Small Group Work
Daniel Wolfson
The shift from physician-centered focus to patient-centered care. We invited 8 individuals who had chronic conditions and caregivers. We provided a place to talk with them and they said, ‘why should we be giving our story? Everyone has a story to tell.’ So this booklet is the result of that and it’s a good teaching tool of patient-centered care. We put it online and make it a blog. Now you can find it. I would ask that you support it as a teaching document and possibly transforming the way of thinking. I would love for you to contribute and to spread the word.
Shared Wisdom - an interactive forum featuring compelling patient and caregiver stories from healthcare professionals who attended the 2008 Forum. Read their powerful stories and share your own.
As a second profession I was a snake oil salesman. Now you can see that. (laughter)
Team Topics
Team 6 – Strategic Plan
I am a consumer of healthcare and teach at a medical school to integrate patient and family perspective to work in a team model. This is part of the discourse on the national level and in great organization. I had some wonderful partners here.
We began with the urgent consideration of ‘no’ not being an option. We want to take the great work that has already taken place. At what point does this alliance increase the trust in the public and of physicians. We want to create a National Alliance website in 2009 and disseminate the work of this group more broadly. We will begin to gain the stature in the public eye.
Is it time for the alliance to become an organization? We think the current economy creates this urgency. We want to enlarge this process and end the turf wars. I’ve been honored to be a part of this alliance. It is hard to have other stakeholders to participate without having a unified mission for the organization.
Under the philosophy of being bold, we posed a set of questions for the group. Should we have a national licensure? This is a long term goal. We have a list of questions here: how we ensure competency of physicians, how we become part of the national agenda, how do we develop a bottom-up strategy are among them.
We strongly believe the bottom up strategy will move this work forward.
Q: Help me understand what is patient-centered healthcare?
A: The most important part is a mutually beneficial partnership. We need to move away from this advocacy model. You have an expertise of being a physician and I have an expertise of how I feel health or illness. This is built on respect and dignity.
Q: What part of the economy is a threat to us?
A: We see what’s happening for all Americans and how the U.S. government is responding has an impact today different than it was in Summit I. Then we felt a nation of influence that we don’t have today.
Q: What about the pernicious nature of the healthcare economy? This drives physicians’ performance. We have to understand how their paid and until we change that we will have problems.
A: The public is ready to have this change.
With the respect to the comment you just made is that there is a crisis in healthcare quality.
Team 5 – Systems Document
We have copies of the conditions of the GMP. In terms of our first charge, we rewrote this to reflect the positivity of the group and compacted the first paragraph to this:
Establishing an optimal environment is essential to allow physicians to fully demonstrate the characteristics of a good doctor as outlined in the Guide to Good Medical Practice. Success requires strong collaboration with other key stakeholders and physician leadership. System characteristics that would support this goal include:
From here we used the bullets from the previous document. We looked at each of them and try to fit the ones for physician control but then we saw with new eyes. We took the shift document and mapped it to these conditions and want to create a synergy. We’d like to display that here.
http://nationalalliance.pbwiki.com/22309-Group-8%3A-Conditions-for-GMP
We want to support the culture of competence. All the points in the shift document can be mapped to the Conditions for GMP document. This can be related to evidence-based standards and tools for performance.
The only other change we suggested are that the essential skills and attitudes which include planned redundancy and we didn’t feel that helped us in any great way. We would change the preamble and request to do further work to map the shift document.
Q: How did your group deal with putting integrated EMR out of business?
A: We didn’t talk about the cost of it but we think it will be very helpful to practices. The financials are critical but beyond the scope of what we did.
There are other groups who are working on this. It’s being actively pursued.
Economics affect a lot of this but we can establish what the condition ought to be but some things are beyond our immediate purview.
Q: I don’t see the new version of the preamble, but I think it’s important that the preamble reflect that there are other important system issues. If we don’t go into that we need to at least make reference to the fact that they’re important.
A: In the phrase where we said physician leadership, we offered ownership as an alternative term.
That would be great because I view this as a type of pledge. We can’t do anything about the economics directly but this we can.
Q: I like the direction you’re moving with this. Since you’re adopting the paradigm of the shift I wonder if you want to reference that in a conditional sentence in the opening paragraph. We could then say what is outside the scope. There is a practical value to have an appendix and have an internal reference that there is other work that one can go looking for.
A: We thought a synergy between our products is a good thing and that adds to it.
