Keys to success and happiness in Family Medicine Anton J. Kuzel, MD, MHPE Virginia Commonwealth University Department of Family Medicine

The coming Tsunami OMG – 32,000,000 more people with insurance! Declining PC workforce! Massachusetts on a national scale! 2

The current reality Too many overworked, underpaid PCPs No idea of how to get to a better place without special financing

Hamster wheel medicine

There is hope, and a way forward We need to get off the hamster wheels A significant minority of practices are doing remarkably well –Physician, staff, patient satisfaction –Ambulatory quality measures –Physician income We need to learn from these practices!

Step 1: Documentation and coding Stop leaving money on the table 28% of FM established patient codes are level 4 60+% of FM established patient codes could/should be level 4 Using Medicare payment rates, this would generate about $50,000 per year per clinician in extra income (more if average payment exceeds Medicare rates) Little/no extra work/time from clinician Why not? Don’t know how, or afraid of audit Coding from the bottom up; memorize This is low hanging fruit! 6

Step 2: Add staff, with a purpose Clinicians are the ones generating income Clinicians should not be doing things that don’t require their expertise Nurses, other staff should take non-clinician work AWAY from the clinicians All people working to the top of their license Systematic attention to prevention, CDM Adds capacity (10-20% or more), increases quality, creates opportunity for increased income 7

Step 3: Rapid access scheduling Requires information system to know panel sizes Balance supply and demand Choose easier ways of working down the backlog Improves continuity, which supports coding to higher levels of care Do today’s work today Patients love it Can add capacity (about 10%) 8

Impact of 3 steps Happier docs and staff Better care for patients, and better experience of care Significant gains in PC capacity Being more prepared for Breathing room for doing the real work of healthcare reform 9

Steps one and three are easy to understand, but step two is the most important And the hardest to achieve Offer two ways of how to improve team function 10

(One of my personal four must read books) 13

Consequences: Pretending to be competent Avoiding risks - Playing it safe “Look out for number one” “Don’t let ‘em see you sweat” #1: Absence of trust 14

Consequences: Leaderthink becomes groupthink Artificial harmony Stale patterns of behavior We’ve always done it this way If it ain’t broke, don’t fix it Arrested development or worse, regression #2: Fear of conflict 15

Consequences: Listless performance at work Resentment among those “carrying the load” #3: Lack of commitment 16

#4: Avoidance of accountability Consequences: Lack of critical feedback regarding behaviors Working in silos – holding team accountable creates incentive to understand how all the parts contribute to success 17

Consequences: Imagined accomplishment Mediocre performance Lack of ownership, and hence, meaning #5: Inattention to results What, me worry? 18

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How does a leader build a foundation of trust? Leader must: Risk being vulnerable Act in service of those on the team Spend time with the team in social situations 30

“I was wrong” “I made a mistake” “I need help” “You’re better than I am at that” “I’m sorry” Get comfortable saying (when appropriate): 31

Teams will look to the leader Leader supportive, coaching-oriented, non-defensive responses to questions and challenges → team members conclude that the team environment is safe Leader acts in authoritarian or punitive ways → team environment is not safe Result: Team members not willing to risk admitting errors, asking for help, experimenting, or seeking feedback Result: Tremendous block to team learning and improvement (Amy Edmondson, Admin. Sci. Quar. June 1999)

Waterline Model When a team is not performing as well as it could, look at what might be happening “below the waterline” –Structural level –Group dynamic level –Interpersonal level –Intrapersonal level

Structural level questions Is it clear who’s in charge here? Is the leadership role being filled effectively? Does everyone understand what the goals are for the team or for this piece of work? Does everyone agree on the goals? Are the team’s priorities clear and agreed upon? Are people clear about their own and each other’s roles?

More structural level questions Are the expectations clear? Does everyone know who is doing what and by when? Are people appropriately held accountable for meeting their expectations? Are the right people here to do the work? Is there a good fit between jobs and people? Are appropriate boundaries maintained so that acting out by individuals is contained?

The secret sauce of primary care Access Continuity Comprehensiveness Coordination