Using a cohort of some 1200 adults presenting to primary care with chest pain, German researchers developed a CAD prediction tool based on five risk factors:

Age of at least 65 for women and 55 for men
Known clinical vascular disease
Worsening pain during exercise
Pain not reproducible on palpation
Patient’s assumption that pain is cardiac in nature

The researchers then tested the tool’s utility in some 700 additional patients. They found that a score of 2 or lower (i.e., 2 or fewer risk factors) ruled out CAD with a sensitivity of 87%, specificity of 81%, and negative predictive value of 98%.

The authors say they believe their tool “will help to prevent overdiagnosis and needless investigations.”

CMAJ article (Free PDF) http://www.cmaj.ca/cgi/rapidpdf/cmaj.100212v1.pdf

As reported in Physician’s First Watch, http://firstwatch.jwatch.org/

Investigators randomized some 500 patients from 24 general practices to self-titration and telemonitoring or to usual care for 1 year. Patients had blood pressures above 140/90 mm Hg despite taking one or two antihypertensive drugs. Intervention patients took pressure readings each morning during the first week of the month. If readings were above the target of 130 systolic for 2 consecutive months, drug dosages were adjusted according to a pre-agreed titration schedule without seeing the family doctor.

By 12 months, mean systolic pressure had dropped 17.6 mm Hg in the intervention group versus 12.2 among controls. Intervention patients were prescribed more drugs over the course of the year than controls — especially calcium antagonists and thiazides. Side effects were largely similar between groups.

An editorialist concludes that wide use of this strategy “is not far off on the horizon.”

(as reported by Physician’s First Watch, http://jwatch.org/)

“Don will have the opportunity to advance the cause of health care improvement at a time when the future of our health care system is inextricably linked to the future health of the American people and the US economy”, says A. Blanton Godfrey, IHI Board Chairman.

Maureen Bisognano, IHI’s Executive Vice President and Chief Operating Officer, will succeed Don as President and CEO of IHI.

Gene Pascuzzo Describes his Patient Journey

We know that the ‘real work’ in chronic disease management is done by the patient themselves.

How can we improve the most important partnership in health?

This was a major focus of the IHI forum in Washington this week.

How well do you provide Patient and Family Centred Care

The Indian Medical Service provides health care to 1.9 Native Americans.
They challenged us with this survey to assess our experience with patient and family involvement.

Are you an A, B or C?

• A. Beyond patient satisfaction surveys or focus groups, our organisation does not have a formal method for obtaining patient and family feedback.
• B. We have an active patient/family advisory panel
• C. Patient and family are members of satnding committess and makes decisions at the program an policy level.

Even more challenging, the IHI has a draft organisational self- assessment tool relating to patient and family centred care.
How many ‘Yes’s can you score?
More information from the IHI on Patient Centred Care is available here

Patients as Partners

British Columbia in Canada (BC), has been developing a ‘Patients as Partners’ program, as part of their wider primary health care agenda.

Kelly McQuillen is Director of Patient as Partners with the Ministry of Health services. Connie Davis is a senior quality improvement advisor with Impact BC, a not-for-profit organisation established to work across BC’s health system in support of system improvement and transformation. They are the co-leaders of the Patients as Partners agenda, and their team presented a Mini-Course on Patient Partnerships.

The Chronic Disease Model emphasises the important of the informed motivated patient working in partnership with an available activated primary care team.

In BC, they want to wrap the patient in a general practice, and wrap this practice in support.

Patients as Advocates

“Why do we want patients as partners?”, asked the Ministry of Health Services.

Poor experiences in health care lead to poor safety, poor outcomes, increased costs, and reduced support for the health service. Providers want to provide good experiences.

The patient voice can change the ’soclal contract’ between the government and primary care. In a time of health care reform, they can be our strongest advocates – if we let them in on the secret. When decisions are made as to where resources should best be allocated, the patients voice is the one that has the most influence before government and opposition.

Training for Patients

When the BC government and the BC Medical Association asked General Practice how they could assist in making their primary care role better, the answer was
“Value Us, Pay Us, Train Us, Support Us”

The same applies to improving the participation of patients in primary care delivery.

They need training in understanding of the structure of general practice and the health care system, the nature of patient involvement,communication, self-mamangement and listening skills. They need support to meaningfully engage with physicians.

The Consumers Health Forum (in Canberra) would say there is a great difference between a ‘patient’ and an ‘informed consumer’.

