that transform relationships among hospitals, and between hospitals and their medical staffs, suppliers, and their purchasers.

Practical Application Integration of data sources can improve reliability, validity, and sufficiency of data sets/analytics; reduce unexplained variation; identify new insights into performance; and enhance the dialogue with clinicians regarding necessary change. Working with real-world data from a 7-hospital network (hospitals A-G), researchers demonstrated that integrated data leads to different conclusions. The network sought first to identify the leading practice for a

dual-chamber pacemaker implant procedure and then to devise a supply contracting strategy. For each hospital, the team calculated: (a) the total supply cost for dualchamber pacemakers, (b) the diagnosis-related group profit and loss, (c) facility-level procedure complications and mortality, and (d) facility-level readmissions. Comparing the hospitals on these cumulative parameters, a leading practice hospital (D) was identified. Unsure that their data were sufficient, the team further investigated the cost of the dual-chamber pacemaker by supplier at the facility level and calculated the price variation at the supplier level. Variation in selection (single chamber vs dual chamber) was analyzed by facility as well. On the basis of these findings, a different leading practice hospital (G) was revealed. This hospital was partnering with physicians, bringing the most appropriate technology to its patients, keeping readmission rates low, and achieving the narrowest loss margin. The teams concluded that if hospital D practiced and operated like hospital G, it would be profitable; and if hospital G had more competitive supply pricing, it too would become profitable. Additional analyses revealing physician-level variations in readmissions, antiplatelet and anticoagulant drug use, and dual-chamber pacemaker cost led the team toward hospital G’s management approach. By bringing together price, utility, and clinical metrics in a “sufficiency” conversation, these analyses were helpful in solving problems and in encouraging discussion with clinicians from a Total Quality Management (ie, clinical and supply) perspective.

Summary Integrated analytics improve the quality of conversations with medical staff and suppliers. Shown the same data, shared goals can be established and new insights and opportunities can be identified. Great variation exists everywhere, but greater sufficiency leads to better results. Technical barriers (eg, obtaining supply chain data, variation in reliability and quality of supply chain data, matching supply with the clinical event) are substantial but not insurmountable. One solution on the supply side is to barcode all items. Similar items can be described very differently, and a unique identification number will eliminate many errors. Likewise, unique identifiers for physicians are essential, particularly in organizations with medical staffs of 200 and physician rosters of 2000. Finally, providing more logic training in the health care sector will effect a dramatic change in our ability to draw inferences.


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Optimizing Patient-Centered Medical Homes and Neighborhoods: First Things First Presented by Peggy L. Nass, MD, MBA, Vice President, Physician Strategies, VHA

4. Systems-based approach to quality and safety— Demonstrate a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction. 5. Practicing population health management—For example, identifying patients who are readmitted to hospitals, segmenting that population and assigning it to a PCMH.

In 2003, a groundbreaking article by McGlynn et al1 made a compelling case for transforming the way health care is viewed and delivered in the United States. The study revealed that US adults receive only 54.8% of all recommended health care—in particular, only 56.1% of recommended care for chronic conditions, and 54.9% of recommended preventive care is actually delivered. Although it would be impossible for an independent practitioner to deliver 100% of recommended preventive services to every patient, we have learned that the “quarterback doesn’t have to carry the ball in every play” (ie, we must make better use of mid-level health care professionals). Faced with the growing burden of caring for chronically ill populations in a complex, uncoordinated system as costs escalate and provider incentives remain misaligned, primary care has plunged toward crisis, and the value of dollars spent on the health care system has diminished. Change has become imperative—and the change must focus on value, consistent quality, economic savvy (eg, fixing the dysfunctional reimbursement system, making health insurance premiums affordable), and patient satisfaction.

Transforming the care paradigm from one that is transactional to care that is value focused and coordinated across the spectrum requires providers who deliver optimal, patient- and family-focused care; payers who understand the salient characteristics of the populations they represent and the key analytics necessary to appropriately align reimbursements and incentives; infrastructure that effectively distributes work across the health care team, minimizes variation, and improves reliability (eg, TeamSTEPPS); electronic health records incorporated into a system of care to effect improved outcomes; meaningful clinical, financial, operational, and process improvement measures; and compensation that motivates desired improvement (eg, operational efficiencies, clinical outcomes).

