Curbside Consult with Dr. Jayne 8/28/17

My heart goes out to the people of Houston along with the many other areas impacted by Hurricane and Tropical Storm Harvey. In addition to residents who weren’t able to leave the area before the flooding, there are scores of out-of-town patients stranded after traveling to Houston for care at facilities such as MD Anderson Cancer Center.

Working in the ED and urgent care space, I’m connected to my community’s emergency preparedness efforts. Natural disasters can strike anywhere at any time and I would encourage everyone to take this opportunity to make sure your family has a preparedness plan. Keeping a small stock of non-perishable food and bottled water is a good idea for everyone. Even if you don’t live in a flood plain, tornado alley, fault zone, or wildfire hazard area, there’s always a chance of losing power or other essential services.

Healthcare organizations large and small should also have preparedness plans, including resources to support staff who might become stranded at work. My area is prone to ice storms, and although I always keep bottled water and energy bars on hand when I have to go out in bad weather, I can’t assume that my staff is likewise prepared. The leftover pizza and freezer-burned Hot Pockets aren’t going to go very far if we ever encounter a catastrophic weather event. I’m not advocating that everyone needs to constantly live in Doomsday Prepper mode, but our society has embraced the just-in-time and convenience culture so thoroughly that many people and organizations haven’t given much thought to basic preparedness in the face of a calamity.

The schools in my state now require education in CPR as a high school graduation requirement. I’d love to see a little coverage given to basic emergency preparedness. We do have a teen CERT (Community Emergency Response Team) program along with an adult program and there is always a waiting list for people to attend. If you can’t get into a community offering or your area doesn’t have one, there are some great educational resources available through the Ready.gov website.

I had two client-facing trips cancel due to the weather, so I’ve been using the opportunity to play catch-up and try to get ahead for the busy times that are surely coming. Although there has been a relaxation in the requirements to have 2015 Edition Certified EHR Technology in place before January 1, I’m not seeing my clients take the foot off the gas as far as preparing for upgrades and workflow changes. I think they’ve already done so much work to get ready they just want to see things through and get the decks cleared for the next thing that gets thrown at them. I’ve also got several clients moving forward aggressively with Patient-Centered Medical Home initiatives, and since I haven’t been to formal training yet for the 2017 NCQA standards, I’m trying to become more familiar with the requirements.

Although there are a lot of details to learn, many of the principles are straightforward. Sometimes those are the hardest to bring into daily clinical practice, not only because they require people to change, but because they require attention to efficiency and detail. Take for example the daily huddle. In its simplest form, it’s the opportunity for the care team to look at the daily schedule and anticipate specific needs related to each patient appointment. It could be basic things like ensuring there is an extra chair in the exam room for an interpreter or family member, or it could range to issues like tracking down lab results or reviewing needed clinical preventive services and counseling.

I’ve seen a lot of daily huddles derailed by the lack of an effective meeting strategy. The team needs to show up on time, someone needs to be the leader, someone needs to be the timekeeper, and someone needs to document and manage the follow-up. The reality in many medical offices across the country is that these skills are lacking, and if the practice wants to be successful, the skills need to be taught and reinforced. If staff members are habitually late, it needs to be addressed. If huddle attendees aren’t paying attention and things need to be repeated, it needs to be addressed. Staff discussion needs to stay on topic and sidebar conversations should be stopped.

I see practice leaders sometimes struggle to address these issues, which is why bringing in an outsider to help with change leadership activities is tempting. It’s also easier to let someone else be the lightning rod, which sometimes happens. One group I’m working with in preparation for an aggressive PCMH rollout has a provider and a nurse manager who are very difficult. The provider often makes changes to his schedule without telling anyone (I’d revoke his access to the scheduling system in a heartbeat) and the nurse manager enables the bad behavior by making everyone else dance around trying to accommodate the last-minute changes. The provider frequently overloads his schedule by double- and triple-booking appointment slots, which makes the entire day run badly and frustrates the staff. The practice doesn’t have a good understanding of their true capacity to see patients, and I suspect some of their panels need to be adjusted by shifting patients from busier PCPs to more accessible PCPs on a given care team. The provider in question is resistant to this change, and although I understand his wanting to maintain patient relationships, it shows that he is not embracing the concept of PCMH and that the practice will continue to suffer until this is addressed.

I’m planning a series of leadership discussions where try to solidify provider buy-in and discuss the benefits that being a patient-centered practice can provide. If we can’t get everyone to arrive at a place where they can at least agree not to obstruct efforts, however, I’m going to recommend that they seriously consider placing the initiative on hold until we can figure out how to get people on the same page. Simply saying “this is what our practice is going to do” hasn’t been enough for them to be successful thus far. Change is hard, but it’s the reality for medical practice in the years to come. I’ll be on site with them in a couple of weeks, so we’ll see how things go.

What’s your strategy for keeping staff sane during times of change? Email me.

Email Dr. Jayne.