- Waitzkin H.
- Compton J.
- Sunstein C.R.
Prioritize Continuity of Relationships
- Sinsky C.
- Sinsky C.
- Swensen S.
- Swensen S.
- Shanafelt T.D.
|Maximize team stability||Team members need an ongoing relationship with each other to build the trust necessary for continuous improvement, appropriate delegation, and to complement and support each other’s unique strengths. Prioritizing the stability of the team within hiring and scheduling decisions will create the highest functioning teams.|
Ex: The same nurses and/or medical assistants are paired with the same physician for each clinic session.
Ex: The same team of OR staff routinely work with the same surgeon.
|Optimize team size and skill level||Fully staffed teams have better outcomes.|
44Teams composed of members with higher training (ie, RNs) can delegate more of the tasks to nonphysician members.
Ex: In advanced models of team-based care,
61a nurse or medical assistant forms an independent relationship with patients as they perform agenda setting, medication reconciliation, self-management support, and, in some models, also assist with real-time documentation and order entry.
63Therefore, the physician is able to provide undivided attention to his patient, focusing on medical decision making and relationship building.
Ex: A hospital nurse, pharmacist, physician, and, in some cases, also a documentarian round together, contributing their unique domain knowledge, operationalizing care decisions in real time, and thus maximizing the undivided attention the physician can provide the patient and family.
|Design physical space to support relationships||Connecting care teams by physical colocation|
65allows for the quick communication and small, frequent readjustments required for a day to go smoothly.
Ex: Co-location of reception staff with the clinical team allows joint problem solving to serve the needs of the patient and accommodate urgent requests. Schedulers who are a part of a specific care team know their patients and their team’s work style.
|Design the schedule to support relationships||A well-designed and managed schedule is key to efficient practice, access, and continuity. It is often beneficial to provide the physician and team a degree of autonomy and control over the nature of the schedule. In some settings, this may include setting appointment duration and/or start/stop times for the clinic day.|
Ex: Scheduling patients on a wave allows more flexibility to meet the inherent unpredictability of patient needs.
Ex: Include a buffer time in each day where the patient care can expand as needed.
Ex: Avoid setting the expectation that patients should be immediately roomed upon arrival. Instead set a standard for maximum waiting time that realistically accommodates the unpredictable needs of a population of patients.
|Maximize inpatient continuity||Continuity, even within a single site of care, such as the inpatient setting, improves care.|
Ex: A hospitalist continues to manage the patient when they are moved from one unit to another (ie, from the medical unit to a surgical unit).
Ex: If multiple hospitalists are admitting, a hospitalist who previously cared for a given patient preferentially readmits the patient.
Ex: A subspecialty attending continues to follow their patient through to discharge even if the attending is no longer on service.
|Enhance inpatient-outpatient continuity||Recognize the importance of enhanced inpatient-outpatient continuity|
Ex: Support and recognize the value of the primary physician caring for their patients across inpatient and outpatient settings for those who are able to do so.
67In such “comprehensivist models,” the patient’s personal physician in that specialty (eg, primary care, neurology, cardiology, or oncology) manages their patients’ care across both ambulatory and hospital settings.
Ex: When the discharging and receiving physicians are not the same physician, create and support systems that foster conversation and coordination between the two physicians for the safest and most satisfying handoff.
Ex: Rather than develop a stand-alone post-discharge clinic, patients are scheduled to see their personal physician in the appropriate specialty for hospital follow-up. For this to happen, the hospital discharging unit takes responsibility for setting up the follow-up appointment with pertinent previsit laboratory testing, and the receiving physician’s practice takes responsibility for the efficiency and schedule flexibility required to see patients within the requested time frame.
|Design EHRs for relationships||EHRs designed to support relationships will facilitate rapid situational awareness of the patients’ social and medical context.|
Ex: A thumbnail photo of the patient is on every screen, providing a visual cue to assist in recall of the patient.
Ex: The EHR includes a list of the patient’s “social vitals” (ie, their support people, hobbies, or job).
|Design EHRs to reduce cognitive load||EHRs must also include human factors designed to reduce the cognitive load associated with the interacting with the EHR.|
Ex: The EHR includes a concise display of past history, medications, results, etc without the clutter of lower priority information, such as the detailed chemical names of medications or the units of measure of labs that are always resulted with standard units. (Hovering technology could make such lower priority information available in the rare instances when it is pertinent.)
|Support team communication||Structurally supporting communication among the clinical team will enhance performance.|
Ex: Daily team huddles (ie, 5-min stand-up meetings to share unique information for the day)
Ex: Periodic team meetings (ie, 30- to 60-min step-aside meetings to optimize workflows) can improve communication, trust, and operations.
Ex: Meeting practices that begin with an informal check-in or time for personal sharing can build trust and relationship among the team.
|Support professional collegiality||Structurally supporting communication and relationships among professional colleagues will enhance care and professional satisfaction.|
Ex: A system that fosters relationships between inpatient and outpatient teams and between physicians of multiple specialties smooths care transitions, reduces redundant testing, and reduces professional isolation.