Components of a Patient-Centered Medical Home (PCMH)

Role of Care Management in a Medical Home Model

A transformative concept, the PCMH is changing how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not as a “place” but rather as a model for the organization that delivers the core functions of primary health care.2 AHRQ’s criteria for PCMH certification encompasses 5 functions and attributes:

In light of the myriad primary care challenges (eg, complex patients; fragmented, poorly controlled care; less than ideal communication; the burgeoning elderly population), the time is ripe for embedding care managers (CMs) in practices. The PCMH approach to care management begins with identifying high-risk patients and targeting specific population segments (eg, heart failure, chronic obstructive pulmonary disease, oncologic conditions, frail elderly). Next, by means of a comprehensive assessment, the primary issues underlying each case are identified and discussed with the patient and family. Finally, care providers and the full team interact daily regarding each high-risk case. The PCMH CM pinpoints referral triggers, including identifying patients with stressed caregivers. The PCMH CM role is 3-fold. The first is a team role: managing a caseload of high-risk patients in close collaboration with physicians and the practice team. The second is a patient link role: conducting comprehensive care reviews and planning (medical, psychosocial,

1. Patient-centered—Care that is relationship based and holistic. 2. Comprehensive—Care is coordinated across all elements of the health care system including specialty care, hospitals, long-term care facilities, home health, and community services with particular attention to transitions among sites of care. 3. Accessible—Shorter wait times for urgent needs, enhanced face-to-face time, alternative communication methods (eg, e-mail, telephonic care) with 24/7, 360-day access to a care team member.


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support systems), facilitating transitions and follow-up visits (discharges, emergency department visits), providing direct-line access for patient questions and concerns, and maintaining a personal connection with the patient and family. The third is best described as a “point of contact” role: attending to regular follow-ups, facilitating access to primary care physicians (PCPs), specialists, and ancillary providers as necessary. Essentially, using a team approach with a CM reduces demand on the physician’s time and provides better access to a greater number of patients in a primary care practice. When used appropriately, embedded CMs contribute to PCMH success. Generally, 1 CM is needed for every 800 Medicare or 5000 commercially covered lives. With a high-risk patient caseload of 15% to 20% for Medicare and 3% to 5% for commercial, the total caseload is approximately 125 to 150 patients. Embedded care management goes far beyond traditional disease management (eg, making reminder calls). Because it focuses on highrisk patients and specific issues for a select patient population, gauging acuity and complexity are key considerations in caseload management.

The “Right” Care Manager It is not a matter of “finding” the right CM but rather one of “creating” the right CM. For this reason, prior experience is not a necessary requirement. Among the traits of a good CM are the following: •• Autonomous and self-motivated •• Highly organized with good time management skills •• Able to understand related complex issues as well as the main driving force •• Able to remain on task in the face of multiple distractions •• Willing to “nudge” providers as well as patients In addition to being a “people person,” essential competencies include strong skills in the following areas: communication, problem solving, negotiation, conflict resolution, and critical thinking.

Creating a Medical Neighborhood The medical neighborhood encompasses all of the health care system entities that come into contact with the patient and family members (eg, hospital emergency departments, home health agencies, pharmacies, nontraditional entities such as convenient care clinics). The value of a medical neighborhood is that the closer relationships developed among aligned providers lead to

improved communication between PCPs and select neighborhood partners. Such relationships span the full continuum of care to benefit all stakeholders—especially patients and families—and broaden opportunities to create higher value. Creating medical neighborhood partnerships begins when an agreement is reached among all entities with regard to the mutual benefits of a partnership. Once opportunities are identified and the means for collaboration is established, the network is narrowed with a targeted group of specialists, including high-volume specialists (eg, endocrinologists) and specialists with limited access (eg, pulmonologists). Eventually, a “web of care” is created to surround the most challenging patients. Sufficient numbers of PCPs and mid-level practitioners (eg, nurse practitioners, medical assistants) are vital to the success of a medical neighborhood.

