Why external rewards undermine internal motivation

We have a great system…how do we improve it?

Doctor's Bag

In my last post, I mentioned the issue of lack of trust in institutions. It appears that our world is increasingly running on financial incentives and regulation. Psychologist Barry Schwartz states that this undermines our will to do the right thing.

This week Dr Todd Cameron, GP and practice owner in Victoria, posted an excellent four-minute LinkedIn video about why financial incentives are not as effective as we sometimes think. He mentioned the following issues with financial performance systems:

  • They assume people are lazy
  • They are not supported by scientific evidence
  • They ignore activities that are difficult to measure
  • They reduce the flexibility of organisations
  • They take away resources for system improvement
  • KPIs often work against each other or against other goals, values or purposes
  • KPIs can undermine collaboration.

Research confirms that incentives, big or small, usually backfire. Like punishments, they affect internal motivation and creativity. Social scientist and author Alfie…

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Systemic Changes to Improve Quality and Safety in Aged Care

Dr Gaveen Jayarajan has taken the time and effort to write this excellent submission to the Royal Commission into Aged Care Quality and Safety. I think this is a great start and support it. I have made the following suggestions – and would be very keen to hear more.

 

Key recommendations 1 and 2 are laudable but unfunded (remember aged care panels) – I would suggest the ACAI be retained or these activities count towards the new QI pip payment. 

Key recommendation 5 – I would recommend RACFs adopt an EMR which can accept EMR notes from GP EMRs Sachin B Patel is the man in regard to this

Key recommendation 6 : good idea, would further recommended funding of this via ACAI retention and QI payment

 

 

We can do better and we owe it to our elderly patients to do so. Read on!

 

19 January 2019

 

Doctors in Aged Care Facebook Group Submission to the Royal Commission into Aged Care Quality and Safety

 

‘Systemic Changes to Improve Quality and Safety’

 

About us

 

The ‘Doctors in Aged Care’ Facebook group was started in September 2017 as a closed Facebook group for all doctors in Australia working in residential aged care facilities (RACFs) or with an interest in aged care. Its purpose is for doctors to discuss, share knowledge and experience, and seek advice about the clinical, administrative and financial aspects of working in aged care.

It has since grown rapidly to 1100 members and includes General Practitioners (GPs), geriatricians, psycho-geriatricians, palliative care physicians and other specialists and junior doctors. Many of these doctors are working at the coalface of aged care on a regular basis and have a unique perspective and insight on the issues faced by RACFs.

Key focus

Our key focus in this submission are systemic changes from a GP perspective that will improve both quality and safety in RACFs. One consistent theme throughout our submission is the need for better oversight, communication between facility nurses and GPs and engagement with family members. While we also support mandated minimum nursing staff ratios with more Registered Nurses (RNs) employed, improved clinical handovers and other issues such as improving dietary quality and options for residents, for the purposes of this submission we will focus on the following five key areas:

 

  1. GP input into the clinical governance of RACFS

  2. GP feedback at accreditation visits

  3. GP involvement in case conferences with families

  4. Uptake of full Electronic Health Records within RACFs

  5. Recognition of significant amount of unpaid work

 

GP input into the clinical governance of RACFs

 

We believe there should be greater GP input in the clinical governance of RACFs given that residents are being admitted at an older age and with more chronic and complex medical conditions. We believe that GP involvement will provide another level of oversight of clinical and care issues that may impact on quality and safety. This is to complement (not replace) existing strong clinical leadership of experienced RNs working within RACFs on a day-to-day basis and to foster a greater understanding and engagement between facility nurses and GPs at a systems level. This at present exists to some degree in Medication Advisory Committee (MAC) meetings held at some RACFs where all issues relating to medication management are discussed within a multidisciplinary team which can include nurses, pharmacists and one or more GPs.