Ex: Clinical spaces built with shared breakrooms, and organizational support for collegial dinners.
Ex: Programs that support relationship-building among leaders and building bridges between leaders and the clinical faculty, including listening sessions.
LISTEN-SORT-EMPOWER. AMA Steps Forward. Published June 25, 2020.
Cultivating Leadership. AMA Steps Forward.
Ex: One model that structurally supports cross-specialty communication is to administratively nest subsets of interacting specialties together (eg, a “pod” of 20 primary care physicians, 4 cardiologists, 2 pulmonologists, 2 endocrinologists, etc) in which consultations and referrals are shared. This clustering can occur through collocated physical or virtual pods. It is easier to pick up the phone or walk down the hall to discuss the nuances of a patient’s care with a colleague you know and trust, which may decrease the need for referrals, ensure appropriate testing is in place when a referral is necessary, and improve efficiency through direct, in-person communication rather than assuming a distant, unknown colleague will understand all by reading the EHR.
Make Room for Relationships by Removing Sludge From the System
- Sinsky C.
- Hilliard R.W.
- Haskell J.
- Gardner R.L.
- Rittenberg E.
- Liebman J.B.
- Rexrode K.M.
- Ashton M.
|Reduce unnecessary work||Removing unnecessary work creates time to devote to deepening relationships. Ex: The Getting Rid of Stupid Stuff|
Ex: Inbox. Organizations can turn off automatic notifications about test results not ordered by the particular physician, reducing both inbox overwhelm and also the hazards associated with ambiguity about who is responsible for responding to the result.
Ex: Signatures. Requirements for signatures for low-risk activities, such as ear wash, fingerstick glucose, and for services that would not require an order in another setting, such as an influenza vaccination, should be removed.
Ex: De-implement outdated policies. A De-implementation Checklist,
91developed by the American Medical Association and reviewed by the Joint Commission, provides specific suggestions to minimize alerts, reduce inbox volume, decrease note bloat, and improve efficiency.
Ex: Avoid over-interpretation of accreditation standards and state or federal policies. The Debunking Regulatory Myths
93initiative prevents over-interpretation of state or federal regulations.
|Reduce the workload of visit note documentation and review||The time required for visit note documentation and chart review can be reduced by improved staffing, processes, and technology.|
Ex: Dictation to a human transcriptionist who over-edits speech-to-text output results in better notes and more efficient use of physician time than requiring the physician to manually type the note or to themselves edit the speech-to-text output.
Ex: Concise, customized notes that communicate clear clinical information make less work for everyone. In place of heavily templated notes, which risk reducing patient interactions to a litany of close-ended questions, technology, regulatory and payment structures could promote the open-ended, conversational style of history-taking that elicits a full, coherent story.
|Streamline log-in and log-out processes||The administrative and security processes involved in accessing the EHR costs time and cognitive focus. Reducing this burden can improve the work environment.|
Ex: Log-ins can be simplified, using RFID proximity identification or bio identification (ie, fingerprint or facial recognition).
Ex: Intervals between auto-logouts can be extended, with the interval adjusted according to the location of the workstation.
|Governance structures||Changing the nature of the administrator-physician relationship so that both groups share accountability for common goals can result in better outcomes and job satisfaction.|
Ex: The impact of new policies on physician workload, and thus on access and continuity, can be calculated before implementation, and the high cost of clinician burnout and turnover
53can be treated with the urgency its financial and cultural impact deserve.
Realign Reimbursement and Incentives
- Guterman S.
|Adopt an owner’s mindset in practice||Physicians in practice can adopt an owner’s mindset, whether they are employed by a health system or own their own practice, and thus strive to maximize their efficiency in how they spend their time and generate revenue.|
Ex: Hiring sufficient staff (in some settings this may be 2 clinical assistants per physician) to develop the capacity to offer same-day access for urgent and semi-urgent visits.
Ex: Attending to the fundamentals of practice workflows,
100such as incorporating the annual wellness visit into the rooming process for an evaluation and management visit; routinely prescribing 90 days plus 4 refills for stable medications
77; and performing previsit laboratory testing.
Ex: Being willing to see one’s own patients who call in on an urgent basis, recognizing that doing so improves patient care, increases patient loyalty, and increases revenues generated.
|Align payment to support relationships||Payment systems can contribute to the sludge in health care that is a barrier to relationships and, on the other hand, can also fund the mechanisms that support relationships.|
Ex: Payers can simplify or eliminate prior authorization requirements or pay physicians for providing this service.
Ex: Payers can provide funding for virtual consultations that support integrated care, including payment for physicians to discuss with colleagues the care of mutual patients.
Ex: Delivery systems can more equitably distribute operating dollars to the clinical units that generate downstream revenue for the organization.
FY 2022 President’s Budget.
- Office C.B.
- Meyers D.
Barriers to Reorientation of the US Health Care System Around Relationships
Opening Vignette Revisited
Potential Competing Interests
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