Choosing patients, training them and supporting them in their role is a challenge for those who want to partner with patients, and is often neglected.

Just as importantly, providers need to be trained to meaningfully engage with patients. In BC, they have developed a comprehensive approach through stakeholder partnerships and leadership of the General Practice Services Committee, Practice Support Program (PSP). The PSP assists clinicians with practice redesign, including patient engagement. The BC Ministry also funds and supports Self-management education and self-management support through programs offered through the University of Victoria (the Chronic Disease Self-management Program) and the Canadian Mental Health Association (Bounce Back). These programs ensure a consistent training experience and curriculum.

Principles
The Institute of Family Centered Care outlines four Core principles for patient centered care delivery.

• Dignity and Respect
• Information Sharing
• Participation
• Collaboration

Using these principles, The Canadian program has a comprehensive approach to patient partnership. They identify three key levels where this should occur.

• Individual Health Care
• Shaping the Primary Health Care System
• Bringing in the Community

This is a challenge to many of us providing primary care, or developing programs to foster patient involvement in the health system.

Individual Health Care

Many of us are aware of the need to foster patient self management. How many of us have systems in place to improve our patients’ ability to self manage? How many of us have measures in place to determine whether we are meeting this goal.

The BC team nominated these as possible measures for self-management support.

• Access to self-management programs
• Patients in Integrated Health Networks & Practice Support Program with action plans
• Number of health care professionals trained in self-management support
• Patient experience survery
• Patient self-management confidence survey
• Provider confidence in Self Management Support

Sample surveys are available at http://www.newhealthpartnerships.org/ & http://www.howsyourhealth.org

For the last two years, Kelly McQuillen has been the director of the Patients as Partners, Primary Health Care, Ministry of Health Services. In this capacity, she has worked with other stakeholders to expand access to self management services such as the Univeristy of Victoria’s “Living a Healthy Life with Chronic Disease”

This is a peer led program, in which leaders (who also have a chronic disease) first attend a four day training workshop.

In the group classes, the leaders work through a scripted leaders manual. Group size is about 10, and meet weekly for 2 and a half hours each week over 6 week. There is a “Living a Healthy Life with Chronic Conditions” workbook for each participant.

The skills taught include Problem solving, Decision making, Resource utilization, Patient-provider relationships and Taking action.

At 6 months there was demonstrated improvements in exercise, communication, self-reported health, disability and social activity.

The two year results in implementation of this Stanford model of CDSMP are encouraging, with a decrease in emergency room visits and health distress and improvement in self-efficacy.

Lorig, K., Ritter, P., Stewart, A., Sobel, D., Brown, B., Bandura, A., Gonzalez, V., Laurent, D. & Holman, H. (2001). Chronic Disease Self-
Management Program: Two year health status and health care utilization outcomes. Medical Care, 39(11), 1217 – 1223.

Training for clinicans

Dr. Shirley Sze is a physician champion in the practice support program and is committed to the ‘Patients as Partners’ agenda. Through the Practice Support Program of the GPSC, physicians like Shirley have assisted to develop and deliver comprehensive training program for clinicans in Patient Self Management Support.

This includes aspects of focusing on the patients agenda, motivational interviewing, behaviour change and dealing with ambivalence. A collaborative approach to support productive interactions through self-management was implemented.

The modules of the Practice Support Program are described in detail here

A number of other resources including instructive videos are available on the practice support section of the impactbc website

Health Literacy

Connie Davis and the PHC partners have been working on a Health Literacy Prototype Collaborative in Communities.

The collaborative teams included adult literacy teachers, physicians, quality improvement advisors from the Health Authorities and patients.

The key themes that emerged were Relationships (values, preferences, respect), Creating Understanding (plain speech, follow up, technology, easy wayfinding) and Partnering with the Community (peers, education, resources)

A key strategy that improved understanding was when clinicians used a Teachback Technique to ‘close the loop’.
eg “Can you say that back to me so I know that what I said was clear”.

Walking through your system from time of making an appointment to leaving the practice, and arranging the follow up, was also a useful tool.

Measures used included a patient survey asking

• “My doctor asked about my ideas, my beliefs, and what I wanted when we planned my care.”
• “My doctor explained things to me in a way that was easy to understand.”
• “I felt comfortable asking questions.”
• “It was easy for me to tell the doctor when there was something I did not understand.”