We propose that this either be expanded in scope or a separate committee be created such as a “Clinical Governance Committee” that includes a multidisciplinary team dedicated to open discussion of all clinical governance issues faced by an RACF at a local level. This could consist of nursing staff and carers as well as other healthcare providers such as a physiotherapist, occupational therapist, speech pathologist, dietician, pharmacist and GP. Meetings could be held quarterly and attendance by healthcare providers should be funded by the RACF at a time-based hourly rate commensurate with the providers’ training and experience. Attendance at these meetings could be in person or by phone or videoconference. Outcomes and actions from such a committee should be fed back to the senior management of the broader RACF group for implementation at a local level.

 

KEY RECOMMENDATION 1

Formation of local “Clinical Governance Committees” at each RACF with direct feedback of outcomes and actions to senior management of the RACF.

 

GP feedback at accreditation visits

The current experience of many GPs when a facility is undergoing an accreditation visit by the Australian Aged Care Quality Agency is that feedback is rarely sought from them about their perspective on how the RACF is meeting quality and safety standards. We believe that it should be mandatory for accreditors to get feedback from all visiting GPs to get a broad perspective on all clinical and administrative issues faced by these GPs working at the RACF, and in particular how these issues may be impacting on quality and safety. This could be through either face-to-face or phone contact and should occur at the start of the accreditation period and also when changes have been made to assess any improvements from the GP perspective. We do not believe that GPs need to be paid for this, as most would happily provide constructive feedback if it were likely to improve their experience of providing care and it would ultimately benefit the care of their patients.

KEY RECOMMENDATION 2

Accreditors to obtain feedback from GPs at their visits (initial and follow up).

GP involvement in case conferences with family

Currently GPs are able to bill through Medicare for up to five case conferences per year if clinically indicated with the amounts received dependant on: the duration of the conference; whether the GP organises and participates in the conference;[1] or just participates in a conference that has been organised by someone else.[2]

If the duration of the conference is greater than 40 minutes and it was organised by the GP (ie. item 743) they would receive $201.65 from Medicare plus $6.30 if the patient is eligible for the bulk-billing incentive (item 10990), so $207.95 in total. Hypothetically if this happened 5 times per year this would generate up to $1039.75 in billings per patient per year which is quite substantial. Currently we believe the majority of GPs working in aged are not utilising these item numbers sufficiently and if they did, or if it was easier to do so, it would not only dramatically improve the financial viability of GPs working in aged care, it would also have significant positive impacts on patient safety and quality due to the benefits of having a multidisciplinary team discussing patient care.

We believe it should be mandatory for all new residents of RACFs to have a case conference soon after admission within 6 weeks, and for this to involve nursing staff, a carer, the family and the GP as a minimum, with other allied health staff depending on the clinical and care needs of the resident (and resident attendance optional and depending on their cognitive status). This is an excellent time to set the scene for how the resident’s care is to be managed going forward and also to discuss Advance Care Directives (ACDs) regarding a resident’s end-of-life wishes. These discussions are often not done in a timely fashion or done over the phone with family where there is no remuneration for the GP for this time and work. Ideally this type of case conference should be done annually thereafter and be a focal point for the resident’s annual care plan.

Currently we note that these conferences are done to varying degrees. Some RACFs facilitate conferences as described above, others facilitate conferences with the family but not the GP and others facilitate conferences with two or more facility staff but without the family or the GP. We believe “admission” case conferences and “annual” case conferences should be done with all present to give the maximum benefit to the patient and all healthcare providers providing care to the patient. We also note that case conferences do not require all members to be present in person, so one or more participants may be involved by phone or videoconference, therefore there is flexibility in how these conferences can be scheduled and run.

We note that while GPs can also organise these case conferences with RACFs themselves this requires buy-in to do so from facility staff, thereby making it harder to schedule and arrange.

KEY RECOMMENDATION 3

Mandatory admission case conference for all new residents followed by an annual case conference thereafter utilising existing Medicare item numbers.

Additional case conferences (either organised by the GP or another party) should be based on clinical indication and we believe that GPs should be invited to participate in all of these conferences (assuming they haven’t organised it themselves) with the patient/family consent. Often case conferences are held by RACFs with families with no GP invitation or input. We consider that there is significant benefit to patient safety and care in having the GP involved and engaged with family members in this way. We also note that this is a remunerated way of staying in regular contact with family without resorting to unpaid phone calls, emails or discussions without the patient present thereby again improving the financial viability of GPs working in aged care.

