- Medical Professionalism & The Physician Charter
- Choosing Wisely®
An important aspect of advancing medical professionalism is ensuring that the environment and culture in which physicians work are conducive to professional behavior. Much of our work focuses on exploring innovative ways to address and overcome existing issues within organizations or within the profession itself to remove obstacles to medical professionalism.
Examples of this work include efforts to determine how physicians are best motivated to provide quality care, address the high rate of burnout and dissatisfaction among primary care physicians, and examine the effect that technology and the system at-large has on physicians’ feelings about their work.
Finding Joy in Primary Care
Only one-third of physicians in the United States practice primary care, compared to about one-half in other developed nations. Fewer aspiring physicians are choosing to focus in primary care, threatening the quality of care patients receive, citing:
- long hours of clerical work that doesn’t utilize their training;
- lower payments; and,
- frustrating models of practice.
To begin finding solutions to these challenges and revitalize primary care, we funded a team of researchers who visited 23 high-performing practices across the United States seeking innovations that could help restore joy in practice. (Learn more in a Patient-Centered Primary Care Collaborative webinar presented by Drs. Christine Sinsky and Tom Sinsky.)
Among the sites with high levels of satisfaction, the researchers found common themes, including:
- Proactive planned care, with pre-visit planning and pre-visit laboratory tests;
- Sharing clinical care among a team, with expanded rooming protocols, standing orders and panel management;
- Sharing clinical tasks with collaborative documentation (scribing), non-physician order entry and streamlined prescription management;
- Improved communication by verbal messaging and inbox management; and,
- Improved team functioning through co-location, team meetings and workflow mapping.
The team’s research culminated in “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” published in Annals of Family Medicine.
In addition to the Annals article, the authors wrote a white paper (pdf) that describes the innovations at each site in more detail and includes a discussion of several themes, such as:
- the surprising finding of a hidden anti-team culture in policy and technology;
- the influence of payment on innovation (practices in a fee-for-service environment developed efficiencies that led to greater capacity; practices in a subsidized environment developed extended services, such as those of a pharmacist and social worker);
- two contrasting approaches to dealing with the volume of work in primary care (decreasing visits per physician versus reducing the amount of non-physician-level work done by each physician); and,
- the degree of waste in primary care.
This research also informed a 2012 conference of the ABIM Foundation entitled, Primary Care Innovation: Improving the Efficiency and Appeal of Practice: “How Did They Do That?”. The conference brought together representatives from the visited practices with leaders in primary care to reflect on the research findings, identify a set of principles that could transform the efficiency and appeal of practice, and consider how those principles could be spread more widely.
The authors created a set of action steps for key actors, including insurers, institutions, regulators, payers and technology vendors, as well as a research agenda for improving the practice of primary care.
Read summaries of the 23 sites visited and learn more about their innovations:
- Allina Health Clinics – A scribing model led to higher patient and physician satisfaction
- Ambulatory Practice of the Future – Melding human and data interaction
- Brigham and Women’s Hospital – Collaboration between physicians, nurses, medical assistants, social workers and pharmacists
- Cleveland Clinic – A “turbo model” of team-based care
- Clinica Family Health Services – “Pods” ensure continuity of care
- Clinic Ole – Data drives ongoing quality improvement
- Fairview – “Success by approximation”
- Group Health, Olympia Medical Center – Patients encouraged to use email and phone to complement in-office visits
- Harvard Vanguard Medical Associates – Measurement is the magic
- La Clinica de la Raza – Empowered medical assistants promote better patient continuity and care
- Martin’s Point Health Care – A group cheer of “go team!” at the end of the daily huddle
- Mayo Clinic Health System-Red Cedar – Nurses play a robust role in patient care
- Medical Associates Clinic – Nurses paired with physicians in “core teams”
- Mercy Clinics Inc., Des Moines – Mission, vision and strategy
- Multnomah County Health Department – Panel sizes adjusted by primary care specialty
- Newport News Family Practice – An example of what real teamwork looks like
- North Shore Physicians Group – Redesign started at the top
- Quincy Family Practice – In the “Office of the Future” there are no desks
- Sebastopol Community Health Center – Fostering a culture of inventiveness and excitement
- Southcentral Foundation – From “design and deploy” to “discover and spread”
- ThedaCare – A LEAN improvement model
- University of Utah Redstone Clinic – Workflows enhance patient experience
- Veterans Administration, West Los Angeles – Established Patient-Aligned Care Teams (PACT)
Bringing Culture into Focus
The 2015 ABIM Foundation Forum: Bringing Culture into Focus sought to reach a common understanding of how culture can affect performance in health care and its role in facilitating the patient-physician partnership in routine care, care of patients with multiple chronic conditions and care at the end of life.
The summary of the 2015 Foundation Forum (pdf) documents highlights from the meeting.
Specific Forum goals included:
- Develop a shared understanding of culture, its importance and how it affects attitudes, behaviors, processes and outcomes of care.
- Explore how culture influences relationships among patients, families, clinicians and administrators. Investigate what a partnership model looks like and how it contrasts with current culture and practice in:
- Preventive and acute care
- Care of patients with multiple chronic conditions
- Serious illness care
- Redesign of care processes
- Explore how community culture, organizational culture, and cultural and individual characteristics of patients, families and clinicians affect experience of care, decision-making and outcomes.
- Examine the experience of organizations and communities that have intentionally changed their culture and improved their performance.
Background materials for the 2015 Forum include:
Rebooting the System for Service and Satisfaction
The 2014 ABIM Foundation Forum: Rebooting the System for Service and Satisfaction focused on how choices in implementation and design of clinical, regulatory and policy environments influence patient care and augment the joy in practice experienced by all members of the clinical team.
Specific goals of the Forum included:
- Explore how an organization’s implementation of health information technology (HIT), performance improvement and measurement leads them to make choices that have differential impacts and unintended consequences on patient care and clinical teams.
- Make recommendations on how to align clinical systems with core values of a health care system, i.e., improvement of health outcomes, patient experience, affordable care, professionalism and strong interprofessional teams.
- Define implementation strategies that activate professionalism and strong interprofessional teams in service of achieving core health system goals.
- Explore pathways for restoring the healing spirit in service of effective and meaningful patient-clinician relationships.
- Review opportunities that exist in training programs to activate professionalism within clinical and HIT system design that lead to joy in practice for the next generation of physicians.
Read the 2014 Forum Summary for meeting highlights.
Purpose vs. Payment: Motivating Change in Health Care
The 2013 ABIM Foundation Forum: Purpose vs. Payment: Motivating Change in Health Care focused on what motivates physicians and other health care team members to perform at their highest level, and how we can harness this motivation to support needed changes to the health care system.
Specific goals of the Forum included:
- Explore what motivates physicians and teams of clinicians to engage and improve health care delivery to achieve the “Triple Aim” (higher quality of care, better population health and lower costs) – professional values, financial rewards or both.
- Examine the intrinsic and extrinsic rewards deployed by professional standard-setting organizations, physician organizations, health systems and patients/caregivers to motivate physicians and clinicians.
- Ascertain how such rewards support or inhibit professional values and behaviors.
- Develop strategies and action plans to motivate and engage clinicians in the processes of change needed to achieve high-performing medical practices that deliver excellent results for patients.
Read the 2013 Forum Summary for highlights of the meeting and action steps.