As the Veterans Administration does not bill third-party payers, VistA is not a billing system.   VistA was released to the public through the Freedom of Information Act by the Veterans Administration and today is publicly available on CDs for a nominal fee.  Althought the software is free, there is a cost to install, implement and maintain it.

WorldVistA

WorldVistA was formed to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. The system was originally developed by the U.S. Department of Veterans Affairs (VA) for use in its veterans hospitals, outpatient clinics, and nursing homes. WorldVistA has a number of development efforts aimed at adding new software modules such as pediatrics, obstetrics, and other functions not used in the veterans’ healthcare setting.

WorldVistA seeks to help those who choose to adopt the VistA system to successfully master, install, and maintain the software for their own use. WorldVistA will strive to guide VistA adopters and programmers towards developing a community based on principles of open, collaborative, peer review software development and dissemination.

For more information on VistA, click here for the Wikipedia entry.

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10. Offer Flexible Work Options Some jobs in medical practices are ideal for flexible work options, but most are not. Any position that requires face-time with the patient will likely need to adhere to appointment hours.  My question: is it “fair” to allow some positions to have flex-time and others not?  If you have a group of people all doing the same general job, letting some people have flex-time and others not may lead to a mutiny.  Consider carefully the precedent you are setting when allowing flex-time, and make sure employees understand that as the needs of the organization change, work arrangements may need to change.

9. Practice Open Communication I couldn’t agree with this one more.  Communicate, communicate, communicate.  One-on-one, in departments, in all-staff meetings, in all-organization meetings.  I typically send out an electronic newsletter every Friday (an idea from my mentor, Tom Girton) that announces/reminds people of events, clarifies policies and acknowledges achievements.  Oh, and don’t forget to make sure that people are understanding what you’re trying to communicate.  Touch base every once in awhile to make sure the message you’re sending is the one they’re receiving.

8. Pencil In Face Time When beginning a new job I often meet with every employee who reports to me (and sometimes meet with everyone in the organization in a smaller practice) for at least an hour to learn a bit about them and hear what they think the practice is doing well, and what the practice could be doing better.  Yes, it takes a lot of time, but it starts to form a bond with individuals and it gives me more information that anything else I could do to start to learn about my new group.  People are fascinating and I really enjoy an uninterrupted hour with someone – it’s almost a luxury in this day and age.  Once you’ve established that bond, make sure to nourish it by connecting with individuals on a regular basis.  Letting people know you truly care about them as individuals is how dynamite teams are created.  And the karma ain’t bad either.

7. Recognize Success and don’t save it all up!  Recognizing efforts, going the extra mile, dealing with a difficult patient, all deserve a pat on the back in front of other employees.  Remember to always praise in public and counsel in private.  Share the joy of something well done, and let the employee have the privacy of a critique.

6. Set Goals I like to establish individual goals every six months during the annual performance review and six months later during a less-formal touch base.  12 months is a long time to keep a goal in mind, so I prefer to deal with 6-month goals.  Performance evaluations should not be a rehash of what was done right and wrong over the year, but rather should be a time to review the goals from the last six months and see what wasn’t accomplished and why, as well as celebrating the goals that were accomplished. See my simple evaluation for more information.

5. Explain the Big Picture I’m often surprised how many medical practice employees don’t understand how their job (especially done well) contributes to the big picture.  Check-in staff might not understand how their job impacts billing.  Scheduling might not understand how their job impacts the nurses.  Nurses might not understand how their job impacts the check-out.  No one may understand what their efforts mean to the financial viability of the practice.  If all the staff know that they haven’t had raises for two years yet new medical equipment is being purchased for a new service line, they need to have some insight into why a decision was made and what potential it may have for keeping the practice viable.

4. Provide Career Growth Opportunities This fits in well with the 6-month performance evaluation when you set goals with your employees.  Goals may include projects, new skills, improved skills, shadowing other jobs, cross-training on other jobs, conferences and workshops, and online or classroom training.  Never think that someone can’t do something as predicting success is one of the hardest things in the world.  Encourage everyone!

3. Give Employees Respect Give everyone respect.  Know that every single person is much deeper than you will ever know and more fragile that you would ever expect.  Never forget that you can make someone’s day and break someone’s day.  Being a manager is making a choice to care for and respect the people who have chosen to work with you.  In many ways, management is the most powerless job (next to parenting) there is.