For these “additional” case conferences we believe the Medicare Benefits Schedule (MBS) rules need to be reviewed to make it easier for GPs working in RACFs to utilise these more frequently. Currently three different healthcare providers need to be present at a conference, either in person or via video/teleconference, in order to meet the MBS rules. These healthcare providers can include a GP plus two other different healthcare providers such as a facility nurse and carer and cannot include family members. Firstly, it is not always easy to find the two other different healthcare providers due to everyone’s own day-to-day work commitments. Secondly, we believe most case conferences would benefit from family involvement. Therefore we propose that for these additional case conferences they only require a GP plus one other healthcare provider (not two, but still allow two or more if necessary) plus a family member, so still three different people, but allow the family member to be part of the three.

KEY RECOMMENDATION 4

GP invitation and involvement in additional case conferences held during the year as clinically indicated, with amendment to Medicare item numbers to facilitate increased utilisation.

Uptake of full Electronic Health Records within RACFs

In our experience there are several inefficiencies and risks to the GP and patients associated with RACFs that still have solely or predominantly paper-based patient records. Paper records can be hard to read and take nursing staff longer to enter. Furthermore, only one person can read and enter notes at a time. Clinical information is also often spread across multiple folders separate to the patients record, for example some maybe in the nurses’ station, others in a medication room or at the patient’s bedside. It makes providing adequate oversight much harder to do, which we believe is a major issue in RACFs. It also makes it harder for senior nursing staff, clinical care managers as well other healthcare providers including GPs to monitor clinical issues and care provided to a resident remotely and without being physically where the relevant paper folders are.

We note that there are RACFs who have moved to almost full electronic health records for clinical, care, medication management and administrative functions and the efficiencies this provides and the benefits to improving quality and safety are significant. In particular these benefits are greater if the records are cloud-based, which allows for access from any device and web browser. We also note that other RACFs use a hybrid system where some records are electronic and other aspects remain on a paper-based system. Others remain in a completely paper-based system.

The benefits of full electronic health records are significant, for example the GP can be at the bedside of the patient and pull up all the information they need to make any clinical decision at the point-of-care when they need it the most, without spending time chasing up the various folders in different locations. Any gaps in the information required can be seen instantly with a quick scan of the relevant sections in the electronic record. This can also be fed back to facility nurses to ensure compliance with GP clinical and care directives.

KEY RECOMMENDATION 5

All RACF providers to move to full electronic health records , with a preference for cloud based software, for their residents within 2 years.

Recognition of significant amount of unpaid work

One recurring theme among GPs working in aged care is the vast amounts of unpaid work required. This comes about as GPs usually attend a facility approximately once a week and for the remainder of the week may work in their usual practice. During this time they still need to be on-call and available by phone, fax or email to RACFs to contact them. This work is not remunerated by Medicare and acts as a strong disincentive for GPs who work in a regular practice to continue to care for their patients as they enter an RACF. Examples of unpaid work for GPs working in aged care include: responding to phone calls/emails from/to nursing staff and families, writing prescriptions when off-site, completing letters of capacity, guardianship tribunal forms, Coroner’s reports, taxi vouchers and disabled parking permits, family meetings when the patient is not present, completing Advanced Care Directives (ACDs) when the patient is not present and completing death certificates.

A number of options could be considered to reduce this disincentive. We believe this should initially be focussed on remunerating unpaid phone calls taken directly by GPs from/to facility nursing staff or family members of patients. This will create an incentive for GPs to provide direct access to nursing staff at RACFs to deal with urgent/important clinical issues when they are not on-site and will also enable GPs to engage with family members about their loved ones more frequently. This could be done by phone or videoconference.

RACFs could therefore be a good starting point to introduce more MBS-funded telehealth item numbers. These could be untimed and start with a fixed fee per phone or video call and include a limit on the number of times it can be claimed per day. For example $15 per call with a limit of 5 calls per day. And with no requirement for the patient or other healthcare provider to be directly present at the telehealth consultation, as we note that the current telehealth items are only for a GP to sit in on a consultation between a patient and specialist.

