Keys to success and happiness in Family Medicine

1. Keys to success and happiness in Family Medicine Anton J. Kuzel, MD, MHPE Virginia Commonwealth University Department of Family Medicine

2. The coming Tsunami • OMG – 32,000,000 • more people with insurance! • Declining PC workforce! • Massachusetts • on a national scale! 2

3. The current reality • Too many overworked, • underpaid PCPs • No idea of how to get to • a better place without • special financing

4. Hamster wheel medicine

5. There is hope, and a way forward • We need to get off the hamster wheels • A significant minority of practices are doing remarkably well • Physician, staff, patient satisfaction • Ambulatory quality measures • Physician income • We need to learn from these practices!

6. Step 1: Documentation and coding • Stop leaving money on the table • 28% of FM established patient codes are level 4 • 60+% of FM established patient codes could/should be level 4 • Using Medicare payment rates, this would generate about $50,000 per year per clinician in extra income (more if average payment exceeds Medicare rates) • Little/no extra work/time from clinician • Why not? Don’t know how, or afraid of audit • Coding from the bottom up; memorize 99214 • This is low hanging fruit! 6

7. Step 2: Add staff, with a purpose • Clinicians are the ones generating income • Clinicians should not be doing things that don’t require their expertise • Nurses, other staff should take non-clinician work AWAY from the clinicians • All people working to the top of their license • Systematic attention to prevention, CDM • Adds capacity (10-20% or more), increases quality, creates opportunity for increased income 7

8. Step 3: Rapid access scheduling • Requires information system to know panel sizes • Balance supply and demand • Choose easier ways of working down the backlog • Improves continuity, which supports coding to higher levels of care • Do today’s work today • Patients love it • Can add capacity (about 10%) 8

9. Impact of 3 steps • Happier docs and staff • Better care for patients, and better experience of care • Significant gains in PC capacity • Being more prepared for 2014-2019 • Breathing room for doing the real work of healthcare reform 9

10. Steps one and three are easy to understand, but step two is the most important • And the hardest to achieve • Offer two ways of how to improve team function 10

11. (One of my personal four must read books) 13

12. #1: Absence of trust • Consequences: • Pretending to be competent • Avoiding risks - Playing it safe • “Look out for number one” • “Don’t let ‘em see you sweat” 14

13. #2: Fear of conflict • Consequences: • Leaderthink becomes groupthink • Artificial harmony • Stale patterns of behavior • We’ve always done it this way • If it ain’t broke, don’t fix it • Arrested development or worse, regression 15

14. #3: Lack of commitment • Consequences: • Listless performance • at work • Resentment among those • “carrying the load” 16

15. #4: Avoidance of accountability • Consequences: • Lack of critical feedback • regarding behaviors • Working in silos – holding team accountable creates incentive to understand how all the parts contribute to success 17

16. #5: Inattention to results • Consequences: • Imagined • accomplishment • Mediocre performance • Lack of ownership, • and hence, meaning What, me worry? 18

17. [placeholder for pyramid slide] 20

18. 21

19. 22

20. 23

21. 24

22. How does a leader build a foundation of trust? • Leader must: • Risk being vulnerable • Act in service of those on the team • Spend time with the team in social situations 30

23. Get comfortable saying (when appropriate): • “I was wrong” • “I made a mistake” • “I need help” • “You’re better • than I am at that” • “I’m sorry” 31

24. Teams will look to the leader • Leader supportive, coaching-oriented, non-defensive responses to questions and challenges → team members conclude that the team environment is safe • Leader acts in authoritarian or punitive ways → team environment is not safe • Result: Team members not willing to risk admitting errors, asking for help, experimenting, or seeking feedback • Result: Tremendous block to team learning and improvement (Amy Edmondson, Admin. Sci. Quar. June 1999)

25. Waterline Model • When a team is not performing as well as it could, look at what might be happening “below the waterline” • Structural level • Group dynamic level • Interpersonal level • Intrapersonal level

26. Structural level questions • Is it clear who’s in charge here? Is the leadership role being filled effectively? • Does everyone understand what the goals are for the team or for this piece of work? • Does everyone agree on the goals? • Are the team’s priorities clear and agreed upon? • Are people clear about their own and each other’s roles?

27. More structural level questions • Are the expectations clear? Does everyone know who is doing what and by when? • Are people appropriately held accountable for meeting their expectations? • Are the right people here to do the work? Is there a good fit between jobs and people? • Are appropriate boundaries maintained so that acting out by individuals is contained?

28. The secret sauce of primary care • Access • Continuity • Comprehensiveness • Coordination