PCMH Model: Real-World Results Geisinger Health System’s Proven-Health Navigator (PHN) Program conducted patient and provider surveys to assess the effectiveness of embedded CMs in improving the quality of care. Overwhelmingly, patients believe that CM effectiveness is “very good” (79%) and that the quality of care is better than in the past (72%). Moreover, 86% perceive that the care is more comprehensive than under the previous system. Providers report that timely information is available regarding their patients’ transitions of care (82% agree) and 93% would recommend PHN to other PCPs. Readmissions to 5 nursing homes have decreased substantially over the first year of the program (−12.7% to −66.6% reductions), and acute readmissions have decreased in the Medicare and uninsured populations. PHN sites had fewer Medicare readmissions than non-PHN sites, and PHN patient emergency department visits have been stable while non-PHN patient visits have increased. These improvements in quality have been achieved with a significant decrease in total per member per month spending.

Key Discussion Points •• Attendees were encouraged to speak with colleagues about current practices in managing patients across the care continuum with an eye toward identifying the biggest challenges inside and outside of the hospital community (eg, managing the most expensive “super-utilizers”). •• The difference between a care manager and a case manager is that CMs are a part of the care team— the operative difference being that patients are “our patients” versus “cases.” When hospitalbased, CMs are referred to as Care Navigators.


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Clarke Some multi-practitioner groups have embedded doctors of pharmacy who make home visits. •• A nursing home readmission strategy was used as an example of how care management can be leveraged. Nurse practitioners embedded in a multispecialty group make rounds in nonowned nursing homes and skilled nursing facilities under the terms of risk contracts that offer shared savings in exchange for positive outcomes. In one instance, an embedded CM investigating a patient fall in a skilled nursing facility was able to diagnose a hip fracture, stabilize the patient, and schedule a sameday admission for hip pinning, saving an inpatient day. References 1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-2645. 2. Agency for Healthcare Research and Quality. What is the PCMH? http://pcmh.ahrq.gov/portal/server.pt/community/ pcmh_home/1483/what_is_pcmh_. Accessed May 20, 2013.

Navigating Change: Putting Willpower to Work for Your Patients and Yourself Presented by Kelly McGonigal, PhD, Lecturer (“The Science of Willpower”) and Psychologist, Stanford University, and author (The Neuroscience of Change)

Health care workers need willpower to support themselves through long days at the bedside and in meetings, and to bear up under the demands and stresses of the job. Unfortunately, willpower is woefully misunderstood in our society. The classic view of willpower involves resisting temptation and “being strong.” Recent advances in neuroscience suggest that we may be hurting ourselves by striving too hard for self-discipline. Willpower is really about the ability to be one’s self. A person struggling with addiction, for example, has 2 competing “selves”—the self that sees goals and motivates toward them versus the self that seeks short-term satisfaction. The notion of competing selves is fundamental to the human mind; it must respond to immediate needs for survival, but it also must be strategic and flexible to regulate impulses. We shift back and forth between the 2 selves. Shown temptation, researchers are able to predict how an individual will react on the basis of which part of the brain is activated. This is beginning to change our way of thinking. Giving in to temptation is not a negative trait, nor is it a moral virtue to resist temptation. Everyone has

