Persistence pays off
by Marion David Stipe, 2018
The Port Smithson Family Clinic of the Martin General Hospital Family Clinics is a rural practice nestled on the banks of a large river in Washington State. When Healthy Hearts NW Practice Coach David Stipe began working with Martin General clinics, he discovered that Port Smithson, the smallest in the family, had experienced significant provider and clinic manager turnover. Although it initially seemed that this clinic could have given up, they didn’t. It turned out that its slow start was just the beginning. David Stipe describes their journey.
My work with this group of four clinics began, per usual, with scheduling a project kick-off meeting with each. The purpose of this first meeting is to complete the Quality Improvement Change Assessment (QICA), an instrument introducing team members to the high-leverage changes guiding the project’s technical assistance approach as well as assesses the practice’s current capabilities. Although kick-off meetings are intended for all staff, just two Port Smithson people attended. At the start of the meeting, I looked around the large room and with just the clinic manager and one provider staring back at me. I asked when the rest of the team would be joining, and was told they had too much work to do that day, and would not be attending. So, I went ahead with the meeting.
Is it the end of the road?
The next month I prepared for the second of the fifteen months of technical assistance support for Port Smithson. After that uneventful and awkward first meeting and before their second H2N visit, the clinic contacted me to tell me they would be dropping out of the project altogether. The clinic gave many reasons for withdrawing, and with each reason, I generated a “we can do this” response. My messages didn’t work, and it seemed like the end of the road.
Soon after that conversation with Port Smithson, I met with another Martin General Hospital clinic and to my surprise, the provider champion broached the subject of Port Smithson with me. By the end of our conversation, I was told to expect a call from Port Smithson confirming that they’d re-engage with Healthy Hearts NW and all staff would attend meetings. That call came, and I scheduled a follow-up meeting. But, just prior to the meeting, the clinic manager and provider announced to me that they would be retiring. Once again it seemed like my efforts were failing and Port Smithson was going to let the H2N opportunity pass them by.
Or just the beginning?
Here’s where it gets interesting: what should have been the end of the Healthy Hearts NW (and transformation) journey for Port Smithson ended up being only their beginning. I witnessed a turnaround that was truly amazing. The clinic’s two medical assistants (MAs) and front desk staff took over the project work and were engaged from the start. They quickly started working on the tobacco measure: They created a spreadsheet of patients who reported smoking to determine how many were referred to the Washington State Tobacco Quit Line, and by doing so, designed their first Plan-Do-Study-Act (PDSA) cycle. They were eager to try out new changes in their workflow to better facilitate patient rooming and improve communications with providers. Before the first meeting was over, the staff discussed the necessary changes, drawn up the new workflow, and made a small-scale testing plan with me. Port Smithson repeated this process for all four Healthy Hearts measures.
Reversing initial resistance
Additionally, as part of the project’s mission to provide opportunities for shared learning between clinics, staff from Port Smithson travelled to St. Paul’s Family Medicine Clinic in northern Washington for a site visit. Our site visit had its intended impact, which was to demonstrate how to translate proven quality improvement changes from one practice into another, similar clinic setting. I saw Christmas morning at our next meeting! The faces of the MAs were glowing and animated, full of curiosity, each describing and demonstrating the work and knowledge they took away from their visit to St. Paul’s. The outstanding dedication of those MAs, supported by my patience and persistence, helped this clinic reverse its initial resistance.
The Port Smithson team continued to discuss and test what worked for them and what didn’t. They bubbled with ideas of changes, and I felt a sense of reward working with and guiding them through the next year and a half. Despite provider changes in the clinic, their ABCS numbers still improved. They ordered ASA, statin, and smoking posters from the Centers for Disease Control. They located a state-generated blood pressure poster and developed brochures for all ABCS measures.
I soon became aware my coaching was less and less necessary. The only support the clinic requested from me was to help locate information for them to make their own brochures. For me, Port Smithson is such a great example of success!
Spreading changes across multiple clinics
While working on Healthy Hearts NW, the Port Smithson team implemented a change that was adapted by all four Martin General locations. Their electronic health record (EHR) software was not designed to readily supply necessities for patient exams, so the team added white boards to every exam room with that information. This freed up more time for the providers to spend with patients, face-to-face. If a patient’s initial blood pressure was elevated, they followed the 5-minute protocol and re-took the patient’s blood pressure. If it was still elevated, they marked blood pressure in red on the white board. Today, all four Martin General Hospital clinics have implemented the white boards in all patient rooms. This innovation not only improved patient-provider communications, but the white boards served to visualize this clinical quality measure information.
Leadership takes note of improvement
As Port Smithson continued to progress, their work was recognized by hospital leadership and the team felt excited to know they were making a difference in their patients’ lives.
Port Smithson is special to me. I am confident this group has the knowledge and skills for sustainability. They started this work with so many excuses, but a combination of new staff and engagement turned things around completely. I’ve shared this story with other primary care clinics whose teams believed they couldn’t afford the time or resources to improve, just like Port Smithson.
Marion David Stipe, RRT, Practice Coach at Qualis Health, has worked in health care for more than 30 years. He began his career as a registered respiratory therapist and has 20 years of healthcare IT experience. He is proficient in several EHR systems including Epic, Greenway Medical and MedHost, as well as an expert with implementations and workflow. Additionally, he has deep experience in meaningful use, EHR improvements related to workflow, optimization and reporting. Mr. Stipe has previously been certified in Epic Ambulatory and MyChart modules.
KEY MESSAGE: This story shows the resilience of a small practice getting unstuck early in the improvement journey. It also describes the power of learning and collaboration across clinics. Finally, it highlights specific ways an engaged clinic team can improve upon clinical quality measures. This practice didn’t drop out: instead, it graduated from Healthy Hearts with flying colors!