What is a Chaos Practice?

A Chaos Practice is one that is always responding to “the tyranny of the urgent;” that is, struggling to make it through each busy day providing care to the patients as they arrive. Providers and staff may be motivated to do well and improve in areas, but because they are always in a reactive mode they do not have any capacity to plan improvements, much less test or sustain them. Because it is a stressful environment, turnover is often high in a Chaos Practice, making it additionally harder to develop and sustain new ways of working. Leaders in a Chaos Practice have their hands full dealing with each day’s issues, and do not feel they or their staff have time or energy to execute long-term improvements.

Example from a practice facilitator:

This Chaos Practice was a rural practice with five clinicians. They had never participated in any type of quality data reporting and felt they had been excluded from quality payment programs due to their rural status. In every meeting I had, the clinician on duty was unexpectedly tied up with acute patient crises, while the office manager had either an angry patient on the phone or was dealing with staff who did not show up for work that day. They had every intention of learning how to do quality improvement effectively, and they especially wanted a standard organizational evidenced-based process for their cardiovascular patients. However, there was always a crisis of the day that got in the way of improvement work.

Data

The practice has difficulties accessing and/or refreshing data to guide improvement.

The practice has issues capturing and/or systematically updating the data it needs to drive change. Practice staff may have rudimentary knowledge of where their process and outcome data comes from, but they have no ability to routinely refresh or upload information to their EHR so they can understand their data and act upon it. They often lack an in-depth understanding of data sources and definitions, which raises issues involved in its interpretation. Practices frequently underestimate the effort required not only to incorporate the EHR into the practice workflow for patient visits, but also to utilize EHR data to drive improvement. Without effective workflow integration, it is difficult for practice staff to use the EHR for quality improvement due to missing data or data not being captured in the correct templates during the patient visit. It is common for this type of practice to have inaccurate reports, which cannot be effectively used for quality improvement.

Strategies

Practice facilitators can increase the practice’s understanding of how data flows through the EHR system and the basics behind clinical quality measurement reporting and metric definitions. Help guide practices to create a patient population list, which can be produced in most certified EHRs that support clinical quality measures reporting. Help staff produce patient lists from the metrics such as “patients not compliant” or “numerator misses.” Encourage them to start small - look up about five patients on the list to see if they are appropriately placed on the list and identify gaps in the data capture or gaps in patient care.  If necessary, help the practice engage with external registries such as PRIME to have greater capacity to monitor and identify patients and care gaps. If possible, it is also helpful to connect practices that have similar patient populations, EHRs, and practice delivery models for shared learning.

QI Team and Project Management

The practice lacks a systematic way of identifying issues quickly or anticipating bottlenecks, and instead treats problems on a case-by-case basis as they erupt.

This practice addresses issues as they arise rather than establishing systems to monitor activities to quickly identify and address inefficiencies or prevent emerging issues before they arise. The practice team may identify issues and create ideas on how to solve these issues, but it is often ad-hoc and unsustainable. After a problem is addressed and the crisis passed, there is no opportunity to learn from the situation or apply solutions to other areas proactively. 

Strategies

A practice facilitator can start by teaching this practice why they should monitor the progress of changes over time. Encourage the team to involve all team members that impact a process so that causes are well understood and unintended consequences from the changes are avoided or mitigated. Help them to sustain the change and to not go back to the old workflow after they stop giving it their focus. Use their example of a past quality improvement project as a way to get buy-in from practice staff since it is an example they can directly relate to. Explain that follow-up on these improvements does not have to be intrusive or overbearing. Help them create a mechanism for quality assurance and for follow-up on identified issues that can be applied uniformly across the entire staff and that does not single people out in a negative way. Basing performance off measurable data points is a great way to do this, because there is a shared framework that can be used to define success and monitor counter measures (Steven’s “Supporting people to quit smoking can have an enormous, lasting impact from” H2N blog). Using the PDSA worksheet in conjunction with encouraging the practice to view its own data can be an effective tool with this practice.

Incorporation of Evidence

The practice is aware of current guidelines but does not alter their standard practices, either because they don’t believe new guidelines are better than their existing practices or because they lack a systematic approach to implementing new guidelines.

Providers feel they prioritize the “art of medicine,” an approach where each provider practices according to their own training and experience. Often an influential clinician acts as a naysayer, leading the disagreement with clinical evidence introduced by a practice facilitator. This can be very uncomfortable for the rest of the team and the providers who agree with the evidence and would like to uniformly modify their care practices in accordance with current best practices.

Strategies

If an individual provider does not agree with the clinical evidence behind a specific measure, the practice facilitator should acknowledge this and talk with them about the parts with which they do agree. Academic detailing or using a tool such as the QICA (add footnote) to stimulate a conversation about the practice’s current quality improvement efforts and data reporting capabilities are additional ways to mitigate a naysayer’s resistance. Unearth and deal with this kind of resistance as early as possible. This is especially important if the naysayer is an informal opinion leader within the practice—that may mean the measure may not match the clinical care pathway, and quality improvement efforts may need to be measured manually or may not be possible in that setting.
 
If the practice agrees that guidelines are important but the problem is the lack of a structured way to incorporate new guidelines as they become known, help the practice to plan how this could be institutionalized. Concerns about the need to continuously improve, and questions about tracking adoption of evidence-based guidelines through quality improvement measures need to be addressed. It is important to promote a culture of openness and learning by encouraging dialogue and debate between clinicians. Well-facilitated conversations addressing operational issues or other reservations may not only yield a better solution for the current topic, but a new standardized approach they can utilize for all guidelines. 

Culture

The practice often exhibits a state of stress and of being on a “hamster wheel” of endless work.

This practice is often unreceptive to new ideas due to time pressures and may be reluctant to discuss anything outside their day-to-day tasks. Implementing a new method of work is inherently seen as an additional burden, even if it has the potential to make things more efficient. Team members are often burned out, especially on the idea of making any changes or adding anything new to their workload.

Strategies

Practice facilitators can start by acknowledging the current state, demonstrating empathy, and working with the team to identify small steps and early wins. They may not be able to commit to a long-term project or significant change at first. Alter one small piece of a workflow to increase efficiency, which can demonstrate that they can accomplish improvements and it may also free up time that they can leverage into further improvements. For example, if a practice is struggling with a measure such as controlling high blood pressure in hypertensive patients (CMS 165), meet with all the providers to agree on diagnoses and treatment protocols to use for a subset of patients. Having standardized treatment protocols could enable the clinical care teams to train staff on proper blood pressure techniques and when to recheck readings and may help the team schedule follow up appointments for patients. This would lead to higher quality data and actionable reports, which in turn could lead to better patient outcomes. If successful, this could be a catalyst to get a practice interested in data-driven quality improvement. 

Data

QI Team and Project Management

Incorporation of Evidence

Culture