the capacity for willpower but, in order to cultivate it, 3 “strengths” must work together: (a) “I want” power, (b) “I will” power, and (c) “I won’t” power. It is helpful to understand the neurological underpinnings of self-control and self-awareness. The brain’s anterior insula pays attention to what is happening in the body. It recognizes cravings and anxiety and communicates information via a connection with the prefronal cortex that helps rein in impulses. When these 3 parts of the brain work together, an individual is able to understand what is happening and make a decision based on what she or he values. Willpower is a biological instinct; but unlike the “fight or flight” response, wherein pulse and respiration rates increase, the autonomic system becomes balanced when willpower is exerted. In essence, the “fight or flight” response competes with willpower. Connections between the anterior insula and the cortex of the brain are inhibited with stress. Endemic in our society, the following 5 types of stress make it difficult to change health behavior: 1. Sleep deprivation: After 35 hours without sleep, the “I want” part of the brain becomes functionally disconnected from the part that prompts a person to take care of himself/herself, thus compromising the person’s ability to make good decisions. The problem—as health care workers can attest—is that we can’t always control how much we sleep. 2. Time scarcity: When we have more to do than time available, we shift into fight or flight mode (eg, not eating) and become more driven by habits and cravings. To restore willpower, go outside for a walk or listen to music. 3. Guilt: When a person experiences a willpower setback, she or he is more likely to repeat the behavior and/or give up on goals. The brain shifts to a state that cannot connect with the long term. For example, the worse one feels about the amount one drank the evening before, the more likely one is to drink again the following night. 4. Willpower exhaustion: Like a runner after a marathon, a patient may be in a situation that repeatedly requires him/her to do something that is physically uncomfortable. This raises the level of negative emotions and anxiety. 5. Stress of change: This occurs when a person is uncertain of an outcome and when feeling threatened or undermined (eg, being told to change eating habits). Willpower is like a muscle—it can become exhausted, but it also can be trained. Willpower strategies can help


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one avoid becoming overwhelmed by 1 or more of the 5 types of stress. Self-awareness is a process, and practicing the process increases the density of structures and connections in the brain. The process of mindfulness (ie, choose, notice, act) can be practiced by setting a big goal (choosing), paying attention when straying from the goal (noticing), and returning to the goal (acting). For example, a patient with heart disease chooses to be mindful of heart health. While grocery shopping, she recognizes the pull of donuts and acts by pulling away. Small doses of mindfulness can yield positive results. Set a big goal with a small commitment (eg, walk every day) and attend to the process (eg, why did I not walk on a certain day). Once the reason is understood, refocus on the goal. Mindful tolerance is a useful process for people whose lives or jobs involve a large amount of stress. A person who allows herself/himself to attend to the craving for a cigarette can diminish the power of the experience and not act on it. Accepting an inner experience helps a person through an initial

experience of discomfort. Mindful attention invites the “self” of self-control. The process of self-compassion is helpful to clinicians and patients facing the stresses and setbacks that challenge willpower: (a) be aware that the stress is present (eg, “I feel overwhelmed”); (b) acknowledge humanity (ie, all humans have setbacks and failures—they are part of life); (c) mentor (ie, what advice would you give to someone you care about?). An interesting study of self-compassion was conducted with a group who were watching their weight. All of the women were required to eat a donut and drink water. The study group was told about self-compassion and the control group was not. All of the women were invited to eat as much candy as they would like. Having been told that everyone indulges sometimes and that they should not to be too hard on themselves, the women in the study group ate only half as much as the women in the control group. In the moment of greatest doubt, the women in the study group were able to give themselves “permission” without lapsing into feelings of guilt.


Nursing and philanthropy: a partnership to advance professional excellence and exceptional care.

Hardwiring improvement to achieve exceptional outcomes: Staff as leaders driving performance.

'Driven to distraction' and driving for excellence in ward round practice.

Overcoming barriers to excellence.

A commitment to excellence.

Commitment to nursing excellence.

Driving quality, value, and cost through men's health centers of excellence.

Training the Trainers of Tomorrow Today - driving excellence in medical education.

Ensuring excellence in centers of excellence programs.

New editors, same dedication to excellence.

Recognizing excellence.

Phone use while driving: results from an observational survey.

The exceptional person: approaches to integration.

Sustaining excellence.

Choosing excellence.

Graphical Excellence.

Driving glioblastoma to drink.

Commentary on: "Ensuring Excellence in Centers of Excellence Programs".

Navigating the "Hassle Map".

It's not all in your car: functional and structural correlates of exceptional driving skills in professional racers.

Navigating the Zika panic.

Navigating cancer treatment.

Navigating an open road.

Navigating dietary small RNAs.