Chris Moriates, MD

 

Editor’s note: First published on The Hospital Leader blog under the title, “How I Realized QI Could Be a Dirty Word.”
 

With the recent election, there has been a new recognition of the various “bubbles” we all seem to be living in. It reminds me of the parable I like to often mention, popularized by the late great writer David Foster Wallace: Two fish were swimming along when an older fish swam by, nodded his head at them and said, “Mornin’ boys, how’s the water?” The two young fish nod back and swim for a bit, then one turns to the other and says, “What the hell is water?”

Recently, I read a paper that helped me realize I had been swimming in a different lake from most of the “real world” in medicine. I trained and then spent the first four years of my postresidency career at the University of California, San Francisco, where quality improvement (QI) was well established and celebrated. Sure, I suppose there were some eye rolls from a few surgeons; I would hear on occasion the off-hand snide remark from a cardiology attending, but by and large, QI was not controversial at UCSF. It is what we do. As residents, we led QI projects and contributed to QI projects from our colleagues. As a hospitalist faculty member, I led my own QI-related projects and mentored residents and other faculty who led their own QI projects.

Imagine the hard reality that hit me when I read this quote from a resident: “Truly, the first thing I think of when I hear [QI] is going to make more work for residents.”

Wait – is QI actually a dirty word for other residents and physicians?

The quote comes from an Academic Medicine study titled “ ‘It Feels Like a Lot of Extra Work’: Resident Attitudes About Quality Improvement and Implications for an Effective Learning Health Care System.” I read on, and it got worse.

“This hasn’t really made any difference to the patients. Like this checklist we do on rounds, like I don’t know. Maybe it has.”

And, by far, most concerning: “There’s like the central line protocols … If you suspect that anybody has any type of bacteremia, you don’t do a blood culture; you just do a urine culture and pull the lines … we just don’t even test for it because the quality improvement then like marks you off.”

Wow.

That is some harsh truth about unintended consequences right there. (Also, apparently us kids of the 1990s still say “like” a lot, which is, like, not very professional and also like kinda grating.)

The residents in this study were from the University of Utah, Salt Lake City – an institution I frequently– and publicly – admire for their incredible progress on systematically introducing value improvement into their practice.

What can we do?

Read the full post at hospitalleader.org.
 

Also on The Hospital Leader…

• THIS Is What Teamwork Looks Like, by Danielle Scheurer, MD, MSCR, SFHM
• The Medicaid Overhaul and How Hospitals and Their Providers Could Be Hardest Hit, by Brad Flansbaum, DO, MPH, MHM
• Count Me – and My Intuition – In, by Tracy Cardin, ACNP-BC, SFHM

 

Editor’s note: First published on The Hospital Leader blog under the title, “How I Realized QI Could Be a Dirty Word.”
 

With the recent election, there has been a new recognition of the various “bubbles” we all seem to be living in. It reminds me of the parable I like to often mention, popularized by the late great writer David Foster Wallace: Two fish were swimming along when an older fish swam by, nodded his head at them and said, “Mornin’ boys, how’s the water?” The two young fish nod back and swim for a bit, then one turns to the other and says, “What the hell is water?”

Recently, I read a paper that helped me realize I had been swimming in a different lake from most of the “real world” in medicine. I trained and then spent the first four years of my postresidency career at the University of California, San Francisco, where quality improvement (QI) was well established and celebrated. Sure, I suppose there were some eye rolls from a few surgeons; I would hear on occasion the off-hand snide remark from a cardiology attending, but by and large, QI was not controversial at UCSF. It is what we do. As residents, we led QI projects and contributed to QI projects from our colleagues. As a hospitalist faculty member, I led my own QI-related projects and mentored residents and other faculty who led their own QI projects.

Imagine the hard reality that hit me when I read this quote from a resident: “Truly, the first thing I think of when I hear [QI] is going to make more work for residents.”

Wait – is QI actually a dirty word for other residents and physicians?

The quote comes from an Academic Medicine study titled “ ‘It Feels Like a Lot of Extra Work’: Resident Attitudes About Quality Improvement and Implications for an Effective Learning Health Care System.” I read on, and it got worse.

“This hasn’t really made any difference to the patients. Like this checklist we do on rounds, like I don’t know. Maybe it has.”

And, by far, most concerning: “There’s like the central line protocols … If you suspect that anybody has any type of bacteremia, you don’t do a blood culture; you just do a urine culture and pull the lines … we just don’t even test for it because the quality improvement then like marks you off.”

Wow.

That is some harsh truth about unintended consequences right there. (Also, apparently us kids of the 1990s still say “like” a lot, which is, like, not very professional and also like kinda grating.)