Comment: There are a number of components that can be mapped to a shift document and relate to the purpose of the alliance, so perhaps these are a potential linkage and leverage points.
Q: I’m very concerned about three of the bullets. I’m afraid to eliminate them and the power they have. I’m afraid of this process at all.
A: You may be right. We can’t ignore the economics. But this group can recognize these are important factors but addressing them are beyond us and may be addressed better by other parties.
Maybe we want to change the title to incorporate the shifting paradigm. The history of criticism is replete with responses of defensiveness. Leadership in my view is to say this isn’t perfect. We used to start with the worst case scenario and I made the comment in frustration. You may not like where the ball is but you have to play it from where it is. This is exactly where we are. And we have to play it with the clubs we have.
We could take these documents and take it to payers and say that we see that there are challenges in your arena but what changes do you see that need to be made to improve care. This way we could not lose it in our strategic message but not loot the things we need to change.
Q: Does the GMP address the efficient use of resources?
A: Yes.
R: Then we need to put that in the preamble. This is what the payers, purchasers, public want to know.
Q: I’m not confused between the distinction between this and competency-based care. If these are things that physicians own, why is it not part of the competency? This seems to have moved back towards competency.
A: The content of GMP is focused on the individual physician. This speaks to the collective conditions in which doctors work. Collectively as a profession we could impact, if not drive, the change.
Team 7 – Alliance Business Plan
We looked at the business plan and looked at how this alliance can be sustained. We had four or five ideal goals. We don’t want more regulation. We worked on an organizational chart. The commons are the alliance and we broke out some steering groups and want to implement some tactics so we need a staff to do that. Right now it’s all done by in-kind donations from the various organizations.
We need to set priorities and focus on our mission. We have a list of practical things which also need to prioritized and set expectations for execution. All of these things would be reported to the commons along with next steps and timelines.
Here are some ideas around our operations and what it would take to keep the alliance working. We want to develop and maintain project management. We took a first cut to look at the financial operations. We would want to do some grant writing to continue the support and funding of this.
We wanted to pass around a non-denominational plate at the end of our report. (laughter)
Q: What strikes me about this is we spoke at previous summits not to create something that is so similar to what already exists within healthcare. The conversation needs to ask if we want that or we want to do something new.
A: That’s for the commons to decide.
I don’t think that’s what we’re doing now. There is a sponsor group but we’re just hearing about that for the first time. We need to have much more transparency.
The discussion around this was making sure that the alliance was acceptable and a recognized group of folks who are perpetual or if there is an outcome that once is achieved the alliance would end. We made the assumption that this would be perpetual.
We need to define the alliance. Is it anyone who wants to show up? Is it for whoever signs the agreement? Is it binding beyond the walls of the summit? How do we define the commons? The alliance is the commons and I haven’t heard this group or any conversation focus on what should be part of the commons?
We didn’t talk about long range goals. Do we respond to the environment?
We started from here. We assumed that there is an alliance and that it would be a sustained group. There is a reason we do business like this and that our organizations look like that chart. You have to come out of the clouds and look at the dirt. That’s where we are.
If it’s not broke, don’t fool around with it. This organization seems like they’ve been successful. You don’t want to organize another church, synagogue, or mosque. What comes with that is restriction. It doesn’t mean that the alliance is finished but we need to accomplish a product every time we’re here.
The tension is within the alliance itself. We valued fluidity and equality among all participants. If you get into membership and categories then participation is damaged. Our momentum is limited because of the absence of staff to arrange things. If we have people with salaries then there has to be some authority who oversees them. We need to have a mechanism which allows us to have funds to provide these resources while maintaining this free fluidity of participation. This is hard to do which a commons which means only every 10 months.
Ditto. We’re at a stage where we have to define our resources and that includes contributions from organization. We can’t go on without staff. We’re not going to get the action we need without staff. I don’t see this organization relying on Michael. Someone has to wake up every day to think about this.
Q: Did you talk about the kinds of expertise that need to be represented on the steering committee? Maybe we need certain competencies instead of just who is willing to volunteer.
A: I was on this group last time in Baltimore and it was a sense that we wanted to go on without staff. It is important that we find out if it’s time to have an organization.
Q: I’m probably going to display some ignorance. If we have staff don’t we have to be an incorporated organization that can pay payroll taxes, etc.? What we don’t need is another regulatory body.
A: Well, we all know that.