2. Provide Consistent Feedback For you to effectively provide feedback, positive or negative, the employee must have been trained, must have resources to help them do their job and must understand the expectations of the job.  Do not take for granted that your front desk person knows instinctively that your expectation is to have the day’s charges posted and reconciled before the end of the day.  Have written performance expectations for each person, then explore the reasons why those expectations are not being met (communication, misunderstanding, workload, etc.)

1. Build Trust I’m so glad Ms. Conger put this as #1 -I agree!  Here’s how I build trust: Keep confidences.  Follow the same rules I set for the staff (if they can’t eat at their desks, neither can I.)  Make promises sparingly and fulfill all promises.  Don’t mess up peoples’ payroll or their time off.  Understand the details of their job.  Don’t allow the doctors or the patients to abuse them.

What’s not on this list that you would add?

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But why haven’t we seen much of Lean in physician practices?  I think the reasons are simple:

• Staff in medical practices are already running very slim, and the labor of additional projects may be difficult to take on
• Larger businesses such as hospitals mean higher potential for returns – physician offices may not see significant bottom line changes from Lean reduction of waste compared to revenues from new procedures or partners
• Physicians are not early adopters of management theories and may find it difficult to see the ROI in Lean

Although Cindy Jimmerson says that every hospital she has worked with has more than earned back the program costs through successful Lean projects, it may be a hard sell to most private physicians who see their incomes shrinking year by year.

An excellent article in the Healthcare Quarterly, 12(3) 2009: 32-41 by Longwoods Publishing gives a concise yet meaningful discussion of Lean and describes Lean projects and outcomes in several hospitals.  Healthcare Quarterly focuses on “best practices, policy and innovations in the administration of Canadian healthcare” and is edited by Dr. Peggy Leatt, University of North Carolina, Chapel Hill.

Even if your practice won’t be hiring a Lean consultant in the forseeable future, understanding more about Lean has the potential for enhancing your efforts at improving processes in your practice, or maybe even encouraging you to pursue Lean leadership training.

What follows is an except from the article “Leading Lean: A Canadian Healthcare Leader’s Guide” by Benjamin A. Fine, Brian Golden, Rosemary Hannam and Dante Morrasome, which gives some basic Lean terminology:

Lean Terminology: What Does It All Mean?

Lean: A term coined by those who compared Toyota’s methods to those of other manufacturers: “Lean is the antidote to waste … It provides a way to specify value, line-up value-creating actions in the best sequence, conduct these activities without interruption whenever someone requests them, and perform more and more effectively” (Womack et al. 1990; Womack and Jones 2003).

Value-added work: Work that adds value from the perspective of the client or customer; it is the kind of activity or service for which end users are willing to pay. In healthcare this could be the taking of blood for a medically necessary test or patient time spent with an examining physician.

Waste or muda: Activities of overproduction, waiting, transportation, processing, inventory, movement and defective products. Type 1 muda represents activities that cannot be avoided immediately given current policies, assets and technologies. If a physician cannot eliminate the need to fill out a drug allergies form because of an existing policy, that muda is categorized as type 1. In contrast, type 2 muda is clearly wasteful activity; it is the prime target for immediate elimination. An example of type 2 muda is the time that staff spend looking for equipment that isn’t stored or categorized in a sensible way. This wasted time can be immediately removed by re-organizing storage areas – for example, moving blood pressure cuffs to one standardized location so they can be easily found.

Value stream map: Visual presentation of activities required to bring a service or product from customer order to delivery. Value-added steps and muda are most easily identified on a value stream map. The mapping starts with defining what the customer demands (in the top right corner) and then captures all the steps required to fulfillment. The “current state” value stream map represents the steps as they exist today. The “future state” value stream map is a visual representation of an idealized state. Improvement activities (like kaizen events below) undertaken by front-line staff move the process toward the future state.

Gemba: In Japanese, gemba means “actual place.” In the Lean context, it refers to the place where value is actually created: the shop floor in manufacturing, or a clinic (e.g., emergency department, outpatient dialysis unit, or operating room) in the healthcare setting. The concept of gemba is important because it emphasizes the Lean principle that value – what customers actually want – is created on the front lines, not in boardrooms. The value stream mapping exercise forces workers to “walk the gemba” to see value and the process that creates it.