The residents in this study were from the University of Utah, Salt Lake City – an institution I frequently– and publicly – admire for their incredible progress on systematically introducing value improvement into their practice.

What can we do?

Read the full post at hospitalleader.org.
 

Also on The Hospital Leader…

• THIS Is What Teamwork Looks Like, by Danielle Scheurer, MD, MSCR, SFHM
• The Medicaid Overhaul and How Hospitals and Their Providers Could Be Hardest Hit, by Brad Flansbaum, DO, MPH, MHM
• Count Me – and My Intuition – In, by Tracy Cardin, ACNP-BC, SFHM

 

Editor’s note: First published on The Hospital Leader blog under the title, “How I Realized QI Could Be a Dirty Word.”
 

With the recent election, there has been a new recognition of the various “bubbles” we all seem to be living in. It reminds me of the parable I like to often mention, popularized by the late great writer David Foster Wallace: Two fish were swimming along when an older fish swam by, nodded his head at them and said, “Mornin’ boys, how’s the water?” The two young fish nod back and swim for a bit, then one turns to the other and says, “What the hell is water?”

Recently, I read a paper that helped me realize I had been swimming in a different lake from most of the “real world” in medicine. I trained and then spent the first four years of my postresidency career at the University of California, San Francisco, where quality improvement (QI) was well established and celebrated. Sure, I suppose there were some eye rolls from a few surgeons; I would hear on occasion the off-hand snide remark from a cardiology attending, but by and large, QI was not controversial at UCSF. It is what we do. As residents, we led QI projects and contributed to QI projects from our colleagues. As a hospitalist faculty member, I led my own QI-related projects and mentored residents and other faculty who led their own QI projects.

Imagine the hard reality that hit me when I read this quote from a resident: “Truly, the first thing I think of when I hear [QI] is going to make more work for residents.”

Wait – is QI actually a dirty word for other residents and physicians?

The quote comes from an Academic Medicine study titled “ ‘It Feels Like a Lot of Extra Work’: Resident Attitudes About Quality Improvement and Implications for an Effective Learning Health Care System.” I read on, and it got worse.

“This hasn’t really made any difference to the patients. Like this checklist we do on rounds, like I don’t know. Maybe it has.”

And, by far, most concerning: “There’s like the central line protocols … If you suspect that anybody has any type of bacteremia, you don’t do a blood culture; you just do a urine culture and pull the lines … we just don’t even test for it because the quality improvement then like marks you off.”

Wow.

That is some harsh truth about unintended consequences right there. (Also, apparently us kids of the 1990s still say “like” a lot, which is, like, not very professional and also like kinda grating.)

The residents in this study were from the University of Utah, Salt Lake City – an institution I frequently– and publicly – admire for their incredible progress on systematically introducing value improvement into their practice.

What can we do?

Read the full post at hospitalleader.org.
 

Also on The Hospital Leader…

• THIS Is What Teamwork Looks Like, by Danielle Scheurer, MD, MSCR, SFHM
• The Medicaid Overhaul and How Hospitals and Their Providers Could Be Hardest Hit, by Brad Flansbaum, DO, MPH, MHM
• Count Me – and My Intuition – In, by Tracy Cardin, ACNP-BC, SFHM

EDITOR’S NOTE: A version of this article originally appeared on Medpage Today on May 5, 2015.

---

By now, we have all heard the stories about unconscionable medical bills causing financial harm for patients. We have read about more Americans than ever before on high-deductible health insurance plans. Some of us have even helped our parents navigate the deceptively simple-looking bronze, silver, and gold tiers of the insurance exchanges, weighing the gamble of increasingly unaffordable monthly premiums against catastrophically high deductibles and out-of-pocket costs.

We have accepted the fact that healthcare costs are out of control and causing real constraints on every level, from individuals to communities to businesses to states to our nation.

OK, but now what are we supposed to do about it?

“Remarkably, given the importance of this issue, until now, we lacked a roadmap to attack it,” wrote Bob Wachter, MD, in the foreword to our new book, Understanding Value-Based Healthcare. “Now we have one.”

For starters, we can supply a pipeline for change by embedding the principles of value-based care in the apprenticeship of health professional education. Recently, the leaders of the soon-to-open Dell Medical School at University of Texas-Austin articulated their plan to build their entire curriculum around teaching students to root out waste and to care for the health of the community. This is the clearest example that medical educators are taking seriously the calls to action coming from the Accreditation Council for Graduate Medical Education (ACGME), the Association of American Medical Colleges (AAMC), the American College of Physicians (ACP), and other leaders to address healthcare value in training very seriously. However, the front lines are not waiting for new medical schools to open up or for massive curricular overhauls. The Second Annual Teaching Value and Choosing Wisely Challenge that we organized resulted in 80 submissions spanning the country (and Canada). The authors, including five students, 30 residents or fellows, and at least 41 faculty members, described their bright ideas and innovations for integrating healthcare value into education.

