Your organization is frustrated with change to the point of exhaustion, and a new opioid dosing guideline is published this week. How do you energize and engage folks on the front lines?
You know the problem: You barely instituted the last change, and the next one is banging on your door. Whether you are facing clinical guidelines, ICD-10 implementation or population health; change is thrust upon us in primary care and we struggle to keep up. In this post. I propose building “standard work” to anticipate, analyze, and adopt change initiatives that come from outside the clinic walls.
I recently reviewed the 80 page draft of the Washington Agency Medical Directors’ Group (AMDG) opioid dosing guideline that refined the efforts of previous guidance from 2010 and before that 2007. This time it is annotated with over 300 evidence references and has much more in depth guidance on things like managing dependence within the population of individuals with extended exposure to high dose opioids, and avoiding pitfalls of drugs with unpredictable toxicity like Methadone. How do providers and their leaders keep up, with high-stakes change happening all around them?
None of these topics are new, but what feels new is the pace in which change is happening in primary care. Its happening so quickly that we need to focus not only on the specific content areas, but we need a formula or process for adopting change with resilience. Otherwise we just burn ourselves out. Is it any surprise that yet another change initiative sweeping healthcare are wellness and burnout programs?
Change is happening so quickly in primary care, we need a quick formula for adopting change
Here are some basic ideas on how to create standard work and implement externally driven change in the clinical environment, whatever the source.
1. Learn the Art of “Actively Ignoring” the Issue.
Whether you have 5 providers or 500, pummeling every one of them with a tsunami of raw information, like an 80 page opioid dosing guideline or an arcane ICD-10 manual, makes little realistic sense as your basic clinic improvement strategy. Nor does it make much sense to think that they can change without help and coordination of resources specific to the culture of the organization. To avoid panic and burnout, message #1 should be: “There is a new guideline on the use of opioids for the management of pain, and we think it may be important enough to pay attention to. We are going to assign one person do review it and tell us how we can improve patient care based on the guideline.” Let’s say the fictional person assigned to review it is “Dr. Roberts”. Dr. Roberts agrees to review it.
2. Consume Information Generously and Often.
OK, so now everyone can take a deep breath and trust that Dr. Roberts has been asked to dive deep. But now we need to fully enable Dr. Roberts to “dig in on the fly” with as many information formats as possible like printed copies, electronic copies, power points presentations, summaries, videos, web-based courses and podcasts. So much comes at us in healthcare via an email message with links, locked away in a NORAD style data silos, not well connected to the rest of our world. Dr. Roberts likely has insufficient time in the usual 9-5 work day to consume and digest dense information on behalf of his colleagues. but if he is sitting in the airport and someone took the time to print him a paper copy, then he may have it in his travel bag.
This is a huge reason I am addicted to creating and consuming podcasts. Most smartphones have a podcast app, and podcasts on professional topics abound on iTunes. Whether you drive to work or take the train, your smart phone can automatically deliver fresh audio files and enhance your productivity. I keep up to date on many topic areas by using a bluetooth headset while doing yard work, driving to work, or as a passenger on any form of transit.
For example, I am running a series of podcast episodes with experts contributing and responding to the new AMDG opioid dosing guideline, like Andrew Friedman, MD from Virginia Mason Medical Center in Seattle. (The Friedman AMDG audio episode is available HERE). This makes use of near–total down time, a much better time for consuming new information than prime 9-5 work hours.
You can also access an interview with Family Practice physician and AMDG guideline committee expert advisor Cindy Grande: Pioneering Pain Guidelines in Primary Care.
I learned the value of finding unused down-time from reviewing legal cases with reams of patient records, and reviewing endless board certification study materials. Pretty much anything that can be done remotely, is fair game. I have large paper copies and binders for the couch at home, but I upload electronic files to a secure encrypted “dropbox” like service to access on my iPad, when I am waiting for my pizza take-out order. The point is, the more formats available to Dr. Roberts, the more likely he will find at least one of them engaging and accessible enough to start digging in. An 80 page guideline is a monster, so starting with a narrated power-point might feel less overwhelming as a high-level summary. The point is not to review every last bit of it.
3. Create Transparent Timeframes and Deadlines.
Dr. Roberts needs a “deliverable” and a deadline. Ask Dr. Roberts some key (standard) questions to address before he gets started, like:
- Are there elements of this proposed change initiative that improve patient care, that can actually be understood by patients? Let Dr. Roberts know his job is done with a one page report, where he answers a few key questions, including the most important piece of narrative: “Give us some communication samples for patients, in language they could understand, as to why this is important”. Whether or not you utilize this in patient communications is beside the point, it frames the purpose in everyone’s mind as something more important than an administrative task.
This is so critical because providers get satisfaction by providing higher quality care, and worn out by stuff that doesn’t matter to the quality of care delivery. Patients wear them out as well, when they complain about something that is really in their best interests. However, often patients simply don’t understand it and providers are similarly not empowered to communicate that. Using the new AMDG guideline as an example, don’t ask docs to embrace the changes because “there are new guidelines”, help them translate how those guidelines contain some really specific information in rendering safer care than we might have previously because of the concise and specific information contained there.