We do recognise there were recent changes to Medicare item numbers for aged care (commencing 1 March 2019) by introducing a $55 call-out fee per visit (applicable to only 1 patient seen during that visit). However we note that at the same time the actual minimum rebate for each consultation was reduced. When the financial impact of this is compared before and after the changes, we view these changes as ineffective. For example if a GP were to see seven patients in a visit, before the changes the GP would generate $286.65 per visit, after the changes they would generate $318.20, so just $31.55 more. In our view this benefit is highly unlikely to encourage more GPs to visit RACFs. Furthermore if a GP were to see say 20 patients in a visit, before the changes the GP would generate $810 per visit, after the changes they would generate $807, so $12 worse off (both calculations exclude the bulk-billing incentive item number 10990 for simplicity). Even if a GP were to marginally benefit from this change due to seeing lower numbers of patients per visit, this benefit is far outweighed by the planned removal of the $5000 Aged Care Service Incentive Payment (SIP) worth up to $5000. So the recent Medicare changes are more likely to see GPs worse off financially (assuming the SIP is removed).

KEY RECOMMENDATION 6

Introduce new Medicare item numbers for GPs visiting RACFs for telehealth consultations directly with facility nurses and family members regarding their patients.

Doctors who supported this submission

Dr Gaveen Jayarajan

 

Dr Nick Tellis

 

 

[1]Medicare Benefits Schedule, Medicare item 735, 730 and 743.

[2] Medicare Benefits Schedule, Medicare item 747, 750 and 758.

 

 

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Who is the real winner in the latest stoush between pharmacists and doctors?

As always, Edwin, you’re building bridges 👍🏼

Debbie Rigby is also worth her weight in gold!

Well said.

Doctor's Bag

Last week a state Pharmacy Guild president made a few negative comments about general practice. I thought it was neither here nor there, but what happened next was interesting.

I could not find the original column (admittedly I didn’t look very hard) so I can’t verify his exact words but apparently, he said that increased funding for GPs will only incentivise five-minute ‘turnstile’ medicine.

Most GPs would not have read or been aware of the column until, on the eighth of February, Australian Doctor Magazine, owned by the Australian Doctor Group (ADG), posted an article on their website titled “Pharmacy Guild says GPs working ‘turnstile operations’ filling time-slots with easy patients.”

Then all hell broke loose. There were 170 comments on the article of mostly angry GPs.

A few days later, on the eleventh of February, Pharmacy News published this piece: “Guild takes aim at GPs who favour…

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Discharge summary versus clinical handover: language matters

PartridgeGP is all about professional, comprehensive, and empowering General Practice care by our GPs. When we refer our valued patients for treatment elsewhere we promote the same high standards, values, and communication  that we provide. A letter, referral, or phone call is just part of the standard PartridgeGP service – it’s good clinical handover. Dr Nick Tellis recently collaborated with some excellent GPs in writing an article for the Medical Journal of Australia’s online Insight Blog on ways to improve communication during these times and stressing the importance of better clinical handover. It’s another one of the ways PartridgeGP provides Better Healthcare for our valued patients. Read on.

 

This article is part of a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group with over 6000 members, that is based on GP-led learning, peer support and GP advocacy, and was originally published at the Medical Journal of Australia (MJA) Insight Blog here

 

IN our earlier article we described the concept of “passing the baton” when talking about transfers of patient care. All patients come from their communities and to their communities they shall return. In this transition from tertiary hospital to primary care, they benefit from timely, safe, effective clinical handover as defined in the National Safety and Quality Health Service Standards.

 

In primary care, communication matters, perhaps more so than in tertiary care. Words matter. The language we use matters. It informs thought at conscious and subconscious levels and influences behaviour.

 

The words “discharge summary” evoke feelings of an administrative process at best, and various unsavoury processes at worst. The accidental discharge, the dishonourable discharge, and the smelly discharge all come to mind. The words “clinical handover” instantly sound more professional. They reflect the sort of interaction between clinicians of which we want to be part. Clinical handover is a term familiar to both clinicians and administrators. It is taught in medical schools around the country and practised between junior and senior doctors within our hospitals.

