As the evidence increases indicating that medical homes are successful for patients and their providers, it’s important to remember who the medical home is built around. Successful models are not focused on the primary care office as much as on the relationship with the patient.
As one blogger put it, we need to remember that the patients expect “no PDSA cycles about us, without us.” My friends at South-Central Foundation in Alaska emphasize that the key to a successful model of health care delivery is a focus on the patient relationship, not so much on the process improvement. Unfortunately, the NCQA criteria for medical home tend to focus on structural elements in the primary care office such as EMR… “Check”; extended hours… “Check.”
If we do not continually assess how patients perceive value, and whether their experience is improving, then we can’t achieve patient centered medical home status, and our patients won’t notice! Missing from this improvement effort, and the incentives associated with it, is the business principle that we struggle with in health care: value is determined by the customer!
In health care we tend to believe that if we produce the right outcomes by our own measures, the patients will notice and will reward us with loyalty, and therefore business success in terms of return visits and market share.
I believe that until we view our patients as our customers, and continually listen to their needs, we will remain paternalistic and provider centric. We will continue to view access in our 9-to-5 weekday mindset, view decision-making as driven by the provider rather than shared, and wonder why all our investments in EMRs, health information exchanges, and the ability to print a visit note do not produce improvements in market share and business success. The reality (that we struggle to embrace) is that systems that passionately seek customer opinion, and improve around what our customers want, produce not only fabulous patient experience, but also some of the world’s best health care outcomes. And from that comes loyalty, growth in market share, and business success.
As noted by the Baldrige Foundation, commenting upon the stunning success of the South-Central Foundation Health Care system, there are four simple principles that has led to the Foundation's remarkable success:
(1) customers drive everything;
(2) customers must know and trust the health care team;
(3) customers should face no barriers in seeking care; and
(4) employees and supporting facilities are vital to success.
An example of listening to customers is their approach to access: Customers can see their primary care providers on the same day if they call by 4 p.m. and arrive by 4:30. Seventy to 80% of appointment slots are open at the start of each day.
With such focus on the voice of the customer, the South-Central system has achieved reductions in admissions per 1,000 PCP patients from 8 to 4, and Emergency Department visits from 60 to 36. For context, ED visits per thousand in our health system are 160.
If we remember that the patient-centered medical home houses a patient, not a doctor, then we will passionately focus on what the patient (customer) says to us about what they want their house to look like. Other systems that have listened – and improved care dramatically – tell us it starts with outstanding availability, which sends a message of respect, and leads to a culture of shared decision-making and improved outcomes.