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When I was a first-year medical student in the late 1980s, I was assigned to shadow a family physician in a rural New Hampshire town where many patients
were uninsured. The physician's receptionist knew everyone and made decisions about how much of patients' fees would be waived or whether patients would be
turned away. The doctor said that he did not concern himself with financial matters and was there to care for the patients. Years later, I had an
opportunity to explore the role of front desk clerks in rationing access to care across large health care systems. Most striking was the minimal guidance
given to frontline bureaucrats in how to manage patients who could not afford prepayments and how—in the absence of guidance—they made ad hoc decisions based on their personal values. The strongest predictor of whether an indigent patient received care was which clerk signed him or her into the
Perhaps the most important message is that everyone in a health care organization is powerful and that, without a process for communicating its mission and
obtaining everyone's buy-in, the results are potentially capricious and chaotic. This lesson is particularly applicable to periods of organizational
change. Dr. Murawsky emphasizes the importance of "communicating the need for change, aligning and integrating change activities across all levels of a
health care organization, and pairing leadership engagement with process improvement activities" as essential ingredients for creating an effective
environment for change. In essence, any effort designed to ensure that systems function properly is about getting everyone on the same page. First and
foremost, the effort requires an acknowledgment of the interdependence and equal importance of all individuals in contributing to the desired outcome;
other key elements include clear messaging, incentives, team building, leading by example, and an environment in which every individual is viewed—and views
him-or herself—as a potential problem solver.
How does the researcher's perspective contribute to the organizational change process? From the researcher's perspective, the patient, physician, and,
indeed, all health system employees are potential research subjects. Health services researchers examine the interactions of myriad variables at the level
of the organization, provider, and patient as they facilitate or impede the search for solutions to patients' problems. Close partnership between research
and operations assures that the right questions are being asked and that lessons learned inform decision making.
The changes occurring in VHA pose a specific challenge for systems leaders and researchers. Dr. Murawsky refers to this challenge as creating a "culture of
patient care decisions at the individual level, or an N of one patient, supported by population analytics or an N of 1,000. . . ." For health care
organizations to advance in both arenas, we need valid metrics for both adherence to evidence-based practices and adaptation to patient context. Tools for
measuring the former are far more developed and widely used than those for measuring the latter.
Even as algorithms evolve toward sophisticated patient care management systems that permit us to tailor decisions based on risk levels, capture clinical
actions, and incorporate patient preferences and goals, we still face the challenge of assessing whether care plans are adapted to patients' life
circumstances and needs, or context. For instance, if a particular patient's blood pressure is poorly controlled because his medication delivery packages
are routinely stolen from his entryway, will the provider elicit such information and propose that the patient pick up his medication at the clinic
pharmacy? Adapting care to patient context must be a part of the culture of patient care decisions at the N of one patient.
Challenges are opportunities to innovate. For instance, to assess clinician performance in contextualizing care, we both employ unannounced standardized
patients and recruit real patients to audio-record their encounters. Our performance measure, Content Coding for Contextualization of Care, or 4C, is
designed to answer four questions for each encounter. Were there clues—such as loss of control of a chronic condition—that a patient's life situation is
interfering with the patient's care? If so, has the provider noticed and looked into the situation? If so, has the provider uncovered contextual
factors—such as a Veteran's loss of social support—that can be addressed? And, finally, is the provider or Patient Aligned Care Team taking the steps
needed to adapt the care to the patient's context? When care is adapted to the patient's context, evidence is that patients experience better health care
outcomes. No doubt, we have scratched only the surface with our focus on clinicians, given the key roles that even clerks may play when, for instance,
patients show up late because of contextual factors that may be central to their care.
This is, indeed, an exciting time as HSR&D researchers, focusing on evidence-based and patient-centered strategies, contribute innovative tools and new
knowledge to support VHA's commitment to transformative change that advances the care and health of Veterans.
Kerr, E.A. and R.A. Hayward. "Moving toward a Patient-Centered Performance Management System,"
FORUM October 2012.
Weiner, S.J. et al. "Patient-Centered Decision Making and Health Care Outcomes: An Observational Study,"
Annals of Internal Medicine 2013; 158:573-9.
Weiner, S.J. et al. "Rationing Access to Care to the Medically Uninsured: The Role of Bureaucratic Front Line Discretion at Large Healthcare Institutions," Medical Care 2004; 42(4):298-304.