Practices in the collaborative that had improvements in these scores also had significant improvements in clinical outcomes.

Shaping the Primary Health System

Do you have a goal of including the patient’s voice in the way you deliver primary care in your practice? In what ways do you do this? Can you measure how well you include patients in the design?

This is an area where most practices / system find that little pre-work has been done. There is concern that patients will ’see our dirty laundry’ – when in fact that is what they see every day.

The aim is to
• Include voice, choice and representation in transformation efforts
• Create a habit of patient and family involvement from policy to practice level
• Train and support patients and providers towards meaningful engagement

In a group setting, patients are the ones that don’t allow other patients to make unrealistic suggestions.

One activity that proved very useful in BC was mapping the Patient Journey.

Eugene Pascuzzo was a farmer who presented at the conference. All providers in the system and patients with diabetes got together for a day to process map the ‘patient journey’ – what was required in all his contacts with the health system. There was enormous advantage in having everyone together – pathology, allied health, specialists, GPs. All were surprised at the complicated path required. Very significant improvements were made in the design of the services to enable the patient to undertake the journey to self management.

A video of his story is available here

The patients who worked with Gene found group visits as an excellent way to improve their self management and to simplify their patient journey. Note that ‘group visits’ fizzle out unless the doctor is a participant. In Gene’s group, each patients key measures (BP, Chol, HbA1C) are displayed using a data projector for the whole group to see.

Gene says

We mapped a chronic disease from diagnosis to self management from patient’s view point… Patients felt heard and valued as equal partners and loved it, but for several providers, it was a new and unsettling experience

Having empowered patients involved is key.

The process mapping exercise is based on the work of the NHS. These resources are recommended

• NHS Institute for Innovation and Improvement, (2010)
  Process Mapping, Analysis, and redesign.

• Impact BC (Nov 26, 2009) a step by step
  presentation on mapping

• Willis, D. (2005) Making Every Minute Count

Bringing in the Community

Do you aim to include the voice of the community in the way primary care is delivered? How will you do this? Can you measure the participation of the community in primary care efforts?

Initially, the General Practice Services Committee, responsible for improving the delivery of primary care services in BC, was reluctant to actively engage with patients. Asking might raise expectations of what can be achieved and this could require significant change beyond their scope and mandate.

In the spirit of patient centered care they stepped up to support the desired agenda of partnership with patients and public.

The GPSC Experience and the overall provincial patients as partners experience in primary healthcare has shown the benefits of having patients involved in decision making to such an extent that now each step is taken with the understanding that patients are required at the table to ensure population needs are considered..

Patients have been instrumental in developing developing the patients as partners agenda and have a strong desire to continue to have a voice around provincial programs – they aim to act as a strong voice for general practice.

How well do we achieve patient and public involvement in health
care specifically and in their communities in general. Do we continuously include patient/family and public voice, choice
and representation?

As Sue Davis, Vancouver Coastal Health Authority, says – do you get legitmate engagement from the ‘get-go’?

In BC, there were three programs in particular that were profiled where they have worked to bring the community together to improve health outcomes.

The Vascular Improvement Program brings together patients, community service groups, the Heart Foundation, public health providers, hospital, rehabilitation services, local councils, provincial governments, and other local groups to tackle the problem of premature vascular disease together.

Integrated Health Network

An Integrated Health Network is a formal partnership between patient, family doctor and selected health care practitioners. It is a virtual team tailored to patient’s specific needs, with the patient (and family) as key partners. It is a process used for patients with a number of chronic diseases at high risk of morbidity. The IHNs work to wrap care around the complex care patients to reduce hospitalizations, delay residential care, improve patient and provider experience and to build a sustainable model of quality primary health care.

The PatientVoices Network

The PatientVoices Network is a new program through the leadership of the Healthy Heart Society and the Ministry of Health Services that aims to create mechanisms for patients, their families and community stakeholders to participate in primary healthcare /system changes. The network supports and facilitates the Patients as Partners Primary Health Care agenda.

It provides patients with a forum to discuss health system issues, and provides specific training and guidance for patients in the network to become leaders in advocating patient-centred health reform and peer-peer coaching.

It is centred around a ‘virtual community’ of web resources that is in active development. Details can be found at www.patientvoices.ca

Improved health outcomes require an informed motivated patient working in partnership with an available activated primary care team. Often in design of our health care services the ‘patient’ side of this equation is neglected. The ‘Patients as Partners’ agenda works to ensure that both sides of this partnership are optimised.