 

Transition of care is well known to be a time of maximum risk: “Adverse events are seen to increase particularly during a transition of care, when a patient is transferred between units, physicians and teams.

 

Clinical handover is a recognised, evidence-based, structured and essential safety mechanism for minimising this risk. Remember, all patients come from their communities and to their communities they shall return. Their community doctor, their primary care physician, is their GP. Patients deserve the best clinical handover we can provide, whether transitioning into or out of our hospitals.

 

Junior doctors in hospitals presently perform the clear majority of clinical handovers to primary care, labelled as “discharge summaries”. According to the Discharge Summary – Literature Review, published by Queensland Health in May 2017 (not available online):

 

 

“Junior doctors perform the clear majority of discharge summaries:

  • Many interns have a flippant attitude to the completion of discharge summaries and have a low perception on the importance of a safe handover of care;

  • Most medical education programs provide minimal education on the completion of discharge summaries;

  • Most interns learn from each other with little input or guidance from registrars and consultants;

  • Interns tend to ‘lump’ discharge summaries together, often completing the summaries on patients they have never met.”

 

 

This frequently happens after the transition has occurred. To borrow from our legal friends, you cannot sell what you do not own. How then can you transfer the care of a patient you have never cared for?

 

 

Junior doctors report that they have limited supervision and lack templates or guides to help them produce a comprehensive and useful handover for community-based care whereas they receive a considerable amount of training for internal clinical handover.

 

 

Medical practitioners frequently use ISBAR (introduction, situation, background, assessment, recommendation) to guide clinical handover. A recent GPDU discussion highlighted that the Gold Coast University Hospital was moving to an ISBAR format for clinical handover to primary care. This was seen by many in GPDU to be a significant step in the right direction. ISBAR for the clinical handover to primary care aligns with hospital handovers and can only improve the transfer of care. Brewster and Waxman recently proposed amending ISBAR slightly to K-ISBAR by adding some kindness into the equation. Taking the opportunity to actively incorporate empathy and understanding into the primary care handover would be a great place to enhance collegiality across community and hospital teams.

 

 

When deciding who is tasked with a clinical handover within the hospital, it is unlikely that this would be handed to the most junior member of the team, and exceedingly unlikely that it would be delegated to someone who had never treated or met the patient. Within hospitals, it is expected that a clinical handover occurs at or before the time a patient’s care transitions to another team or provider. Why should this be any different for the clinical handover back to the GP?

 

 

In our first InSight+ article, we used the analogy of passing the baton. But what happens when the baton is dropped?

 

 

Dr Mandie Villis recently wrote a heartfelt plea for hospital doctors to inform GPs when patients passed away on their watch. Discussions around primary care clinical handover are now occurring around the country and pockets of significant improvement are being made. Momentum is building in regard to formally recognising and changing the language used from “discharge summary” to “clinical handover”. Several hospital and health services have, or are in, the process of implementing “same day” or “24-hour” clinical handover policies, and ultimately the best practice standard will be that this clinical handover occurs at the time of transition of care.

 

 

My Health Record (MHR) has been touted as a partial solution to the problems that have traditionally plagued clinical handover. It is important, however, to remember what MHR is and what it was created for. It is a repository of information for patients – a “shoebox” of documents akin to the jumble of receipts we burden accountants with at tax time. It is not, nor was it designed to be, a communication tool for clinicians. The baton transfer cannot occur within the MHR shoebox. It was not designed to replace current clinical record systems or current communication channels between clinicians. These limitations and precautions are outlined in the RACGP My Health Record guide for GPs:

 

 

“My Health Record is not designed as a substitute for direct communication between healthcare providers about a patient’s care, and should not be used in this manner. Healthcare providers must continue to communicate directly with other healthcare providers involved in the care of a patient through the usual channels, preferably through secure electronic communication.”

 

 

The  Australian Digital Health Agency states:

 

 

“The My Health Record system supports the collection of Discharge Summary documents. When a healthcare provider creates a Discharge Summary document, it will be sent directly to the nominated primary healthcare provider, as per current practices. A copy may also be sent to the individual’s digital health record.”