There has to be neutral ground to do this. We don’t trust each others’ organizations to take care of this. And right now we’re spending $10k a minute to make these decisions.
Q: I don’t understand how the work gets done between sessions.
A: The process of administering the work, setting dates for summits, putting the materials together, has been a staff function. We look for the dates when the most players are available. That’s how the date is set. The FSMB has been willing to allow me and Frances to provide administrative support.
Q: Is that an indefinite commitment?
A: If the scope of work remains the same, then yes. But it’s not sufficient for what the commons is asking for now.
We’ve been happy to provide the resources right now but this is a matter for our board to discuss. We have some repairs that have to be done. We have to evaluate to what extent we can make this commitment. We will be making this decision in May.
It’s important to underscore that this has been a loosely organized conglomerate. Many organizations have contributed many things, cash and human resources. So far this kind of informal structure has worked, but if we want to go above the FTE we’re at now. In the current model we’re not getting what we need. If we want to shift to a dedicated staff then we have to find a medium or long-term commitment and maybe a pledge drive. The price of continuing the way we have now is the slow progress. Maybe we need to find a funding stream.
There is a risk of collapse if any of the current voluntary sponsors were to change their minds, like Marty has suggested.
I’m not sure what we’re going to do. We just have to re-evaluate what we can do. It is a significant amount that we’re contributing compared to the resources we have available.
MK: Let’s have a vote if we want to continue as an ad hoc group or do we want to fund it more cohesively.
The problem is that if we formalize then we have a board and you have to pay for travel and all the rest.
How can this group figure that out? Unless you have the key players of these groups who are holding the purse strings, we can’t make that decision.
We could make a proposal to take this back to our groups.
Under the rubric that form follows function and in relation to whether we’re happy with the speed we have now, I’m not sure that we’ve carefully defined our function yet.
Team 4 – GMP Feedback / Working Group / Copyright
We were looking at the GMP document and the feedback and to decide where to go with it. We looked at the responses by the AMA and the AOA. Both of them had a lot of good points. The main concern from the AMA is that it will be used a regulatory document, that it was duplicative and didn’t cite the work that was taken from others.
We want to get new feedback on this document as it goes along. We wanted to have surveys done in between the two sessions. We did this at the last meeting to create the survey but it didn’t get distributed in between. This is the problem of not having a staff just for this work.
We thought it was necessary for the document to have an editorial where we cross-referenced the sources. We spent a lot of time talking about the importance and validity of the survey. Doctors need to look at it and say it’s important. Whether it becomes a standard or not, getting it out there will be the biggest feature of its success.
We could do an ad hoc on this or on copyright. Different groups have lawyers to help us with this. Do we do this in an organized fashion?
This wall is how to do the website. If you go the gmpusa.org you’ll get the current version with explanatory comments. We’ll have it available to give feedback through narrative comments and the survey and then we would incorporate the proposed changes.
We want to define the domain and put the competencies in a common framework. We want to emphasize that this is not a standards document.
Comment: I think that it’s premature to put effort into a website.
As we’re discussing this as a working group, we want to figure out the vehicle to get the information for feedback so we can make modifications in a way that is user-friendly.
When we talked about doing the survey, we decided the two most important groups were physicians and patients, but there may be other groups too. It was pointed out that physicians might have different opinions because they’ve been patients.
Q: Wasn’t there some actual feedback that we were going to get on this document?
A: We never got to the point where this went out. We’re not at the level of science we’d like to see. We did have a discussion at the steering committee that we’re not getting a lot of comments back, but unless we have a staff person who nags the people to nag the organizations, this is not going to get done.
In Minnesota we’ve had a physician competency test and we’ve circulated the GMP among all the stakeholders and got a lot of feedback. I would encourage other groups to consider being the voice for that.
Q: Is the GMPUSA website enough? If we could encourage people to go back and make comments we might want to do that.
A: Don just has to turn it back on.
I think we will have greater efficiency if we can communicate between the summits. We need to have more quality and it’s hard to have that in a survey unless we do it well. We need to decide the timeline of when we’re going to do this.
MK: Rather than looking for the alliance, look for resources for the various projects. Is that right? Do you want a single resource for the GMP? (most of the hands)
There needs to be an organization that gets going. There is a higher order question that we need to resolve.
Team 2 – Shift Strategy
We lumped the 12 topics into four categories. We didn’t put up the old information, just the new. Where it is says current there is a collaborative with 256 members. We think MOC will push this if there is data in that. Employers and insurers need to know and demand the same outcomes.
