Leo Babauta, in Zen Habits: Breathe, said that one of the most frequent questions he is asked is “where do I start in changing my habits?”
We are often overwhelmed by the choices of problems to fix whether it be changing eating habits, or beginning to exercise more, or practicing gratitude routinely. We may try too many things at once or nothing at all. We may just shut down because it all seems insurmountable.
Frequently, this is also the question asked by our Relias customers. “Where do I start? I have mounds of clinical information, demographics, clinical assessment data, social determinant data. I have a raft of performance measures telling me how I am doing, and I am being asked to reduce readmissions and emergency room use, address opioid dependency and physical health needs, along with behavioral health needs and my data is all over the place. The choices (and pressures) are legion, but where in the world is the place to begin?
There are several lines of inquiry that can help:
1. What is your positive vision for your health system and what steps can you take to realize that positive vision?
We often start with the “problem” that is before us, whether that be “what is the latest requirement from your accrediting body,” “what report do I need to produce tomorrow,” or “what was the latest battle cry from the CEO fireside chat?” We are accustomed to finding problems and fixing them. Alternatively, being led by the vision for your health care system will take you in a positive direction, not pull you into a “problem solving” deficit spiral. Being vision-driven inspires and energizes your team. Leading with positive vision is at the heart of Appreciative Inquiry and its sister Positive Psychology. Systems change in sustainable ways when they are led by vision and dreams for the future rather than a “problem solving” orientation. Study what IS going right in your organization. What are your organizations strengths? Identify where you have great success and then do more of that.
2. Of all the possibilities for improvement, where do you have data that will allow you to benchmark and measure progress?
If your focus for improvement is the integration of physical and mental health care, but you have no pharmacy data, start where you do have data or could gather it. Simple laboratory indicators of A1C, BP, and LDL will help monitor your improvement in diabetes management. Start with what you have.
3. Which of your perceived opportunities for improvement are actionable?
Too often data has been collected for years with no real possibility of being used to promote change. Lists showing numbers of high users of Emergency Department care is of little value without the data illuminating the reasons for utilization. If your data shows you that the individuals who use ED care do so for dental problems, or the children who use it are admitted for asthma-related issues, or those who use ED care aren’t connected to a primary care provider, it can then be actionable.
4. Which changes can you make that will leverage other changes?
The best choice can help you realize your positive vision for your health system and serve as a quality improvement project to present to accreditation bodies, or help you with performance reporting activity, or shine a light on other actionable steps you can take in the future to further your mission and business. Pursue what is not only “doable” and “achievable,” but what will have the greatest impact downstream.
I consulted with a community mental health center that had decided to focus on the chronic problem of “physician no shows.” The organization had tackled this problem over the years with multiple interventions, yet no sustainable improvement had occurred.
Should they trudge ahead and try to move the needle on this problem once again? “Physician no shows” create an expensive loss of productivity and billable hours for an agency, but it is difficult to get staff excited about addressing “no shows.” As the team at the CMHC began to dive into the “problem” they wisely hypothesized that physician “no shows” could reflect a lack of patient engagement in the recovery journey and strengthening physician-patient relationships could be instrumental for change.
Creating an environment where there are powerful relationships with patients and providers was already a key value in the organization and part its mission. Now the “problem” of physician “no shows” was not “a problem” to be fixed, but an opportunity to focus on a way to continue to build vibrant and meaningful relationship between patients and physicians. “No shows” was now a meaningful indicator of the connectedness of that relationship.
Using this frame guided the inquiry... “what does it take to increase patient engagement?”
The team reviewed the literature and an internal champion was identified to lead the effort. The data was studied in a new way. It wasn’t a surprise to find that the data highlighted a small group of patients who contributed to most of the “no shows.” It also revealed one particular psychiatrist who had minimal “no shows.” The team decided to study this psychiatrist rather than less successful psychiatrists. Not surprisingly, but inspiring, they found this psychiatrist had great relationships with his patients. He uniquely asked the patient to set their own next appointment, deciding for themselves when they wanted to return. He gave them choices and increased their sense of a mutual effort.
An intervention group was started for the small cohort of patients contributing to the highest no show rates. Analysis uncovered that some patients didn’t like their psychiatrist, others had transportation and scheduling challenges, and some had side effects they had not felt comfortable discussing.
The change and implementation plan revealed itself during the inquiry process. “No shows” for this cohort, along the various dimensions, were benchmarked and measured and rates were reduced. The strength based initiative served as a quality improvement activity for accreditation and paved the way for a series of other improvements building relationships with patients and providers.
When answering your question of where to start, being guided by a positive vision, using and collecting data wisely, and knowing your organization’s strengths, can serve you well.
Leigh Steiner leads the Clinical Applications and Analytics Team at Relias. She holds a Ph.D. in Speech Communications, Rehabilitation Counseling, Psychology Counseling from Southern Illinois University, and is the former commissioner of Mental Health in the State of Illinois. Leigh also holds a certificate in Appreciative Inquiry from Case Western Reserve University.
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