 

 

Mission creep of MHR is real, with multiple reports on GPDU of GPs stumbling across clinically relevant information in MHR rather than receiving a timely clinical handover. Important clinical information is “pushed” into MHR and the receiving clinician is not “pulled” to it by any sort of notification. There is no handover without closing the communication loop. Health professionals and organisations must ensure that clinical handover occurs with the intended recipient at the time of care transition. A copy uploaded to MHR for the patient to access, as an archive, may serve as a safety net if all else fails, but should not be relied on as the only source of communication.

 

 

Hospital systems must support and value the safety delivered by effective clinical handover to primary care. This will reduce the readmission rates to hospital care and improve the care patients receive. Patient care and practitioner wellbeing should not continue to be compromised due to the hospital culture of a discharge summary being an administrative task undertaken by the most junior team member. The challenges of high administrative burdens, inadequate staffing and unpaid overtime all need addressing. Junior doctors should not be left alone grappling with piles of outstanding discharge summaries to complete on patients they have never met.

 

 

The patient journey can be tracked, important milestones bookmarked, and plans documented as they are formed so that when it’s time for a transition, the “baton” is ready. The need for handover cannot come as a surprise when the patient’s trajectory was plotted from the day they were admitted. Adequate clinical staffing levels with protected time for clinicians to prepare clinical handovers should be a key performance indicator in hospital care. Proactive strategies must be put in place to identify and document who will be receiving the clinical handover. The culture that prevails within many of our hospitals needs to change.

 

 

Safety and quality bodies, such as the Australian Commission on Safety and Quality in Health Care through its National Safety and Quality Health Service Standards, and the Australian Council on Healthcare Standards through its accreditation regime, can provide effective oversight. All clinicians must lead in continuous improvement in “best practice” for quality and safety in transition of care both into and out of our hospitals.

 

 

Let us recognise and applaud our hospitals and health services leading the way in acknowledging discharge summaries as the clinical handovers that they are. May 2019 bring us all closer to high quality, timely, safe and patient-centred clinical handovers.

 

 

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clinical handover

 

Dr Katrina McLean is a Gold Coast-based GP, Assistant Professor in the School of Medicine and Health Sciences at Bond University, and a GPDU administrator.

 

Dr Michael Rice is past president of the Rural Doctors Association of Queensland, an educator of students and registrars, a long term resident and rural GP in Beaudesert. He’s a keen user of social media.

 

Dr Nick Tellis is passionate about great general practice. He’s a proud GP, beachside Adelaide practice owner, and a happy new father. He blogs at www.partridgegp.com when not administrating on GPDU.

 

Contact Dr Nick Tellis at drnt@partridgegp.com.au or 0882953200 if You are a Great GP and want a Better Place to practice great medicine!

 

 

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Kintsukuroi Christmas

Some Christmas reading for you all…

Merry Christmas and enjoy this in the best of health!

Dr C. Edward Pitt

Have you ever opened a Christmas present to find it wasn’t quite what you expected?

I confess, I hate Secret Santa. I’ve been scarred more than once. One time a group of my friends decided it would be good to do a Secret Santa. I spend an hour or two making sure that I found a present for my secret santa that was good quality, something small but meaningful. After all, no one wants to get some dud present. In the end I bought this person a small sampler of some good quality chocolates – something discreet, tasteful and universally enjoyed.

In return, I got a tin of cat food … and not even good quality cat food, but the cheapest generic cat food from the worst supermarket chain.

Stunned, I remember stammering, “But … I don’t have a cat …” (For the record, my friends were very unsympathetic and…

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Make Everything an Adventure

Great thoughts Terry 👍🏼

Terry The Tourist

Although we are blessed in Australia with a truly great outdoors, when other factors come into play such as bad weather or lack of means to drive to a beach or similar, children have a wonderful way of being quiet and calm one moment and the next being as animated as a Tasmanian Devil (think the Disney cartoon kind). They also appear to take to, and welcome routine and sometimes practicality.

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