All Marie T. Brown, MD, FACP, wanted to do was meet her Maintenance of Certification (MOC) requirements. Instead, the Oak Park, Illinois-based internist and geriatrician increased immunization rates for her patients and became a national advocate for adult immunization. Next, she improved care processes for patients with diabetes leading to better hemoglobin and blood pressure control. Moreover, the lessons Dr. Brown learned about practice transformation were so powerful that she now lectures on the topic across the country.
Board certified in Internal Medicine with a subspecialty in Geriatric Medicine, Dr. Brown used one of the American Board of Internal Medicine’s (ABIM) performance improvement modules (PIMs) to meet Improvement in Medical Practice (Part IV) requirements for Geriatric Medicine. “It was a bit of a struggle to look at my own practice patterns,” said Dr. Brown, who chose the preventive care PIM to assess immunization rates. What started out as “a little intimidating” turned out to be very eye opening. A random sampling revealed the practice’s influenza vaccine rate was more than 80 percent, while its tetanus/diptheria/pertussis (Tdap) vaccine rate was closer to 30 percent. “When I looked at the data, I realized I was not as stellar as I thought I was,” she said.
Fortunately, the PIM offers coaching tools to walk users through the improvement process, said Dr. Brown, who is also an Associate Professor of Medicine at Rush University Medical Center in Chicago. The next steps required analyzing the data and determining an intervention. The PIM tools encourage users to include the team in the process; a challenging concept for doctors trained in an era that emphasized the physician, and only the physician, was in charge. So Dr. Brown convened the team consisting of her and another physician, two licensed practice nurses, and two receptionists. Among the tasks, team members anonymously filled out a survey that asked if the physician looks for someone to blame if something goes wrong. She was surprised to learn that staff characterized her as reacting that way. “That started me on the journey to think more broadly and focus on team-based care, rather than assigning blame,” Dr. Brown said. PIM tools helped her reframe the conversation, listen carefully to what the team members had to say, and discontinue the traditional top-down practice model.
In the end, it was a receptionist who recommended an intervention during a team brainstorming session. She suggested giving patients the vaccine information upon check-in. That way, they can review it and know whether they need a vaccine even before the physician enters the room. This easy fix had the added benefit of not lengthening the patient visit; greatly appreciated in this busy practice. The intervention was so successful that it is now used for all adult immunizations. In addition, Dr. Brown has instituted standing orders for all vaccinations. Rates of Tdap and other vaccines have doubled and remain high.
“As internists, we tend to think that immunization is a pediatric issue,” Dr. Brown said. But the recent rise in whooping cough and the measles outbreak point to the importance of adult immunization. Internists need to pay attention to their immunization rates and engage the entire health care team in the process, she added.
Several months later when Dr. Brown was recertifying in Internal Medicine, she did a PIM assessing diabetes care. Once again, Dr. Brown discovered that her patients’ hemoglobin A1c, lipid panel, and other metrics were not at the levels she expected them to be. During a team brainstorming session, it was mentioned that patients were routinely asked to bring in their medications for review, but they seldom complied with the request. Essentially, the team assigned blame to the patients. The receptionist noted that three to six months could pass between visits, too long of a time to remember to bring in medications. The receptionist suggested asking patients during the reminder call she makes the day before appointments. In addition, patients are now asked to review a medication list while they’re in the waiting room, noting any changes and refill needs. “This saves an enormous amount of time during the appointment and increases patient engagement,” Dr. Brown said. “Patients should know all of the medications they’re taking. Those who do are true partners in directing their own health.”
With the new protocol in place, staff found some medication errors, including duplications. The patients’ A1c rates significantly decreased and their blood pressure rates substantially improved.
During the intervention, staff also learned that some patients who said they were taking their medications really weren’t. Thus, began Dr. Brown’s interest in medication adherence. “Rather than make patients feel foolish or unappreciative of your efforts, the PIM encourages us to engage these patients to find out why they’re not taking their medications,” she said. Dr. Brown discovered that some patients had a distrust of the pharmaceutical industry and its interactions with doctors. Some patients shared concerns about the polio and flu vaccines causing sterility, and the measles vaccine causing autism. When patients consider one vaccine suspect, whether or not the information is accurate, there is a fog of suspicion on all vaccines, she said, adding, “You need to engage patients and find out what they’re thinking.”
One of her patients, a Westside minister, didn’t see the need to get a whooping cough vaccine as he didn’t have any grandchildren. He did, however, participate in five or six baptisms at church every week. Dr. Brown convinced the minister to get the vaccine, and he, in turn, convinced the deacon to get one. “This minister, who is a leader in the community, will have a greater impact on the vaccination rates of pertussis on the West side of Chicago than I ever could have,” she said. “Engaging him as part of the team is very powerful. It’s this type of patient encounter that keeps you thinking outside of the box because it’s all about population health now.”
Since meeting her MOC requirements, Dr. Brown became involved in an adult immunization advocacy effort undertaken by the American College of Physicians (ACP) and the Centers for Disease Control and Prevention. She has conducted several webinars on adult immunization communicating the risks and benefits of vaccines. Dr. Brown also can be seen in a medication adherence video entitled We Didn’t Ask and They Didn’t Tell on ACP’s website. “These activities have helped me own the process and recognize that this is my responsibility,” she said.
Additionally, when Dr. Brown saw how effective the practice changes she made were, she began sharing her experience with colleagues. “I became passionate about changing processes using the team approach,” said Dr. Brown, who currently serves as the Governor of ACP’s Illinois Chapter Northern Region.
She became active in ACP’s program called Closing the Gap (now known as ACP Quality Connect), which offers members and other clinicians quality improvement resources designed to help physicians and health care teams improve patient care and gain ABIM MOC (Part IV) credit. Her staff shared how they contributed to improving patient care on a video posted on the ACP website as a practice-to-practicepearl.Dr. Brown speaks about practice transformation nationally. Most recently, she presented a lecture at ACP’s annual Internal Medicine Meeting held April 30-May 2 in Boston.
As hard as it was for Dr. Brown to first scrutinize her practice patterns and then engage the whole team in improving them, the impact of the MOC activities is invaluable. “The internist has sixteen hundred guidelines that could be applicable to any one of our patients during our seventeen-minute visit,” Dr. Brown said.“Unless you take a good hard look at what you’re doing, you’re not going to see the gaps.”
Not only has patient care improved because of her participation in MOC, the practice environment has improved. “I have more joy in the day-to-day practice,” she noted. “It really changed my whole outlook on transforming your practice and improving the health of your patients, and not just those sitting in front of you but those in the community where you live,” Dr. Brown concluded. “I have experienced professional growth, beyond my own practice, by participating in MOC.”
Dr. Brown served on the ABIM Board of Directors from 2008 to 2013.
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