Education is fundamental but will not be enough. We must also practice what we preach. Practicing clinicians can deflate medical bills for their patients by advocating for appropriate care, considering patient affordability in customizing treatments, and leading local initiatives to improve value of care.

Clinicians can advocate for appropriate care by avoiding low-value services at the point of care. Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. Physicians will need to understand the true risks and benefits of recommended therapies and learn ways to communicate this balance with patients.

Patient affordability is increasingly important, with more patients now facing astronomically high out-of-pocket bills, even for simple medical treatments or procedures. A December 2014 CBS/New York Times poll found that 80% of Americans now think their doctor should discuss the cost of recommended medical treatment with them ahead of time. Clinicians can screen their patients for financial harm and can help them navigate the trade-offs of lower cost options. Physicians should seek to provide high-value prescribing, which entails recommending the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome. In other words, decreasing either cost, complexity, or risk of medications can improve value—and clinicians should aim to improve all three simultaneously.

In addition to reducing waste and considering patient affordability, clinicians are ideal leaders of local value initiatives, whether they accomplish this by running value improvement projects or by launching formal high-value care programs. Our framework to guide value improvement project design is “COST”: culture, oversight accountability, system support, and training. This approach leverages principles from implementation science to ensure that value improvement projects successfully provide multi-pronged tactics for overcoming the many barriers to high-value care delivery. At some locations across the country, individual efforts have matured into entire groups dedicated to designing and implementing value-improvement initiatives, including the UCSF High Value Care Committee, the Johns Hopkins High-Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering (PRO), and “High-Value Carolina” in North Carolina.

 

Health professionals are faced with a responsibility to help deflate medical bills. To achieve this goal, clinicians can advocate for appropriate care, consider patient affordability, and lead local value improvement initiatives. For those ready to tackle this challenge, we elaborate on and explain some of these necessary tools in our book, Understanding Value-Based Healthcare.

EDITOR’S NOTE: A version of this article originally appeared on Medpage Today on May 5, 2015.

---

By now, we have all heard the stories about unconscionable medical bills causing financial harm for patients. We have read about more Americans than ever before on high-deductible health insurance plans. Some of us have even helped our parents navigate the deceptively simple-looking bronze, silver, and gold tiers of the insurance exchanges, weighing the gamble of increasingly unaffordable monthly premiums against catastrophically high deductibles and out-of-pocket costs.

We have accepted the fact that healthcare costs are out of control and causing real constraints on every level, from individuals to communities to businesses to states to our nation.

OK, but now what are we supposed to do about it?

“Remarkably, given the importance of this issue, until now, we lacked a roadmap to attack it,” wrote Bob Wachter, MD, in the foreword to our new book, Understanding Value-Based Healthcare. “Now we have one.”

For starters, we can supply a pipeline for change by embedding the principles of value-based care in the apprenticeship of health professional education. Recently, the leaders of the soon-to-open Dell Medical School at University of Texas-Austin articulated their plan to build their entire curriculum around teaching students to root out waste and to care for the health of the community. This is the clearest example that medical educators are taking seriously the calls to action coming from the Accreditation Council for Graduate Medical Education (ACGME), the Association of American Medical Colleges (AAMC), the American College of Physicians (ACP), and other leaders to address healthcare value in training very seriously. However, the front lines are not waiting for new medical schools to open up or for massive curricular overhauls. The Second Annual Teaching Value and Choosing Wisely Challenge that we organized resulted in 80 submissions spanning the country (and Canada). The authors, including five students, 30 residents or fellows, and at least 41 faculty members, described their bright ideas and innovations for integrating healthcare value into education.

Education is fundamental but will not be enough. We must also practice what we preach. Practicing clinicians can deflate medical bills for their patients by advocating for appropriate care, considering patient affordability in customizing treatments, and leading local initiatives to improve value of care.

Clinicians can advocate for appropriate care by avoiding low-value services at the point of care. Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. Physicians will need to understand the true risks and benefits of recommended therapies and learn ways to communicate this balance with patients.

Patient affordability is increasingly important, with more patients now facing astronomically high out-of-pocket bills, even for simple medical treatments or procedures. A December 2014 CBS/New York Times poll found that 80% of Americans now think their doctor should discuss the cost of recommended medical treatment with them ahead of time. Clinicians can screen their patients for financial harm and can help them navigate the trade-offs of lower cost options. Physicians should seek to provide high-value prescribing, which entails recommending the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome. In other words, decreasing either cost, complexity, or risk of medications can improve value—and clinicians should aim to improve all three simultaneously.

