Mike Nelson, former Medical Director, Quality Improvement, Presbyterian Medical Group, Albuquerque, NM
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"We've started something new and exciting in the clinic this month. Our patient advisors are making rounds with our clinicians, observing the doctor-patient interactions, giving feedback, and coaching us on how to be more patient and family-centered. It's wonderful; we've learned so much."
Mike Nelson, MD, is an obvious champion for patient- and family-centered care. Even though the first patient and family council of the Presbyterian Medical Group, the ambulatory care clinical division of the Presbyterian Healthcare System, came into being just over a year ago (2006), three councils are actively engaged in changing the experience of care for the 11,800 people served at two of their 11 clinics (total population = 160,672). "I don't see any other choice; patients and staff see the value almost immediately. There is no going back. Other clinics (within the system) are asking me how to get started."
Prior to the implementation of patient- and family-centered care, Dr. Nelson was saddened by the nature of the relationships that had developed between his patients and his colleagues. Even though he had been successful in decreasing patients' waiting times, improving continuity of care, and increasing office efficiencies, he was concerned that adversarial, rather than collegial, associations were developing. He didn't understand how or why this was occurring. And worse than that- he didn't know what else to do about it. Then he attended the Institute for Family-Centered Care Seminar in Dearborn, Michigan.
He was touched by the patients' and families' stories. He has always seen himself as an innovator, an early adopter of new and creative ideas. He realized that if he changed the nature of conversations with his patients and their families he could change the entire character and experience of care. He made a pledge to himself that he would "bring patients into our meetings to force conversations to be different."
Upon returning from the Seminar Dr. Nelson appointed a three-person team from the health system to provide assistance to the clinic. This group helped to select patient and family advisors, developed agendas, and provided role-modeling meeting facilitation for this new collaborative endeavor. Three patient and family advisors and five staff members (two physicians, a manager, and the heads of clinical and clerical services) made up the clinic's first Patient and Family Advisory Council. Membership quickly expanded to the present eight patient and family advisors and the original five staff members.
Soon after the Council's initial meeting, members studied all phases of the clinic's operations from the patient's and family members' perspective. The Council made a list of areas where improvements could be made and took over the management of the clinic's waiting area. They installed refreshment machines, ordered reading materials, changed entryway signage. Then they recommended waiting room options; patients now choose between waiting in the exam room or in the general waiting area.
The Patient and Family Advisory Council has become the de facto council for the entire health system. Its activities and structure serve as a model for establishing councils elsewhere in the system. Mike Nelson said, "their changes have made such a monumental improvement that I've made a promise to implement whatever they suggest or to have an acceptable reason for not doing what they suggested." This clinic's Council even developed their own Mission and Values statement that complements the overall health system Sense of Mission Statement.
The second council was developed as a response to the impending construction of a new facility in Albuquerque's West Side. Twelve patient and family advisors are part of the group that meets with the architects. Patient and family advisors will be included in every detail of the construction that impacts the patient experience. Room layouts and décor, common areas, and communication systems are among the items reviewed by the council. And when the construction is completed, this group will be the advisory council for the new hospital.
A third Patient and Family Advisory Council will begin operations in January 2008 as they develop a care model for the Primary Care Medical Home. This Council will have the opportunity to participate on teams that are totally redesigning how care is provided in the medical groups clinics.
A fourth ad hoc Patient and Family Advisory Council was formed to write a patient-centered organizational handbook that, when finally approved, will be distributed and used throughout the entire health system of clinics and hospitals.
Dr. Nelson illustrates why these advisors are so crucial by telling the following story:
"We were going to hire another physician for the practice," he explains, "and I talked my colleagues into including one of the patient and family advisors on the recruitment committee. At the interview a physician asked the interviewee to describe a past incident that, upon reflection, might have been handled differently—or better. The physician candidate gave the example of a patient that believed she had ringworm. The patient's symptoms were not typical of ringworm; the rash was not itchy, red or in a ring shape.
The physician told the patient that it was not ringworm and rendered an opinion about treatment and healing. However the patient was back again, the rash worse. Again, the patient suggested she might have ringworm; again her primary care provider disagreed. Finally, at the third visit, the candidate continued, I scraped the lesion; it WAS ringworm."
Dr. Nelson continues with the story,
"When my colleague asked the applicant what was learned from this episode, he responded, 'I should have done the skin test sooner, I needed to be more vigilant about ordering appropriate diagnostics."
After the potential partner left, at the debriefing, my colleague sought everyone's opinion. People were favorably impressed with the candidate, but the patient advisor asked, " Why did he not answer 'I should have listened and paid more attention to my patient when she said she thought she had ringworm?"
"Wow!" Mike Nelson exclaims. "We have learned SO much, but we still have so far to go, which leads to the current activities. With patients' permission, Council members are shadowing practitioners. They are asking, patient-to-patient, for honest feedback about their experience of care. And, one-on-one, they are giving feedback to clinicians-and coaching them, on how to be more patient- and family-centered.
Dr. Nelson is leading the effort to develop a patient centered multidisciplinary team primary care delivery model. RN care managers, diabetes educators, pharmacy clinicians and masters level mental health workers working in primary care offices are partnering with patients and physicians to develop and implement collaborative self management programs for people with chronic conditions. He and his team have instituted a self management population based patient registry, implemented electronic medical records, put organizational leadership incentives into operation, and will be using patient input to select community organizations to complement care.
Dr Nelson has practiced pediatrics in Albuquerque for over 25 years and was associated with Presbyterian Healthcare Services for 15 years. While Director, his responsibilities included oversight of chronic care programs (Diabetes, CHF, lipid and blood pressure management and anti-coagulation, asthma and preventive services). Dr Nelson received his medical degree from the University of Kansas and completed his pediatric training at Fitzsimmons Army Medical Center in Denver, CO. In June 2004, he obtained national certification as a quality engineer and, in October 2007, a Six Sigma Black Belt.