The building industry uses checklists to ensure major projects run to schedule and are safe.

So why don’t we use checklists more in medicine?

This is the question asked by the American surgeon and columnist, Atul Gawande, author of ‘Better’, (previously reviewed)

A number of studies have shown the effectiveness of checklists in improving surgical outcomes. The most famous of these is the work of Peter Provonos. The Keystone Initiative in Michigan reduced central line infection rates by 66% – in 18 months saving $175 million and more than fifteen hundred lives. As Atul Gawande says, ‘all because of a stupid little checklist’.

‘Under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgement, but judgemnent aided and enhanced by procedure’

The answer would appear to be that we should use checklists more – if we want to get things right.

There is a definite art in designing effective clinical checklists. When well done, the results can be extraordinarliy successful in improving safety and quality.

We’ll start a checklist sharing service here at practiceimprovement.com.au.

Send us your thoughts through the comments below.

Bob W will tell you that his life was saved from bowel cancer by his doctor. The surprising thing in Bob’s story is that he is referring to his orthopaedic surgeon!

Bob is one of 8.6 million people cared for by Kaiser Permanente, a US health care organisation that looks after 8.6 Million people, employing a staggering 14000 physicians, and 160000 other staff. They provide all aspects of their customers’ health care needs – acute, preventative, routine, hospital care, allied health care,investigation and chronic disease management. In this ‘vertically integrated system’, they run 431 office practices and 35 hospitals.

If you are a patient of Kaiser’s, all your care needs are ‘pre-paid’ – if they can keep you healthy, then it will be easier and less expensive to look after you. They have both the usual ethical interest in keeping you well, as well as a huge financial one!

Kaiser have developed a ‘Proactive Office Encounter’ protocol as part of their system. Dr Michael Kanter is a physician and the Proactive Care Group Leader with Kaiser. He and Dr Ozzie Martinex presented at the IHI Forum in Washington this morning.

“Every time a patient has any contact at any of our services, his or her record is checked to make sure that they have had all of the health screening activities that are indicated – given their age, sex, history and other medical problems.”

Dr Kanter says that

applying this integrated and coordinated care delivery process has resulted in a positive impact on the lives of members in areas of cancer screening, blood pressure control, cardiac health, diabetes, asthma management, immunizations, tobacco cessation, weight management, and exercise.

Go in to have a mammogram, and they’ll let you know that you are due for a cholesterol check. Go to the ED with an acutely swollen and painful knee, and the orthopaedic surgeon will fix your knee – and send you home with a bowel cancer screening kit, if it is due.

All Good Now

Bob saw his orthopaedic surgeon with his crook knee one afternoon in the urgent care centre. She fixed his knee- and handed him the kit for his bowel screening, which he’d put off for a year.

He was surprised to get a call a few days later by his regular primary care doctor. A colonoscopy had been arranged for the next week, as the screen was positive.

The colonoscopy did show a cancer. He was booked for surgery.

The night before he was due to go in, the surgeon rang him at home at 7pm. Bob tells this part of the story with a tear in his eye. The abdominal MRI had shown a large renal tumour, which had to be dealt with first.

Now, according to Bob, its all good. “I’ve lost one kidney and one foot of bowel. No problem – I’ve got another kidney and still have four feet of bowel left”

System Changes

Think about this system – how many processes have to be done just right for Bob’s cancer to have been discovered.

For a booked appointment at any of their facilities, the ‘Proactive Office Encounter’ begins a week before the appointment is scheduled. An automatic service lets the staff know that the patient should have some preventative activities or other tests. Where practical, these are arranged beforehand, so that the results will be available when they come in – or the necessary test booked on the same day they are coming in to save a revisit.

For acute and unscheduled appointments, the necessary tests are flagged when the patient arrives.

The Proactive Office Encounter system will flag any other activities that should be done when the patient has arrived and before they see the doctor. All of these are done by the ‘Medical Assistant’. Any ‘labs’ required are signed off by the doctor, and the need for them is reinforced by the doctor

When Bob was seen in the urgent care centre, the medical assistant was notified of Bob’s ‘care gap’, even though this was not the usual office that Bob attended. The assistant included the bowel test kit in his papers, and informed the orthopaedic surgeon when he handed Bob over to her. It was made very easy for the surgeon to provide comprehensive care – as it should be. A good system should not be dependent on the individual delivering the care.

