David Ascher, MD, MBA
Chairman, Department of Pediatrics
Inova Fairfax Hospital for Children
When people hear the word “change,” they often have a few thoughts. Change what? Change to what? And why do we need change? In that aspect, the word change carries powerful challenges, both to thought and to action.
The word “change” also carries a few basic assumptions: one, that something needs to change; two, that there is a way to effect the change; and three, that there is a willingness to institute that change.
The current state of our healthcare system is about to change. The reasons are beyond the scope of this column, as is whether you agree with this change or not. But now that the wheels of change have been set into motion, what are we to do?
We have a few choices: one, resist the change, with the caveat that those who oppose change must propose a different solution; two, do nothing and see what happens, with the consequence of being swept under the approaching change tide; or three, embrace change, using the opportunity to adapt new initiatives to our mission.
At the core of this change is the way we deliver care. We know that the healthcare industry is costly and often inefficient. We've been fortunate that our geographical location provides us with a steady and reliable payer mix that helps our revenue stream and our bottom line, allowing us to retain an excellent workforce that provides excellent care. We can do better. We should do better. And we are working to improve.
Across Inova Fairfax Hospital for Children, several "experiments" are underway to launch us on this journey. Some of these processes involve improving our Emergency Department-to-inpatient unit transitions, others aim to improve communication with our families during the admission process by establishing clear and easily identifiable discharge goals, and to coordinate all aspects of care by including the patient’s bedside nurse in physicians’ deliberations of the care plan.
Change can be evolutionary or transformative in nature. I would like to accentuate some of the changes on the horizon:
(1) The Joint Commission (TJC) now requires all inpatient chart entries to be dated, timed and signed, with either a provider code or legible name present. This is evolutionary. The Electronic Medical Record will automatically contain this, and many of its other benefits will be transformative in nature. Inova is now going with the EPIC system.
(2) For hospital privileges, TJC is requiring Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) based on the six competencies upon which our medical students, residents and fellows are judged: Patient Care; Medical/Clinical Knowledge; Interpersonal/Communication Skills; System-Based Practice; Practice-Based Learning and Improvement; and Professionalism. The American Board of Pediatrics will include these competencies in Maintenance of Certification.
OPPE is an every-six-month documentation of competence for recredentialling on the two-year cycle.
FPPE is when a physician first comes on staff (six months) and then transitions to OPPE; it is like a supervision period. It is also when physicians upgrade their procedural privileges to something new. Or when a physician causes a serious safety event.
(3) Effective July 1, our interns will be limited to 16 hours. The hour reductions over the years have been evolutionary in nature. The reduction from 30 hours to 16 hours will likely be transformative. Will they graduate competently? Will they be ready to work all week and take call over a full weekend in private practice? Many unanswered questions. Or maybe a grand experiment.
(4) The word change also implies a journey. It implies a beginning and an end. We have been on a patient satisfaction journey now for three years with some positive results. Key physician components are: keeping patients and families informed; explanation of tests/treatment; courtesy/consideration; and our area of greatest opportunity, overall teamwork. In 2013, CMS plans to take 1% of the DRG and give it back to hospitals based on a formula weighted 70% on Core Measures (ours are in asthma) and 30% on patient satisfaction. For Inova as a system, this puts tens of millions of dollars at risk.
(5) Healthcare Reform: Accountable Care Organizations (ACOs) will put an emphasis on continuum of care and the medical home. This will be a transformative change for hospitals that are currently reimbursed on the inpatient admission. With an ACO, the goal is to keep patients healthy and out of the hospital, and reimbursement will be weighted on the success of keeping patients from having to be admitted.
But change for the sake of change does not add value to our endeavors. The journey we should embark on is a journey without end, a journey of continued and sustained improvement with a strategy of measurably better value. Better value is the key characteristic of the changes we are facing.
As we move forward, it is essential for all of us to work in collaboration for the benefit of the whole and not lose sight of our most important focus: our patients and families.
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