- Ask Dr. Roberts to report: Why would implementing this initiative be critical to the organization five years from now? Let’s face it, some initiatives are highly abstract or externally proscribed, that it is difficult to identify or communicate a patient-centric purpose, especially to patients with minimal health system literacy. Nevertheless, something like ICD-10 implementation is a “keeping the doors open” kind of change. Keeping the doors open matters to both doctors and patients. This is why we call our jobs “work”.
- Ask Dr. Roberts: What are hidden elements to this, that providers might overlook? Make sure Dr. Roberts is tasked to pull out some of the “meta” components. For example, while many clinicians may consider it reasonable for patients who are more or less stable on their medication, to continue opioids for chronic pain; whereas the new guideline suggests a 30% improvement in function during acute titration is necessary to document as a standard of care. Without such documentation the reasonable nature of continuing therapy is called into question. Dr. Roberts should include in his report to his colleagues: “Three years from now, is there a possibility that we might be judged in a civil or regulatory environment for failing to adhere to new standards set forth in the guideline?” or “Are we doing our patients a disservice exposing them to risk without evidence of benefit?” Is it possible the new care standard elements might be interpreted by a jury or administrative judge, as reasonable?
- Turn these questions into “standard work” applicable to reviewing any proposed change initiative. In other words, in order to consider how the new guideline recommendations differ from the current standard that your practice, consider the potential consequences of ignoring that, in each of the various domains like regulatory compliance, clinic financials, risk management, patient safety, insurance contracting, etc. Make a checklist rubric for Dr. Roberts that becomes the standard checklist rubric for ANY new change initiative.
- Establish a transparent deadline for turning around 1-2 sentences for each section on (for example) a one-page form. This is Dr. Roberts’ report. The end of the form should say “On behalf of the entire clinic, please give us your bulleted list of recommendations for what our organization should do to implement this change”.
4. Design the Support the Clinicians Will Need.
Remember, your entire group was enjoying the opportunity to ignore the new guideline, but now you have Dr. Roberts report in hand. There may be more even questions than answers, but at least you are asking them. You want to start creating an action plan from Dr. Robert’s recommendations. You also want to question Dr. Roberts’ judgement and recommendations, after all, we all have our blind spots and biases. The key thing however, is to get resources organized (or at least the needs identified) before you lay it on the group. I discussed a book in recent webinar “Workflow of Champions: Raising the Quality of Care while Introducing Efficiency (audio link). The name of the book is called Switch: How to Change when Change is Hard by Chip Heath and Dan Heath.
The analogy in the book asks how do you get an elephant to go where you want it to go? The illusion is the rider controls the elephant. The reality is there are more effective ways to influence the direction of the elephant than “steering” from on top. One is to get the attention of the rider, show them the big goal, “go there”. These are your recommendations and bullet points in Dr. Roberts report.
Next is to motivate the elephant, because the rider may have a reason to go in a certain direction, but the elephant is the one whose emotional influence must by won over. In your project, these are things like defining do-able “baby steps” or “chunking it down”, like defining the purpose as discussed above. This blog post is an example of “chunking it down”. Take an overwhelming task and break it into a series of doable steps.
The third way to get the elephant to go where you want is to create the path. The illusion is that something as simple as telling providers to read a clinical guideline is going to change behavior, or even telling them what is in it. The original AMDG guideline was studied for its influence and a small percentage of providers were familiar with it, and a much smaller changed care patterns as a result. A revised guideline was published in 2010, and some components included there were incorporated into state laws and licensing board standards in Washington. Still, the elephant avoided change as if it were a den of snakes, and laws smell like snakes.
Clinicians need tools more than rules
Creating the path, means creating real support. There is a reason that so many prescriptions are written for high risk controlled meds, and so little actual meaningful care happens in the context of those (often phoned-in) refills: It is because we have made the process of medication refills easy in comparison to the process of longitudinally measuring patient function and quality of life over time. Its easier to write a prescription than ask for a urine sample. Its easier to write a prescription, than calculate a patient who claims to be “out of medicine” has received 120 days’ worth of medicine in the last 113 days. Doctors need tools more than rules, but they can also work hand in hand. For example, a proposed policy: “Our organization will provide not provide a prescription unless in the past six months a “PEG score” has been performed documented, and thoughtfully compared to previous scores.” . Then use IT to track the timing, empower the support staff to obtain the information, communicate with patients why it is important, and make the standard work for the provider easier than writing a prescription.
5. Train to a Simple, Standard System.
By the time you are done, the message to providers is “We have become accustomed to providing care in a particular way. Here is what we have learned about how we can provide better care for our patients, and here are the reasons we need to start doing things in a new and different way. We anticipate you might need extra help with this so here are some resources to make it easier. This would otherwise be a difficult change, except that we analyzed what we need in order to adopt this change, and here is the (cheat sheet, master reference file, etc). Oh, and by the way here is the FAQ page for patients, one for MA’s and one for clinicians.”
By now you have decided what’s new and what your organization is going to do about it. You developed a system for the initiative custom to your environment. More important, you utilized a change strategy that can be used over and over for the next important initiative coming down the pike.
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A link to the 2015 revision of the AMDG opioid dosing guideline can be accessed here.