Culture Change

Dr Kanter says that it requires quite a culture change for many specialists to participate in a program like this. The POE system monitors how effectively the ‘care gaps’ are filled in each facility and by each physician within the system. (the ‘care gap’ is not considered closed when the test is requested, only when it has actually been done! “You can’t get away with saying that its not your job”.)

Tools

The tools that have been developed for the Proactive Office Encounter program include

• Standardd Office Workflows
• Condition Specific Workflows
• Phyiscian Specific Workflows
• POE Skills Inventory for Staff
• Training for staff (including videos of each step)
• Skill Validation Tools
• Performance Monitioring Tools.
• Chart Review Tools
• Workflow Efficieny Audit Tools
• Physician Surveys

eHealth Investment

Kaiser has invested heavily in eHealth throughout their facilities, and programs like the POE demonstrate the opportunities that are only available when health records are linked across a system.

The electonic medical record system Kaiser Permanente HealthConnect is used in all their facilities nationwide. The data it contains is up to date, coded, and available anywhere. They have accurate disease registers and use these to facilitate proactive and systematic management. As well as preventative and disease specific preventative health prompts, physicians have decision support tools built in to the medical software.

Patients have access to their health information via their web portal kp.org. Post consultation instructions and follow up arrangements, including recommended screening tests, and available to the patients immediately after their visit. Patients can also be contacted by secure email through this system, and contact their clinicans.

Has it worked?

Dr Kanter says that measurement and data are the key to pulling a program like this together. They collect data at every level, including a “Successful Opportunities Report” and a “Clinical Strategic Goals Report” to make sure that the changes they have made are leading to improvements.

Kaiser has documented how many lives have been saved through their many screening programs.

Since the POE was introduced in 2007, there has been improvement in Kaisers clinical strategic goals. One thing I find amazing in these figures is from a very high base rate of screening – and still were not satisfied with that.

The POE system is supplemented by an ‘outreach system’ (mail and email) for people who have overdue tests and haven’t been in. Dr Kanter says that given the success of the POE they will soon introduce a Proactive Inpatient Encounter System for hospital patients.

Many practices are using Doctor’s Control Panel to match up the patient’s screening requirements with the RACGP ‘red book’. Imagine this being available proactively throughout the entire health system!

How are you going in your practice?

Do you deliver evidence based care to every single patient, every single time?

Please share your story, or your comments, below.

Each year the Institute of Healthcare Improvement hold a major forum on Improving Clinical Office Practice.

This year ‘Improving Patient Care in the Office Practice and the Community’ is the 11th such forum and will be held in Washington.

I’m currently posting from AA76 LA to Washington Dulles, so will keep ‘practice improvement’ informed of any new points of interest.

So far, I can report that in flight WiFi access ($12.95 per flight) works very well.

This can be used as the key component of a GP Management Plan and Team Care Arrangement. It can act as a communication tool between all providers involved in a patient’s care – are they all ‘on the same page’?.

It can also contain information for the patient about their conditions. This can be provided by a range of team members to assist in self management.

‘A4 Document Folders’ with plastic sleeves have been used by many practices.

The Patient Held Record may contain

• the patients current problems
• medical history
• current medication list
• key goals and targets, and progress towards them
• recent results (bloods, Xrays, ECGs, spirometer readings)
• specialist letters
• a care calendar
• referral letters to specialists, Xray and pathology
• information about their condition (handouts)

Doctors Grand Plaza have posted their story ‘The Blue Folder‘ to the APCC 1001 stories web site. This includes an example of “the care calendar” they have developed.

Your comments and suggestions are welcome.

Are there any pages or templates you have found useful to include in a Patient Held Medical Record?

He was a hard headed man....

“Life in the Fast Lane,
Surely make you lose your mind“

The Collins Street Medical Centre has developed a strategy that has been effective in changing their capacity to match their demand.

Why block up a 15 minute slot if all that is needed is a brief appointment for a script, a certificate, a referral or a normal result?

Andrew Knight has collected a number of variations on this idea in this article at our new sister site APCC Stories.

The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!

What did they do? Like many of the successful practices in the collaborative they created a new creature – the chronic disease coordinator.

Their story is on our new sister site at

http://stories.apcc.org.au/2009/11/the-rise-and-rise-of-the-chronic-care-coordinator/