In addition to reducing waste and considering patient affordability, clinicians are ideal leaders of local value initiatives, whether they accomplish this by running value improvement projects or by launching formal high-value care programs. Our framework to guide value improvement project design is “COST”: culture, oversight accountability, system support, and training. This approach leverages principles from implementation science to ensure that value improvement projects successfully provide multi-pronged tactics for overcoming the many barriers to high-value care delivery. At some locations across the country, individual efforts have matured into entire groups dedicated to designing and implementing value-improvement initiatives, including the UCSF High Value Care Committee, the Johns Hopkins High-Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering (PRO), and “High-Value Carolina” in North Carolina.

 

Health professionals are faced with a responsibility to help deflate medical bills. To achieve this goal, clinicians can advocate for appropriate care, consider patient affordability, and lead local value improvement initiatives. For those ready to tackle this challenge, we elaborate on and explain some of these necessary tools in our book, Understanding Value-Based Healthcare.

EDITOR’S NOTE: A version of this article originally appeared on Medpage Today on May 5, 2015.

---

By now, we have all heard the stories about unconscionable medical bills causing financial harm for patients. We have read about more Americans than ever before on high-deductible health insurance plans. Some of us have even helped our parents navigate the deceptively simple-looking bronze, silver, and gold tiers of the insurance exchanges, weighing the gamble of increasingly unaffordable monthly premiums against catastrophically high deductibles and out-of-pocket costs.

We have accepted the fact that healthcare costs are out of control and causing real constraints on every level, from individuals to communities to businesses to states to our nation.

OK, but now what are we supposed to do about it?

“Remarkably, given the importance of this issue, until now, we lacked a roadmap to attack it,” wrote Bob Wachter, MD, in the foreword to our new book, Understanding Value-Based Healthcare. “Now we have one.”

For starters, we can supply a pipeline for change by embedding the principles of value-based care in the apprenticeship of health professional education. Recently, the leaders of the soon-to-open Dell Medical School at University of Texas-Austin articulated their plan to build their entire curriculum around teaching students to root out waste and to care for the health of the community. This is the clearest example that medical educators are taking seriously the calls to action coming from the Accreditation Council for Graduate Medical Education (ACGME), the Association of American Medical Colleges (AAMC), the American College of Physicians (ACP), and other leaders to address healthcare value in training very seriously. However, the front lines are not waiting for new medical schools to open up or for massive curricular overhauls. The Second Annual Teaching Value and Choosing Wisely Challenge that we organized resulted in 80 submissions spanning the country (and Canada). The authors, including five students, 30 residents or fellows, and at least 41 faculty members, described their bright ideas and innovations for integrating healthcare value into education.

Education is fundamental but will not be enough. We must also practice what we preach. Practicing clinicians can deflate medical bills for their patients by advocating for appropriate care, considering patient affordability in customizing treatments, and leading local initiatives to improve value of care.

Clinicians can advocate for appropriate care by avoiding low-value services at the point of care. Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. Physicians will need to understand the true risks and benefits of recommended therapies and learn ways to communicate this balance with patients.

Patient affordability is increasingly important, with more patients now facing astronomically high out-of-pocket bills, even for simple medical treatments or procedures. A December 2014 CBS/New York Times poll found that 80% of Americans now think their doctor should discuss the cost of recommended medical treatment with them ahead of time. Clinicians can screen their patients for financial harm and can help them navigate the trade-offs of lower cost options. Physicians should seek to provide high-value prescribing, which entails recommending the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome. In other words, decreasing either cost, complexity, or risk of medications can improve value—and clinicians should aim to improve all three simultaneously.

In addition to reducing waste and considering patient affordability, clinicians are ideal leaders of local value initiatives, whether they accomplish this by running value improvement projects or by launching formal high-value care programs. Our framework to guide value improvement project design is “COST”: culture, oversight accountability, system support, and training. This approach leverages principles from implementation science to ensure that value improvement projects successfully provide multi-pronged tactics for overcoming the many barriers to high-value care delivery. At some locations across the country, individual efforts have matured into entire groups dedicated to designing and implementing value-improvement initiatives, including the UCSF High Value Care Committee, the Johns Hopkins High-Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering (PRO), and “High-Value Carolina” in North Carolina.

 

Health professionals are faced with a responsibility to help deflate medical bills. To achieve this goal, clinicians can advocate for appropriate care, consider patient affordability, and lead local value improvement initiatives. For those ready to tackle this challenge, we elaborate on and explain some of these necessary tools in our book, Understanding Value-Based Healthcare.