Kaizen event or rapid improvement event (RIE): Kaizen means “improvement” in Japanese, and kaizen events are focused on implementing improvements to the process of meeting customer demands. In healthcare, these week-long events provide the opportunity for front-line workers from different disciplines to work together to rapidly plan, implement, measure and adjust improvements.

Kamikaze kaizen: Kaizen activities that improve an isolated segment of a process but negatively affect the entire process are referred to as “kamikaze kaizens.”

If any readers out there have experienced Lean in your hospital or medical practice, please share by leaving a comment.

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Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request. If you receive a request for information in the manner described above, please check with your contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website found here or here.

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Nextgov.com’s

In addition to MySpace, FaceBook, and Twitter, Brewin notes:

The agency also uses sites such as YouTube to reach to the younger age group with videos on subjects ranging from prosthetic legs to golf therapy clinics for combat wounded veterans to a short profile of an occupational therapist who works with combat-wounded veterans.

The video on prosthetic legs had the most views last month. The second-most-viewed video was a 2008 video on the Bataan Memorial Death March at White Sands Missile Range, N.M., which features Army medic Staff Sgt. Matthew Sims, an indication that troops crave more than just medical information. Kilpatrick said MHS posted 66 videos on YouTube in May, with the top five viewed 3,785 times.

The portal has been available for about two years, but the Twitter feed was just launched in March.

The MHS web portal is impressive as is their stated mission: The Military Health System mission is to provide optimal Health Services in support of our nation’s military mission—anytime, anywhere.

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In March 2009, PBS’s documentary program Frontline aired “Sick Around the World”, a look at healthcare in five capitalist democracies: the United Kingdom, Japan, Germany, Taiwan, and Switzerland.  The documentary attempts to answer the question “What can the US learn from these countries?”  In addition to watching the documentary online, you can read the transcript, or order the DVD ($55), and the website includes interviews, discussions, a teacher’s guide, reading and links, analysis (The Cost of Drugs Issue is enlightening) and more.

Also tale a look at “Sick Around America” from Frontline.

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Ladies and gentlemen,

In late April, WHO announced the emergence of a novel influenza A virus.

This particular H1N1 strain has not circulated previously in humans. The virus is entirely new.

The virus is contagious, spreading easily from one person to another, and from one country to another. As of today, nearly 30,000 confirmed cases have been reported in 74 countries.

This is only part of the picture. With few exceptions, countries with large numbers of cases are those with good surveillance and testing procedures in place.

Spread in several countries can no longer be traced to clearly-defined chains of human-to-human transmission. Further spread is considered inevitable.

I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose.

On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met.

I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6.

The world is now at the start of the 2009 influenza pandemic.

We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch.

No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the last five years, in pandemic preparedness.

We have a head start. This places us in a strong position. But it also creates a demand for advice and reassurance in the midst of limited data and considerable scientific uncertainty.

Thanks to close monitoring, thorough investigations, and frank reporting from countries, we have some early snapshots depicting spread of the virus and the range of illness it can cause.

We know, too, that this early, patchy picture can change very quickly. The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time.

Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity. As we know from experience, severity can vary, depending on many factors, from one country to another.

On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery, often in the absence of any form of medical treatment.

Worldwide, the number of deaths is small. Each and every one of these deaths is tragic, and we have to brace ourselves to see more. However, we do not expect to see a sudden and dramatic jump in the number of severe or fatal infections.

We know that the novel H1N1 virus preferentially infects younger people. In nearly all areas with large and sustained outbreaks, the majority of cases have occurred in people under the age of 25 years.

In some of these countries, around 2% of cases have developed severe illness, often with very rapid progression to life-threatening pneumonia.

Most cases of severe and fatal infections have been in adults between the ages of 30 and 50 years.

This pattern is significantly different from that seen during epidemics of seasonal influenza, when most deaths occur in frail elderly people.

Many, though not all, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include respiratory diseases, notably asthma, cardiovascular disease, diabetes, autoimmune disorders, and obesity.

At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people.

Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.

Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries.

Let me underscore two of many reasons for this concern. First, more than 99% of maternal deaths, which are a marker of poor quality care during pregnancy and childbirth, occurs in the developing world.

