Do you need a facilitator or consultant?
The TransforMed medical home National Demonstration Project (NDP) compared 18 practices that had "facilitators" to 18 practices that did not. Facilitators were individuals with varying degrees of training who assisted study practices in transforming into medical homes. The facilitators served as guides and connectors for practices, but they did not dictate what practices must do or provide simple answers. NDP practices utilized facilitators in many different ways, including making software vendor connections, prioritizing to-do lists and structuring communicative care teams.
The "control" practices were self-directed and were expected to go through many of the same processes that the facilitated practices went through. The control practices had ready access to information about change and medical home components, but they needed to recognize their weak areas, find solutions and prioritize projects on their own.
Facilitated practices also benefited from learning collaboratives where industry experts were invited to teach on such topics as open access, group visits and team-building. Ironically, the self-directed group organized their own collaborative and taught each other on these topics from lessons learned in the first half of the study.
So, if your practice decides that it wants to take on this medical home business, do you need a facilitator or not? This is a good question without any easy answer. As the self-directed practices demonstrated, it is possible to transform without a facilitator. (See "Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home" from the Annals of Family Medicine.) However, facilitators keep the momentum going. Practices transform in "fits and starts." Without a facilitator nudging the process along, practices can stall. The facilitator does not have to come from a firm outside the practice. He or she can certainly be a practice employee, but that employee must have the time, financial support and authority to be the facilitator. Practices will likely transform best if they have a dedicated concept pusher.
Practices may also want to strongly consider a facilitator if they do not have a strong team structure with good communication in place. A practice lacking this fundamental infrastructure will perform poorly in the face of disruptive change (the only type of change in this endeavor). If practice employees tend to be passive-aggressive and negative and work in silos ("that's not MY job"), these are signs that outside help may be needed to build healthy relationship scaffolding before taking on medical home initiatives.
Cost is another factor. If a practice is not a part of a demonstration pilot or does not have extra money lying around, it may want to consider "free changes" first (see the upcoming post "What you can do with no money" in this series). Facilitators can provide online consultation, "spot" solutions or the full transformation package. Prices start in the $100s and can go up to the $10,000s, depending on services, facilitator and practice size.
The most important thing with medical home transformation is to realize that it is a journey, not a destination. Building the team's capacity to change and adjust to outside forces is the most important task in the transformative process. Most practices will likely need some outside help to do this. If not, consider yourself one of the lucky few.
Six ways to communicate better with your administrator
The TransforMed medical home National Demonstration Project (NDP) had a breadth of practice types. Our practice is a "satellite" family medicine clinic with three family physicians. We are part of a regional 250-provider multispecialty clinic. This gave us some advantages (such as already having an electronic medical record) and some disadvantages (like having to go through a lot of bureaucracy to get new projects approved). Communicating effectively with other members of the health system, particularly administrators, became crucial during the NDP. We found some simple steps to help us:
1. Do as much as you can locally without involving the system. By this, I do not mean be deceptive. We simply found that if we could do easy things -- like scheduling team meetings, running an ad in the local paper or surveying patients -- without involving our marketing department or directors, things would get done much faster. This often meant that more physician time was spent on the task, but in the end, the overall efficiency warranted the time spent.
2. Be direct when asking for approvals. Like physicians, administrators are busy people. It is often helpful to have a quick "elevator speech" ready to deliver when you find yourself crossing paths with your administrator. The elevator speech is essentially a 2-minute pitch that summarizes your service or project request, why it is important to the administrator and what action the administrator needs to take. The speech should be very specific, and you should always follow up on the action to ensure it gets done.
3. Listen and establish common ground. Listening requires you to clear your mind and really hear what the other person is saying. Too many times, we are busy formulating a response to the speaker and don't truly listen. It is by listening that physicians can understand better the administrator's operating premise, which is usually quite different from the physicians' perspective. Physicians tend to operate by doing what is best for patients, where administrators are charged with doing what is best for the business. These two basic operating premises are often at odds, but we can learn from one another and find common ground if we truly listen and seek to understand one another's perspectives.
For instance, in studying our immunization rates for patients with diabetes, we were stunned to discover that more than 50 percent of eligible diabetics had not received recommended immunizations. Other NDP practices were using a registry software product that mined the electronic medical record for such data and printed a point-of-service list of services due. We thought using this software would easily solve our immunization problem. We approached our IT administrative team with the request. Five meetings later, we came to understand that the administrative team was blocking our request due to concerns over software incompatibility and cost. From our perspective, the most important consideration was patient care. We did not want one of our patients with diabetes to contract pneumonia and land in the hospital. However, from the administrative side, the most important consideration was that our little project did not crash the system. Once we came to this understanding of each other's perspectives, the IT team was able to show us how to use our existing EMR to perform the registry function we needed.
4. Reserve adequate time for communicating. Good communication takes focused time. Physicians are notorious for running on a continuous, unfocused, multi-tasking hamster wheel. However, we need to slow down from time to time and spend time together listening and problem-solving, at least for large issues. Though most physicians I know dread being summoned to an administrative meeting, these meetings should give both administrators and physicians time to focus on the matter at hand. An even better scenario to allow increased focus would be to ban cell phones and pagers from these meetings. (I'm dreaming.)
5. Run meetings effectively. Respect all meeting attendees' time by sending out an agenda and supporting materials for consideration prior to the meeting. Start the meeting on time, and follow the agenda. Make sure to delegate tasks or action items that come out of the meeting, and follow up on those items with progress reviews at pre-determined intervals. Also, take good notes. You don't want discussion items or actions from one meeting to be forgotten by the next. A lack of follow-through will send a message that members' time and efforts are not respected and appreciated.
6. Take immediate responsibility. Problems should be identified, explored and resolved immediately. Ignoring problems and letting them fester leads to passive-aggressive and counter-productive behaviors. Physicians and administrators both need to own up to problems or failed initiatives and work together using good communication techniques to change course or correct problems.
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About the Author
Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.
Note: This blog is no longer updated; this is archived content.
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