In teams and systems, it is already being incorporated in education. This is at the specialties but not necessarily across professions. Similar to the strategy group, there might be other kinds of meetings where we can invite other people in. There is still some indecision about where we’re going.
The current things, like PQRI, are tools that maybe we can look at. We know that the cystic fibrosis organization makes all their data public. HCAPs data has their stuff out there on a website. Maybe we need to get involved and provide rational consultation. We can consider it as a strategy.
How can we increase the amount of data at the organization and individual level? We want to have integrated data support and to have any of this data and evidence-based support is essential.
How do we disseminate the results? There are all these demo projects that are going on. We have a list of many of those things here. We had a parking lot of issues we didn’t get to, such as re-entry issues, and removing people who have questionable competence. This may be a place to get the public engaged because they have a lot of energy around this.
We thought disseminating GMP is important and we believe that the things that are occurring at these summits will impact what is happening. We want to push the impact on licensure and re-licensure. We had a conversation about which generation is in this.
Comment; Ann brought out the best of the strategy bunch. There is a call to action. There is a good push to the group to whether we are here next year and whether we’re willing to fund it.
Since the group is dissolving in front of our eyes now, there is a big question about the financial and resources that we have to resolve.
In order to get the organizations involved we have to take into consideration their concerns. I’m worried about how much buy in there is from the representatives.
I’m not on the board for the AMA, but I can tell you that being in this group has mitigated and mollified our concerns. This was a membership concern not a leadership concern. We’re trying to help you get this done. If it goes off the rails that is not good for us either. The AMA is not the enemy. You need to help us get it out there. If we can go back to our members and say this is not as bad as it seems that it is. If we can say that we’ve completely changed the tone of the document, then that’s something. Don’t jump to the conclusion that plain speaking means opposition.
I want to go back to whom we represent but also to go out from that. We need to have a unified message. We need an elevator speech.
The question that’s coming up for me, there are people here who are trying to move us forward. There is a limit to how much they can speak because of who they represent. What’s not being discussed is the question of whether people can be here
Why this works is because it has been outside of the organizations. If we go with staffing and steering committees will that hurt us or do we not have an option?
I have an outrageous suggestion and I’ll probably regret it. It has seemed that our progress is slow is because we keep revisiting the same issues. We do have three kinds of groups I the room: education, regulatory, membership, and a small number of public. I wonder if it would be worth an experiment to have a different sequence of having the people putting together the documents and then having the broader group reacting to it. Maybe we need to have something that’s a real draft and then get the feedback.
I think that’s a wonderful idea.
MK: Between summits one time, the certifying boards met to solve something and another group looked at eFolio and brought the results to the next summit. This is possible. That could be an ‘and’. The next two groups to report are to bring back this value.
I am reflecting on the work that has already been done. There was a staff group who worked on things for the alliance which was very detailed. We considered different organizational models at the time two years ago. This thinking took place at that time and though it was premature then we may want to revisit that information again.
From an operations perspective, if we were to aggregate all the work done here, the scope is huge. I struggle with knowing the difference between a yes that it’s in and we have to do it, or we just don’t want to lose the ideas.
Yes, I think there is too much here and we don’t have the jurisdiction to do these things.
We didn’t say what the alliance should do but to put together the ideas of strategies that will shift from the old to the new.
I’m sensing a tension. We’ve brought ourselves together as a sense of the commons. I would posit that some of those things that are going now are because of the conversations we’ve had here. The sense of the commons provides a sense of movement in our own spheres of influence and I think that’s very valuable.
We need to get clear about what the alliance is responsible for. We want to support the organizations here achieve their own missions.
One of the concerns I’ve had. I remember talking about the book we had to read about being a starfish organization. We wanted to make it easier for physicians to be patient-centered. We’ve seem to expand that focus and we’ve had mission-creep. We seem to be a mile wide and a centimeter deep. There are 10 organizations and acronyms here. If our job is to be a catalyst, let’s do that well and focus on it instead of spreading ourselves so far. We’re becoming a spider instead of a starfish.
There was a plan from the last summit to get feedback. It didn’t get done fully because we didn’t have the resources to do it. Our group agreed that the most important thing is the data to validate it. If this were really my job it would have more priority. That’s why we need to have some resources. Most of us don’t have the time to follow through effectively on the nitty gritty stuff that has to be done.