Second, around 85% of the burden of chronic diseases is concentrated in low- and middle-income countries.

Although the pandemic appears to have moderate severity in comparatively well-off countries, it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems.

Ladies and gentlemen,

A characteristic feature of pandemics is their rapid spread to all parts of the world. In the previous century, this spread has typically taken around 6 to 9 months, even during times when most international travel was by ship or rail.

Countries should prepare to see cases, or the further spread of cases, in the near future. Countries where outbreaks appear to have peaked should prepare for a second wave of infection.

Guidance on specific protective and precautionary measures has been sent to ministries of health in all countries. Countries with no or only a few cases should remain vigilant.

Countries with widespread transmission should focus on the appropriate management of patients. The testing and investigation of patients should be limited, as such measures are resource intensive and can very quickly strain capacities.

WHO has been in close dialogue with influenza vaccine manufacturers. I understand that production of vaccines for seasonal influenza will be completed soon, and that full capacity will be available to ensure the largest possible supply of pandemic vaccine in the months to come.

Pending the availability of vaccines, several non-pharmaceutical interventions can confer some protection.

WHO continues to recommend no restrictions on travel and no border closures.

Influenza pandemics, whether moderate or severe, are remarkable events because of the almost universal susceptibility of the world’s population to infection.

We are all in this together, and we will all get through this, together.

Thank you.

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My personal list of new employee orientation best practices has been shaped by my experiences in private practices as well as hospitals. Every organization has different resources to draw upon, but each group has core goals that must be fulfilled by a good orientation:

• completion of paperwork including federal and state W-4s, I-9, direct deposit and benefit elections
• emergency contact information (included in hospital employee health intake)
• orientation to the organization, including designations, specialties, departments, sites, affiliates and an organizational chart
• completion of mandatory annual training such as safety, standard precautions, and HIPAA
• mechanics of name tags, parking tags, lockers, keys and codes
• signing off on understanding and agreement to confidentiality, compliance and personnel policies

In addition to these core goals, critical information to be shared during this time should minimally include:

• personnel policy review with emphasis on important (typically abused?) policies
• code of conduct/ shared basic competencies (mission and values, professionalism, communication, chain of command)
• computer security (passwords, internet policy, protection of PHI)
• workstation ergonomics and patient lifting policy (sadly lacking in many medical practices)

Important training that is rarely covered:

• Customer service (what is it and how do we measure our success or lack thereof?)
• Cultural sensitivity and diversity training
• Non-clinical employees’ role in medical emergencies
• Personal safety (coming in early or leaving late, patients threatening staff by phone or in person)
• Expectations for the first 90 days (training, communication, questions, problems)

Making Orientation Memorable

Most managers do not have the expertise to design a custom orientation program to address all types of learning styles (see below), but you can try to integrate a variety of techniques to assist learning and retention of information.  For instance, you can incorporate PowerPoint programs, videos, worksheets, lectures, interactive discussion, a physical activity and a team activity.  Not only will you keep your program from being boring (for you and your new employees), but you will increase the potential for a prepared employee stepping into the clinic.  According to learning-styles-online.com, the major types of learning styles are:

• Visual (spatial). You prefer using pictures, images, and spatial understanding.
• Aural (auditory-musical). You prefer using sound and music.
• Verbal (linguistic). You prefer using words, both in speech and writing.
• Physical (kinesthetic). You prefer using your body, hands and sense of touch.
• Logical (mathematical). You prefer using logic, reasoning and systems.
• Social (interpersonal). You prefer to learn in groups or with other people.
• Solitary (intrapersonal). You prefer to work alone and use self-study.

Characteristics of a Successful Program:

• The employee has been given adequate breaks, and has been regularly fed and watered.
• The employee feels welcome.
• The employee feels informed and excited about the organization s/he is joining.
• The employee feels that the information delivered is truly important and the orientation team is not just “going through the motions.”
• The employee feels confident that the employer cares about the employee’s safety, satisfaction and success.
• The employee has a sense of belonging, and feels prepared to start workstation training.

What other aspects of orientation (also called “onboarding” – a new buzzword!) do you place importance on, or what ways do you help your new employees to assimilate a lot of information in a short amount of time?

