Improving Ambulatory Care

I recently attended the IHI conference entitled “Improving Patient Care in the Office Practice and the Community” in Washington, D.C. It attracted about 1000 people from around the country to share their stories about how to make care better, and I want to share two of them with you.

If you have ever imagined what primary care could look like if you “blew it up” and started over instead of nibbling around the edges of process improvement, then you would enjoy learning more about the Southcentral Foundation. Their president, Katherine Gottlieb, and their medical director, Steve Tierny, gave a detailed account of their journey from a dysfunctional, bureaucratic provider-driven health system providing mediocre care to native Alaskans to a national Baldrige Award winner built around the concept of community wellness. Don Berwick is quoted on their website as saying that “I think it’s the leading example of health care redesign in the nation, maybe the world,” and I can see why. They have truly put “customers” (not “patients,” which would imply that all of the people they serve are in need of medical care instead of wellness promotion) at the center of what they do, and have wrapped data-driven team-based services around them in what they call the “Nuka” system of care. Really impressive.

Laura Adams of the Rhode Island Quality Institute gave a keynote address in which she told a cautionary anecdote about ill-conceived efforts of providers to become more “patient centered.” She had been involved in the design of a “breast center” at a hospital in a small community, which had included all the things that the providers believed (without asking) that women wanted – pastel colors, soft lighting, soothing music, massage therapy and the like. After it opened, she interviewed patients to see how much they liked it and was horrified when one asked her “what were you thinking when you named this the ‘Breast Center?’” The woman went on to say that she didn’t want her friends and neighbors to know that she had something wrong with her breasts, any more than a man would feel comfortable walking into a building with a big sign that said “testicle center” or “penis pavilion” over the door. Ooops!

Turns out we really don’t know what people want or patients need unless we ask!

3 thoughts on “Improving Ambulatory Care

  1. Good for the Rhode Island woman that spoke up. I think part of this is the attention given to men and their problems. Nobody questions things like Viagra, while needs of women and children are unmet, and not approved by Medicare.

    I’m one of the millions of people of both genders that does not have breast cancer. Lung cancer kills more people or affects more people each year than breast cancer. It sounds odd, but people with many other types of cancer keep asking, when will research resources start going to other types of cancer-lung cancer, ovary cancer, mouth-throat, testicle , bone, brain, melanomas, blood cancers. The counseling is for breast cancer patients. The counseling for care takers is for breast cancer.

    I was told by the ACS that there are more breast cancer patients. I wrote back that is because breast cancer research is successful, and there are more survivors. It’s time to throw a bone-even a small bone to the rest of us. On my favorite ACS cancer blog last week, a woman in her 20s, asked why isn’t there more research in blood cancers?

    The rest of us should count for something.

    1. Thanks for your comments.
      You raise an important point about the “politics” of certain diseases and conditions. It is no doubt the case that some advocacy groups have done a much better job of elevating “their” disease in the public eye, thereby attracting more funding for research and treatment.
      As a cardiologist, I have always been a been a bit frustrated by the fact that people don’t often recognize that heart disease kills many more women each year than breast cancer does.

      1. Two things that I know patients don’t want 1. pain and 2.life threatening illness that is assymptomatic, and they 3. don’t want to waste time. All three terrify them because the management is out of their control. The first could be assessed by ambulatory setting, and treaged to a higher level of care with some pain management. Particular attention to a chronic, subacute vs acute exacerbation should be determined, as well as if this is a new onset problem independent of chronic conditions. There is a trend in surgery to handle acute problems by generalists, leaving the more chronic complicated problems to the specialty folks that offer a more definitive management. The down side is the time it takes. The assymptomatic patient may benefit from a wellness evaluation, with attention to the “NSLIJnumbers”, or a V02 eval( NY Timesarticle), with attention to what are likely health problems by age, behaviors, culture and gender.
        No one likes to look for problems, but simple( key in the numbers on a phone app) , cost effective screening works, and you can give them instant answers , documenting compliance.
        Time is the most difficult thing to use/save- I know that if it is spared, we’ll all be in less pain (potentially) , richer ( put money into research) and be able to improve ourselves further ( with the time to focus on wellness for both patients and providers) take a walk outside and smell the roses.

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