Talk to people who work in health care organizations that have made dramatic improvements in the way they serve and care for patients, and it's impossible not to notice a common theme underscoring everyone's description of the improvement journey: a culture of change.
"We have an inherent cultural vision of excellence, we are aggressive about looking toward the future, about finding ways to do things better," says Greg Long, MD, a family physician and medical director for the physician services division of ThedaCare a large, community-owned, three-hospital health system with 87 physicians in 21 locations, based in the Fox Valley of Wisconsin, USA. ThedaCare also includes behavioral health services, a laboratory, home care services, retirement living, assisted living, and skilled nursing facilities. Through a joint venture, ThedaCare shares ownership of Touchpoint Health Plan, a for-profit health insurance plan covering 160,000 people.
ThedaCare's culture of change has supported improvements on every front, from inpatient care to office-based care in their clinics. And it is here, in practice redesign, that ThedaCare has really made change a way of life.
You name the office practice improvement strategy — open access, group visits, chronic illness management, electronic medical records, even Internet access for patients to their own medical records and the ability to schedule appointments online — and ThedaCare is doing it or trying it. The results they have achieved show why.
For example, through a combination of strategies aimed at improving care for patients with diabetes, ThedaCare has:
- Increased the number of diabetic patients receiving a yearly eye exam from 65 percent to 85 percent
- Increased the number of diabetic patients with HemoglobinA1c (HbA1c) levels below 8.0 from 43 percent to 60 percent
- Reduced the average HemoglobinA1c (HbA1c) level among its diabetic patients from 8.7 to 7.6
The financial implications, as well as statistics on productivity, satisfaction, and revenue, are equally impressive. But more on that later. First, the story of how they did it.
"This System Is Broken"
The story begins in 1997, when ThedaCare's physician leaders made a difficult, brave, and ultimately profound admission. "They said, 'This system is broken,'" recalls John Toussaint, MD, then ThedaCare's Chief Medical Officer and today its Chief Executive Officer and President of its health plan. "Patients couldn't get in to be seen, they were complaining, the doctors were complaining because their patients were angry, we just couldn't seem to deliver on the value we knew we had in us."
So ThedaCare's leaders formed working groups focused on access, service, and clinical care. Fortunately, it was at about this time that the Institute for Healthcare Improvement (IHI) was beginning its Idealized Design of Clinical Office Practices (IDCOP) project and ThedaCare's leaders were interested when they got wind of it. "We had worked with IHI in a Coronary Artery Bypass Graft (CABG) collaborative, so we were familiar with the concept of shared learning," says Long. The IDCOP project seemed like the right fit with what ThedaCare wanted to accomplish, so they enrolled two ThedaCare practices as IDCOP pilot sites.
They were already one step ahead of the game: they had laid the cultural groundwork for change. "We've been fostering a 'change culture' and pursuing quality improvement for 10 years, so we were prepared for IDCOP," Toussaint says. "There is a preparation process required to get people to that level. Doctors and nurses aren't trained in the culture of open sharing of information."
What's the secret of creating a culture that embraces change? "You have to spend significant time, money, energy and resources to have staff in the mindset of revolutionary process improvement," says Toussaint. "They have to understand that incremental change doesn't always work, that sometimes you have to blow things up and start over."
Toussaint subscribes to the theory that successful revolutionary change is 80 percent about the people involved in it, and only 20 percent about technical application of change strategy. That's why ThedaCare has a large and very active training and development department. "About 30 percent of staff are innately 'gung-ho' about change, 50 percent are on the fence, and 20 percent aren't going to go along. The ones who don't get charged up about it don't stay with the organization long." Despite this, Toussaint says unequivocally that "preparing your staff is the hardest part."
Step two, says Toussaint, is to have, take or adapt creative ideas. "For us, that's where IDCOP comes in," he says.
Long elaborates. "IDCOP draws on a vast knowledge base among its faculty. They teach you concepts, you take ideas home and try them. If they work, great, if not, you try something else. The collaborative approach means you come back and compare notes, you learn from one another, you encourage one another, and you all learn together."
The third step is to have a good implementation process, which Toussaint says is "mostly about people." And step four is maintenance of change. "You have to keep pushing," says Toussaint, "which is why we've continued on with new projects, to help reinforce the changes."
Challenged By Change
The pilot sites began by implementing open access, a way of scheduling appointments that enables patients to request the appointment time of their choice, including same-day. Greg Long practices at ThedaCare's Family Medicine Clinic in Kimberly, Wisconsin, USA one of the pilot sites. He recalls the difference before and after open access was implemented.
"We were scheduling physicals six months out, the patients were not satisfied, the office wait times were way too long, we always felt behind, and my staff was generally here until 7:00 PM or 7:30 PM. All these things affected how satisfied we were in general." But after open access was implemented, a process that usually takes several months, things changed.
"The patients can get in to see me on the same day they call, and they are much happier. I get comments from patients daily about how great it is. It is very satisfying. Staff is going home at 5:00 PM or 5:30 PM, and it's a much better work environment. Both patients and staff are much happier."
And it's a good thing they were, says Long, because the next challenge, implementing electronic medical records (EMR), was much harder. "There was a huge learning curve on EMR," he says, "especially in the exam room. There you are in the inner sanctum with patients, trying to focus on them, fumbling with the mouse and keyboard." The pilot sites tried everything related to EMR, including ordering tests, getting lab and x-ray results, and documenting visits via computer. "For the first three or four months, we were so slow and inefficient, we would take our laptops home at night and finish notes. The nurses used to kid us about whose notes had the latest time logged on them."
Now, says Long, using the computer in patient care is second nature. "It is by far better than the old way," he says. "Drug interactions are flagged, information is more accurate, and it is better patient care."
Two years into their IDCOP work, ThedaCare has created its own internal collaboratives using staff who have "lived through it" to guide other practices along the same route. Currently, says Long, nearly all of ThedaCare's 21 owned practices are at some stage of clinic redesign. All sites have been educated on the concept.
Long knows there is no one-size-fits-all answer to idealized clinical office design. "There is an overall theory and philosophy, but you have to individualize it. You have to look at the practice, the care teams, and create solutions that work for them."
ThedaCare's efforts have produced results that most clinical offices would envy. In the two pilot IDCOP sites, the average number of visits per doctor per month dropped while the net monthly revenue rose, as did net income. Access is wide open, more patients are seeing their own doctor when they visit, and clinical measures have improved. System-wide, staff satisfaction is at an all-time high, and turnover is at 9 percent compared to an industry average of 17 percent.
But because they take seriously the notion of continuous improvement, ThedaCare leaders are forging ahead into still newer territory. "Open access begins to make you think about so many other things you can do in terms of interactivity with patients," says Toussaint. "We will be piloting Internet access for patients to scheduling, prescription refills, email, even their own charts."
Toussaint says the culture of change breeds the continuous desire for more and better ideas. "As you make one revolutionary change, you realize there are 15 more things you would like to do. We have barely scratched the surface. But that's what's fun: you get up in the morning and know you can make a difference."
Long puts it this way: "For too long medicine has revolved around physicians. We are moving toward a new model where medicine revolves around the patient, which, when you think about it, is really the way it should be."