QUALITY: Physicians Healing Thyselves (or at Least Their Offices)

Tired of waiting for Washington to fix health care, doctors across America are doing it themselves. I just attended a conference in Dallas where hundreds of physicians exchanged ideas on how to improve the quality of care they deliver, make their clinics more efficient—and rediscover the joy of practicing medicine. In future posts, we'll touch base with some really smart and dedicated people we met there and highlight specific innovations that got our attention—new ways of reaching hard-to-serve populations, managing chronic diseases like diabetes, involving patients in their own care, new twists on "shared visits."

But here's our basic takeaway on how the 9^th annual summit on Redesigning the Clinical Office Practice, run by the Institute of Healthcare Improvement, could contribute to the high quality, cost-efficient and caring health system we envision for the future: as we noted when we posted on former Gov. John Kitzhaber's keynote on Monday, IHI and its CEO Dr. Donald Berwick (pictured) get a ton of (well-deserved) attention but mostly for what they are doing in the inpatient world, fighting hospital-acquired infection, developing rapid response teams and the like. (Yes, for any health policy newbies among our readers, IHI is the make-doctors-wash-their-hands-and-send- their-ties-to- the-cleaners-now-and-then" group.) Maybe figuring out how to apply "queuing" theories that work in supermarket checkouts and LEAN business practices to outpatient primary care isn't as sexy to the headline writers but it's just as important. Reducing wait times— waiting time to get the appointment and then all the time we sit around in waiting and exam rooms—isn't just a matter of convenience. It's about reducing waste, freeing up time and resources so people get the care they need, when they need it.

There was lots of talk about electronic medical records (one session was called "Going Digital Without Going Bankrupt") but a lot more talk about patients. How to streamline office practices so instead of having three nurses answering the phones you can have two on the phones and the third working one-on-one with a chronically ill patient, keeping them out of the hospital. How to create a "medical home," where a patient's care is truly coordinated by a primary care team that knows the patient instead of fragmented care by a half- dozen specialists flung across various clinics and hospitals, none of whom knows what the other is doing. Dr. Carole Redding-Flamm, executive medical director of Blue Cross Blue Shield Association, described Patient-Centered Medical Homes that are up and running in several states, rural and urban. The insurers, in some cases, are paying the doctors extra for successfully managing the care. An extra benefit, doctors report, is higher rates of patient satisfaction.

One high risk time for patients is transitions, for instance from the hospital to home health care. It sounds like a no-brainer to say that sick, frail people at high risk of finding themselves back in the hospital within a month need more than an occasional visit from a home health aide. But in reality, that's sometimes all they get. Consultant Ann Hess described a pilot program between Mt. Sinai Hospital in New York and the Visiting Nurse Service of New York. She showed how getting a nurse practitioner to a home-care patient soon after leaving a hospital reduced the rehospitalization risk. But that required tools for assessing the risk so that the nurse practitioner (who costs more than a less skilled home health aide) goes where she is really needed. It also requires getting the patient to see a doctor after a high-risk hospitalization within seven to 14 days (which often does not happen - that's where the smart business practices and reduced waiting time makes a big difference to the quality of care).

The "reinventing clinical practice" concept is an exciting one to anyone who has spent years in Washington (where all too often policymakers reinvent stalemate). One thing we'd like to see happen in this blog is for policymakers to hear about clinicians who are creating change, and for clinicians to understand how policymakers are beginning to understand some of the linkages between cost, quality and coverage. If you know any "clinician innovators" with good stories to tell, please post a comment and let us know.