Case Examples

 

Coordinated Care: Engineering Excellence for Patients Through Systems-Based Thinking

Jennifer L. Hunt, MD, MEd, FCAP
Jennifer L. Hunt,
MD, MEd, FCAP

Pathologists and other laboratory professionals engineer systems-oriented solutions that benefit large populations. Many positive process changes involve small steps that draw little attention. Screening all new admissions for Methicillin-resistant Staphylococcus aureus (MRSA), for example, may have sounded like a bother until clinical experience demonstrated the time and money saved downstream in hospital operations.

As the specialists who work with all disciplines, with patients of all ages, and with colleagues who practice in every setting, pathologists sometimes will be the only doctors in a position to see trouble coming and question the historic approach.

For a fix to be enacted, people have to be willing to listen to what might sound like criticism. Yet, when everyone is looking for ways to accommodate the new realities of coordinated care, some of the many furiously-paddling ducks in the pond will paddle in circles…and some will circle the wagons. If nobody speaks up, opportunities for systems-based initiatives that can benefit many patients may remain beneath the radar.

Pathologists, who work with all specialties and disciplines, know intuitively that the most successful transitions involve engineering-oriented solutions. Physician payment, always competitive, is more and more a zero-sum game. Leadership and value-showcasing opportunities, too, are engineered in small steps.

Actions/Solutions

Jennifer L. Hunt, MD, MEd, FCAP, isolates three essentials to structure pathologist leadership around transition to coordinated care: systems-based thinking, engineering-driven change, and embracing the many small steps that lead to marginal gains.

Dr. Hunt is professor and chair, Department of Pathology and Laboratory Medicine, at the University of Arkansas for Medical Sciences in Little Rock. Her credentials in process improvement, quality, and laboratory operations safety are those of a clinician and educator—an anatomic and molecular genetic pathologist who subspecializes in diagnostic head and neck and endocrine pathology and over-sees the training of more than 20 pathology residents and fellows. In previous positions—most recently, as associate chief of pathology and director of quality and safety for the Pathology Service at Massachusetts General Hospital—she learned that systems-based thinking is the engine that drives behavior change. And she knows intuitively that it will be behavior change that enables successful transition to coordinated care.

"The strongest tools are systems tools that not only enable, but actually force the right behavior," Dr. Hunt says, "The most powerful tools we have are engineering based. The system has to be optimized to get to the best quality, to make the right thing to do the only way to do it. That's where the best results come from in process improvement."

Then there's that whole carpe diem business, known in some trades as the teachable moment.

"I think you have the best opportunity to remind people [about quality and patient safety] when something goes wrong," Dr. Hunt said. "A problem is an opportunity to remind everyone that there is a patient on the other side. A careful step-by-step root cause analysis will give us answers to system-based problems, but it will also impact people—and will affect their thinking beyond just one area. A formal root cause analysis can bring patient safety to life."

But how to recognize (or create) those opportunities?

:Within our department, we solidify the value of the pathologist by being of service, often in the arena of quality, safety, and efficiency," Dr. Hunt says. Members of her team are encouraged to resist the temptation to respond defensively to criticism. Instead, they are asked to listen for the underlying pearls of truth in every complaint, to make sure that people know they've been heard, and to respond with action.

Instead of pointing out flaws in the evidence or logic driving an individual to criticize the laboratory, Dr. Hunt's staff will say, "'Let me look into that.'" She finds that there is almost always something actionable and fixable in a complaint. Taking that attitude, she finds, allows every complaint or problem to generate an opportunity for shared success. To illustrate, Dr. Hunt recalls a recent experience.

A clinical department was under pressure because the discharge statistics showed that their patients were often released late in the day. Although their faculty blamed the late discharges on late laboratory results, the department data showed standard and excellent test turnaround times. A deeper dive into the data revealed the pearl of truth.

"Our microbiology team did a fantastic analysis and discovered that the negative culture results were being batched instead of reported as they were ready," Dr. Hunt says. "On average, the numbers looked good. But, for any given patient, the result might be reported long after it was actually ready. A relatively simple system change resulted in real change for the clinicians who were waiting on those results to send patients home."

A new rolling system of reporting now enables clinicians to discharge patients as soon as their results are ready, Dr. Hunt says. A small step generated a marginal gain in quality and safety that validated clinician concerns and brought the laboratory staff closer to their patients.

Summary

Pathologists who share what they know about systems-based thinking can drive contagious improvements in the practice environment that foster collegial approaches to quality improvement.

"I always have thought that in any administrative job, the most important thing you can do is solve people's problems or help them solve their problems for themselves," Dr. Hunt says. "From there, we can build momentum to really change health care."


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