Listening to patients and staff

By Ted O’Callahan

"Listening is a political act," says Zeev Neuwirth, the vice president of clinical effectiveness and physician affairs at Atrius Health, a nonprofit alliance of five medical groups in Massachusetts. In leading an effort to remake healthcare within his organization, Neuwirth has discovered that "listening breaks down the barriers of power and hierarchy — the engagement that comes when people are listened to can produce profound changes."

In 1997 Neuwirth published a survey of research showing that doctors who are empathetic communicators produce better healthcare outcomes. He spent the first part of his career training physicians in how to listen to their patients. One approach he used was arranging improvisation workshops for doctors to hone their communication skills. Looking back, he says, "The doctors are excited for a day or two, but they fall back into old habits. If you haven't changed the environment, the changes won't last."

Now Atrius Health has begun a pilot program to change the healthcare environment, starting with two offices of Harvard Vanguard Medical Associates, the largest of its five affiliated group practices with 500 physicians providing primary and specialty care to 350,000 patients.

The effort draws on an eclectic variety of management techniques, including elements of Toyota's Lean system that show up in rapid prototyping and empowering frontline clinicians and staff to make process improvements and innovations.

In the first test office, a group that included representatives from every patient touchpoint and every administrative function was tasked with designing the ideal healthcare experience. It isn't uncommon to take years to design and implement healthcare initiatives. But in just six weeks, this group clarified and reorganized work duties, restructured the patient's experience, and increased usage of Harvard Vanguard's web portal, which allows patients to securely access their personal health information and request appointments.

Karen DaSilva, a physician with Harvard Vanguard, explains that this far-reaching change happened in part because the process broke down the organizational hierarchy. "We were getting 20 to 30 people in a room — medical secretaries, main desk registration staff, lab people, pharmacy people, clinicians, nurse practitioners, nurses — all saying, 'Okay, this is the problem that we need to solve,' and then having a discussion about how to solve it. Through that we were building an environment where a medical assistant can turn to a doctor and say, 'That's not the best way to do it,' which we've never had before."

According to Neuwirth, in one session, a physician, who is a former chair of the Atrius Health board, described a streamlined referral system. The medical secretary sitting next to him responded. "She said, 'That sounds pretty good, but let me tell you how I think it should be done.' And she just started to outline the workflow. He scribbled down exactly what she said."

Neuwirth says that rather than seeking solutions to a discrete problem the group made a decision to invest up-front in trying to establish a self-generative culture of continuous learning, improvement, and innovation. "To create cultural change, you don't focus on cultural change. You focus on the goal of outstanding, respectful patient and family care. You support the frontline folks who are working to achieve that goal. And in the process of getting there, it's necessary to create a respectful and collaborative work environment. People are happier because they are doing meaningful, creative, empowering, partnering work."

Thad Schilling, another Harvard Vanguard physician, says, "My patients' experience is as dependent on my medical assistant as it is on me." As part of the new program, medical assistants take a more active role in patient care, including meeting with patients to get complete lists of medicines, in order to minimize errors. Having people work to the top of their training keeps them engaged and challenged — and frees doctors to do what only they are trained to do.

"The conversations that I'm having with the patient are much more proactive and much more effective," DaSilva says. "A year ago, if I saw a patient who was obese, I would tell them they should lose weight, and I would tell them to think about Weight Watchers." Now lab work and other pre-visit work is arranged by medical assistants and completed before visits, so the results can be the focus of the conversation. "I understand my patient's life better because of the new screening assessments we're doing. And I'm coming up with a plan with them."

The new system aims to ensure that patients leave each appointment with a written "after-visit summary." Research shows that patients remember the details of a visit poorly, resulting in their not taking medications appropriately or completing necessary follow-up steps. The summary creates a few minutes of work for physicians and other members of the team, but may pay off with patients better able to follow care plans. In another effort to increase communication, patients can use the web portal to contact their doctors with questions that they might otherwise be hesitant to ask or that don't seem to merit a visit.

But even at a nonprofit like Atrius Health, changes need to pay for themselves, something they haven't yet done. The effort is being underwritten with a grant from Blue Cross and Blue Shield, a sign that while many elements of the healthcare system recognize the need for improvement, the kinds of changes Atrius Health is instituting would be difficult to maintain under the current encounter/procedure-based fee-for-service payment regime.

DaSilva points out that when she sends emails to patients, it may be convenient for the patients and increase their engagement with their own health, but it reduces billable, if unnecessary, office visits. Along the same line, "medical assistants spend time doing chart review, getting people in for pre-visit labs, and looking through rosters to see who is overdue for monitoring tests. None of that work is compensated," DaSilva said.

Neuwirth adds, "There is a tremendous amount of collaborative work, coordination, and basic preventive care that is required on the part of primary care physicians and specialists — very little of which is recognized or paid for in our system. In essence, the system punishes physicians and staff who spend time collaborating with their patients and with one another. As a result, you get a payment system that drives us increasingly towards higher cost, non-preventative care."