Richard Bohmer in the NEJM on the 4 habits of high performing healthcare systems

Free full text at: http://www.nejm.org/doi/full/10.1056/NEJMp1111087

His big point is that while the models and frameworks that are currently hot in the realm of health system transformation (e.g. the Patient Centered Medical Home, Accountable Care Organizations) are important, there are some more foundational habits and attitudes shared by high performing healthcare systems that are worthy of emulation. A brief summary of these four habits is below, but I encourage you to read the real thing, because I think these get to some of the deeper skills and attitudes that we as primary care trainees need to get accustomed to and comfortable with thinking about.

Thoughts?

His four habits:
1) Specification and planning--by which he means prospectively specifying processes and decision points around the specific needs of defined populations of patients. Most organizations "do not plan care processes in advance in such detail; instead, they treat each new patient or problem as a random draw from a heterogeneous population and must therefore reinvent the strategy for solving it."

2) Infrastructure design--by which he means matching the resources deployed to the processes they have so clearly specified. 
"The various tasks of care are allocated to different members of a clinical team (including the patient), with the skill and training of each staff member matched to the work. Such organizations make thoughtful use of assistive personnel and alternative providers, and they ensure that each has the necessary resources by carefully designing the supply chain of equipment and information, simplifying workflow, and reducing work stress."

3) Measurement and oversight--these organizations don't just collect data for quality measures to report to outside or for their pay for performance contracts, they scrutinize everything about what they do on a realtime, ongoing basis.
"Such organizations integrate their measurement activities with other organizational priorities such as pay for performance, annual target setting, and improvement activities, making measurement an integral part of accountability and performance management."

4) Self-study--these organizations treat knowledge as a organizational  rather than individual property, and build mechanisms for "learning systems" that allow the organization to constantly learn from and improve the care it provides. 

Thanks Dave for pointing me to this article.... we need more more more of this thinking.

A prevelent tone through US health systems is: "we can't deliver better healthcare until we start getting reimbursed for delivering better (not more) care". While I agree we need payment reform in a major way, this article and countless examples of high-performing health care systems in the US show that high quality, good experience, low cost health care can be delivered today--we only must learn from the systems that are doing it.

In our primary care "microsystem" world, similar common themes can be described from high-performing primary care practices. In the next few months, two reports are being issued that will profile these "best of" practices-- one funded by the RWJ and the other by ABIM Foundation. I will post them when they are available, and I hope everybody has a chance to note their own common themes. Of course, I'll give you a teaser below, borrowing language from Richard Bohmer's article:

1, Specification/planning: In the primary care of yesterday, any individual being seen by a PCP automatically gets slotted into a 15-minute face to face visit. Whether they are sick or healthy, old or young, in need of behavioral therapy or just here to get a form filled out. High-performing practices tailor primary care delivery to the needs of each individual or groups of individuals.

2. Infrastructure design: This category encompasses two large assets, non-clinical managers (http://primarycareprogress.org/groups/videos/29/101) and team co-location. These two assets can not be understated; keep these in mind as you read about innovative practices.

3. Measurement and oversight: Data Data Data. More than collecting data... and then feeding back data... at each high-performing practice there is a "culture of data and quality improvement".

4. Self-study: I'll stray out of the US for a moment here, all the way to Jonkoping, Sweden. In this county in Sweden, there lives what is widely regarded as the best health care system in the world. One of the crucial tenents of this system is the Qulturum (http://www.lj.se/infopage.jsf?nodeId=31736), essentially an innovator's think tank headquarters for quality improvement. I bring it up in regards to US primary care, because for high-performing primary care systems, the Qulturum has served as the model for "self-study" and even non-self study. Their full-time job is innovation and improvement... imagine if your system had that!

In summary: stay tuned for more on this front...

Enjoying all of your dialoge on this topic. Very nice to see people beginning to think about these very critical issues early on. It will help your choice of work setting and result in much more satisfying, sustained careers. I only wish I had such forethought many years ago.

I do have one thought to add. Waiting for someone else to improve before you improve (pay us first before we start innovation, change or new operational behavior) only results in being a very late adopter. One of the most influencial drivers of change is setting an example for others to quantify or build upon. What is reimbursed today was at some point experimental musing. Do it because its the right thing, worry about being paid after. Even if it leaves you financially poor, you are much richer overall.

Steve Tierney MD
Southcentral Foundation

This article is timely as I'm finding the discussion of around the development of retail clinic models particularly short-sighted nontheless a disruptor for health care especially primary care and prevention models.  "There's more profit in a pound of cure than an ounce of prevention"  this has to change.

I'm impressed with the CareMore model developed by Dr. Sheldon Zinberg as described in Health-care's Quiet Revolution in The Atlantic Montly.  The model works because decision-making stays with clinicians.  The model-bends the cost curve with high-quality compassionate care.

"The CareMore story begins almost two decades ago, with a man named Sheldon Zinberg, a gastroenterologist who was deeply concerned about the changing economics of health care in Southern California. There, as in other U.S. markets, health-maintenance organizations, or HMOs, had come to dominate the landscape. The theory behind HMOs was attractive: “managed care” was supposed to coordinate and guide treatments in order to maximize both patient wellbeing and economic sustainability. But under pressure from corporate health-insurance sponsors and government agencies (as well as investors seeking profits), HMOs increasingly focused on reducing costs by any means necessary—including short-term fixes that often led to worse patient outcomes and, in the long run, even higher medical expenses. Patients were suffering, doctors were getting squeezed, and costs, after falling for a time, were soon spiraling upward again."

Link
http://www.theatlantic.com/magazine/archive/2011/11/the-quiet-health-care-revolution/8667/

Hi Dave,
Great post. The new practice that I've joined is working toward these aims in North Carolina. We are unique in that UNC has teamed up directly with a payor, Blue Cross & Blue Shield of North Carolina. If you're interested in hearing more, there is a brief video at http://www.youtube.com/watch?v=4FijAqJc_-c.

One of the goals is to spread our model if it is successful, but Richard Bohmer raises a great point: it is more likely our habits in planning, design, and evaluation that lead to success, not the specific model itself. That being said, I suspect there is another element of success that is not mentioned, and that is making every decision with the patients' best interests as the highest priority. Unfortunately, sometimes the patients get lost when competing interests sit down at a table together to innovate - we've seen this over and over in the past. I think we should never underestimate the power of using our patients' experiences as our guide, and adding a 5th habit in which we constantly return to the question "How will this impact our patients (on the individual and population level)?" can only make our decisions more sound.