I agree with your perception that there is mission creep, but it doesn’t negate the need for resources for the contributions that we can make.
Team 1 – Alignment of CME and Performance Improvement
As a team, we decided that what we really want to do is two things. We want to align the performance activities for multiple groups into one that is based on your practice gaps that will count for all of the other groups. Some of the performance that we do are not CME based. We realized that not everyone understands the accredit system or requirements. We have a lot of work to do to make that clear. Not only do we need to align the activities, but we need to get the ones that are not CME aligned into the CME process. For example, health grades, which you have to do for your institution. We need to align into one system to reduce the redundancies.
We feel like this group is the only group that could get all of the other groups (CMS, ABMS, MOC) together for a common performance requirements. We need to convene the groups and get them to talk. We tried something like this a few years ago and agreed that we needed to be streamlined, but no one was willing to take it on. We should add this to Carol’s list to prioritize.
Q: Did you have a phasing approach?
A: There was a general consensus that CMS would be left out of the first phase of talks because they are so different. It is important to emphasize that they are not to be left out entirely, but it was a question of streamlining.
Another observation is that there were a lot of commonalities in performance and evaluation improvements. They may have some minor difference, but there is an overall interest in a snapshot of evaluation. CME can provide the mechanism to accomplish this.
In the spirit of budget, this might be another invitational meeting, but it should be held at the same time as the next summit. We need to get CMS, insurance, and a larger consumer group in the room so we have a broader perspective. We need to address the policies around transparencies as well. What are our guiding principles around transparencies?
Q: Is it necessary for us to do this ourselves, or can we leverage the energy that is being put into this reform from other groups? Does it have to be the alliance?
A: Good question. I have looked at other groups and they are changing the system and changing accreditation, and not what we want to do. The mission for this work group grew out of practice improvement, a broader topic of conversation. If we make this easier for other groups to do, then we will get less push back. I cannot ask my doctors to do more performance evaluations that don’t count for their day to day activities, they won’t be happy.
There is a lot of overlap from your group and the alignment of MOL/MOC. We need to make sure that we are working together and come forward with one plan. This issue is around aligning, simplifying, and streamlining. This is physician centric.
Why is this discussion different then MOL/MOC? They could be tied together. This is about performance improvement. The next conversation will be broader on CME but narrower on organizations. The two conversations can come together down the line, but right now they need to stay separate. We need to remember that there are multiple phases. We need to get MOC right, then MOL, and then bring MOC and MOL together, and finally, bring everything together.
Team 12 - Alignment of MOL and MOC
Our group looked at the differences, commonalities and barriers to brining MOC and MOL closer together.
You can see that MOC serves as a priority for MOL and other groups. MOC is more standard setting while MOL is more process improvement. Both realize that there is more work that needs to be brought forth. MOL has a lot more work than MOC around what they are going to be and what they will define themselves as. MOL has more political issues based on the fact that they have state legislatures to comply with.
We looked at the common ground and felt that the barriers were that both programs have issues with physician buy-in. Both can be perceived as adding burdens of cost and time. If we can come into alignment it could be common ground for both areas. If we can come up with common standards we can move forward.
Both MOL and MOC are designed to ensure physician competencies in their area of practice and improve public perceptions of what the boards do.
An open question is who do they report to? We need to know about availability of MOC elements to non boarded MB’s. Right now, the discussion is that if I want to practice a certain practice, I can declare that, but with MOC, I get train them. We need to rectify this disconnect.
Dealing with the different state boards is like herding cats, and in many cases, herding feral cats. We need to continue the conversation to continually move the MOL and MOC towards alignment. We agreed upon a group that will continue this conversation outside of the alliance.
Residencies have a moral obligation to educate their residents about this process. We need to borrow anything that we can to improve the residents’ buy-in. There are sequential conversations that need to be going on. The boards know their needs, and we need to figure out how that relates with receiving CME credits.
Although there are commonalities, there is a big difference in the starting level of the bar. The discussion about licensure must include the general license of practice across the different states and maintenance of licensure.
There is a very different language across the states. There are lots of similarities and lots of differences, and we need to understand the differences first.
Q: How did we discuss the trusted agent or key portfolio questions in past summits?
A: I don’t have an answer, but I do know that there are experiments going on with trusted agent right now, and it has moved away from the alliance in the past. I think that we need to have discussions about trusted agents brought back into the fold.