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I’ve been doing a lot of thinking about my new community, my new job and my chance for a fresh start. A television commercial I saw recently says something about being able to be more yourself where no one knows you. It’s true. Here in my new community I can be a better me as no one knows any different. A new job is always an opportunity to do things differently and I’ve made a list for myself of the things I will do differently, better, or not at all:

1. I will stop rolling my eyes. I don’t like it when someone rolls their eyes at me, yet I think I roll my eyes without even realizing it. I will become aware and stop it.
2. I will arrive to meetings on time. I have the compulsion to do “just one more…” that compels me to read one more email, squeeze in one more phone call and so I don’t arrive places on time. It’s rude and it sends the message that I think my time is more valuable than the time of others. Nope.
3. I’ll work a normal amount of hours per week, as soon as I can find out what that is. Boy, is this a can of worms. I’ve always heard that you have to put in more hours if you want to advance and that managers should be the first ones in the office in the morning and the last ones to leave. The problem is, of course, that you will be exhausted, sick, cranky, unfocused, estranged from your family and one-dimensional if all you are is a workaholic. It is a disease and I want to be on the road to recovery.

I have lots of new stuff to share.  For one thing, I just completed the best orientation I’ve ever had, and several readers have expressed an interest in creating a stronger orientation program for their practices, so I’d like to expand on this.  I also kept extensive notes on my job search process and will write about searching for a job in 2009.

As always, I thank you for coming along for the ride with me and I welcome your comments and feedback.

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1. Do you have a policy for dealing with a community illness that is more than your typical flu season?
2. Does your policy include detailed information that most anyone in your organization could follow if you were not able to give directions?
3. Do you know what the local hospitals’ plans and policies are?
4. Have you clarified roles for each of your clinical and administrative staff and provided them with detailed information on their responsibilities during a community illness?
5. Do you understand what your practice is required to do to report information to local, state and national authorities?
6. Have you located resources for or designed patient education materials appropriate for your population?
7. Have you integrated community illness information into your new employee orientation and your annual staff training materials?

If you answered “no” or “maybe” to any of the questions above, here are some resource links to help you finalize your plan and get it firmly in place before it’s needed.  Also check my previous article on preparedness here.

News Coverage of the Swine Flu – alltop.com is a feed aggregator and this page on alltop gives you the latest news coverage on swine flu from all the major networks in the world.  Alltop is a fascinating site to investigate; I have a feed from alltop.com on the sidebar of my site that gives you fresh topics on leadership.

This article on the Spare Change blog by Nedra Weinreich is one of the VERY best articles discussing communciating about the flu.

Medscape’s H1N1 Influenza A (Swine Flu) Alert Center is updated frequently to provide the latest news, clinical guidance, commentary, and resources on influenza A (H1N1).  Medscape Today is by WebMD.

How EHRs can be used to track and suppress an infectious disease outbreak such as the Swine Flu by EHR Scope blog.

What’s On the Horizon for a Swine Flu Vaccine by Steve Simmons, MD with Q & A, from the Better Health website.

Facts About Pork Safety and the Flu Outbreak by the National Pork Board

Telephone Triage of Patients With Influenza by Jonathan L. Temte, MD, PhD on the American Academy of Family Physicians website (Excellent triage template!)

Let’s Hold Hands: Why Viruses Love Humans by Meredith F. Small, LiveScience’s Human Nature Columnist

Viral Goes Viral Online, the Pew Research Center reports that Americans tracked news about the fast-moving swine flu virus more closely than any other story last week, with most turning to television for details on its spread. Still, when people were asked to name which information source was most useful, the largest share chose the internet. (How are you providing your patients with fresh information electronically?)

Schools Consider Distance Learning Alternatives to Prepare for Swine Flu Pandemic By Jamie Littlefield, About.com Guide to Distance Learning since 2004 (What about distance medicine (telemedicine, virtual visits) as an alternative to office visits for non-flu patients?)

“Flu Safety Kit” for travelers by minimus.biz.   3 travel-sized products and advice on staying healthy are contained inside of the clear, vinyl  bag with a snap closure. Includes: Clorox Disinfecting Wipes To Go Pack – Fresh Scent, Kleenex® Tissues Pocket Pack and Purell® Hand Sanitizer, 1 oz ($5.77) – (I’m surprised it doesn’t have a mask.)  Tuck in a refrigerator magnet with your practice name and you’ve got a great patient giveaway.

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