As the health care industry moves toward value-based care, we are all experiencing an influx of articles and presentations on the latest and greatest methods for practice transformation. Health plans and other payers want to incentivize physician practices to implement changes that will improve quality and reduce the cost of care. At the core of this effort is the directive to implement best practices, both clinical and operational. Of course it makes sense to leverage the experience of other organizations as opposed to re-inventing the wheel. But there are also times when these so-called best practices can become a barrier to real transformation.
During my 14 years in the health care industry, I have participated in many practice transformation programs – first as a practice manager, and now as a consultant.
There is one common design flaw that most of these practice transformation projects had in common: an emphasis on process over outcomes.
This fundamental flaw can often inhibit practices from attaining meaningful and sustainable improvement, which is the ultimate goal of transformation.
When any organization attempts to implement a best practice, it is easy to become so focused on doing things “the right way” that the staff fails to consider whether what they are doing actually makes sense. This is what I have come to refer to as “check box” transformation. The desire to follow the prescribed model and put a check in each box overrides the ability of the team to be flexible and adaptable to the unique needs of the organization.
Here are a few examples of programs I have been involved with over the years that fell into the trap of “check box” practice transformation. Both of these stories involve widely-recognized industry best practices.
Daily Huddle Disaster
When I was working with physician practices to implement a patient-centered medical home model, one of the best practices we recommended was the use of a daily huddle to improve communication, teamwork and pre-visit planning. As a practice coach, I couldn’t fathom a scenario when this best practice would not be helpful. One of the first physician practices I worked with proved me wrong. This office had impressive teamwork and communication in place already, largely due to the fact that physicians sat side by side with their medical assistants during patient appointment hours. Their entire day was made up of a series of informal mini-huddles, but technically they did not fulfill the best practice criteria for a structured daily huddle.
As a requirement of our program, the practice spent time formalizing their informal huddle sessions in order to put a check in the box. The practice staff found this exercise to be frustrating and pointless, which is understandable since they were expending valuable time and energy to solve a non-existent problem. The practice did eventually implement the structured daily huddle as required, but they discontinued it soon after. This experience taught me a valuable lesson about the dangers of one-size-fits-all solutions.
Patient Portal Overkill
In another transformation program, practices were required to offer access to a patient portal and to encourage portal use by all patients. This best practice was extremely valuable for some practices, and a huge waste of time for others. Primary care practices and specialists that treat chronic conditions tend to find patient portals effective at improving patient access and communication. Patient portals can also be valuable for practices that serve a younger patient population that is more reliant on technology. Practices that treat acute conditions or have older patient populations may not experience any significant benefits from implementing a patient portal.
One example is an ophthalmology practice. A large portion of ophthalmology patients are treated solely for cataracts, which develop gradually and are treatable by surgery only when they begin to significantly impede daily activities. Cataract patients engage annually with the practice until they are ready for surgery, and then more frequently in the weeks immediately before and after the surgery. Cataract surgery is a routine procedure that typically does not require further treatment. Even patients who are being treated for long-term conditions such as glaucoma or macular degeneration rarely have needs that could be addressed through a patient portal. When you consider the typical patient’s age and low comfort level with technology, they are much more likely to call the office if they need something.
Implementing best practices in situations where neither the practice nor the patient finds value does not lead to meaningful transformation; it just steals focus from more valuable efforts. And considering the cost of implementing a patient portal, some practices would benefit from directing their limited resources elsewhere.
How to Avoid “Check Box” Practice Transformation
These are just a few examples of the dangers of process-driven transformation. While best practices can save time and effort, they are only effective when they are applied under the appropriate circumstances. Here are a few ways to avoid falling into the trap of “check box” practice transformation:
- Recognize that each practice is unique.
- Assess and document the strengths and weaknesses of the practice.
- Listen and observe the practice staff doing their jobs before recommending changes.
- Offer a robust toolkit with many options that can be adapted to the needs of each practice.
- Be flexible in interpreting guidelines for best practices and transformation programs.
- Do not assume that practice staff are being obstinate if they do not immediately adopt a best practice. Instead, initiate a discussion to find out why that specific requirement may not make sense for that practice.
These tips can apply to on-site work at the practice, as well as best practices that are communicated by the health plan in writing. Health plans and practice transformation coaches should offer support and guidance, while remaining flexible and encouraging practices to discover what works best for them. When a practice takes ownership of the practice transformation process, they are more likely to demonstrate the desired outcomes.