Imagine that you are the administrator of a large teaching hospital. You and the other members of the leadership want to address overuse to reduce waste and save money, so you decide to set up a program of incentives to encourage physicians to stop performing unnecessary tests and procedures. The program seems to be working well at first, but soon you see clinicians and care teams going back to their old habits of unnecessary care. What went wrong?
When we talk about trying to reduce overuse in practices and hospitals, we aren’t satisfied with reducing overuse in the short term – we want lasting cultural change. But too often, programs designed to reduce overuse turn out like the scenario above. An effective strategy for curbing overuse in the long-term has remained elusive. Until now.
Michael Parchman, MD, PhD, and Brian Austin, the director and associate director (respectively) of the MacColl Center for Health Care Innovation at the Kaiser Permanente Washington Health Research Institute, have spent a year studying the best practices for reducing medical overuse. Through the project team’s review of the literature, interviews with health care organizations who are leading the way, and site visits, they gained insight into why some of these programs fail and others succeed. We spoke with Parchman and Austin about their Taking Action on Overuse framework and their upcoming workshop at the Lown Conference.
Lown Institute: After looking at this issue for a year, what did you find helps anti-overuse programs “stick”?
Brian Austin: We found that programs that are sort of forced on clinicians – we call these “top-down crams” –help in the short term but not in the long term. What works better is having the front line bubble up ideas that are then supported by the leadership. The leadership needs to give providers the tools, capacity, and the time to make this happen. And they have to give these initiatives the equal weight as they do underuse initiatives.
Michael Parchman: We’ve heard of experiences with “heroic individual efforts,” where one doctor tries to take on this issue on their own, but there’s a point where you need leadership to help take it to the next level. The clinician had to demonstrate there was a way forward and convince the leadership to put resources toward this.
BA: Prioritizing the work is critical, because often there’s no time or space provided for these conversations to happen, and no messaging. In many cases we saw, nothing changed until the leadership started to support it.
LI: I see that a key part of the framework is having “sense-making conversations.” Can you tell us more about that?
BA: So a big part of the process is creating a shared sense of reality, a shared ownership of the problem among the providers, the care teams, and between clinicians and patients. We do this through critical conversations within these groups.
LI: The sounds similar to an organizing practice, where people talk one-on-one to find shared values and a sense of the problem.
BA: Yes, it is similar to that! Something we heard a lot in the environmental scan was the vital importance of stories that come out in these sense-making conversations. But you have to have data also. We like to say, no data without stories, no stories without data.
MP: Data is huge because providers consistently underestimate how much unnecessary care they provide. You need to have the data on measures of use and talk about the potential for harm to the patient. Providers love to tell the one story about how an “unnecessary” test saved someone’s life… This bias is difficult to overcome. Stories of patient harm from overuse are also important. It helps to discuss the relative risk – ask them, “How many other patients are you willing to harm to help the one patient that is helped by overuse?”
LI: What can conference attendees expect from your workshop on Saturday May 6, “Taking Action on Overuse: A Framework and Tools for Reducing Medical Overuse”?
BA: We will have a short introduction to the framework, and then break into small group discussions on how to apply it in specific situations. We have a self-assessment tool that participants can fill out, and then we will help them develop ideas for initiatives they can do in their own institution. We want to give everyone something practical that they can bring home with them.
LI: If people are interested in Taking Action on Overuse, what can they do before the conference?
BA: We have a new website, where we’ve put the results of our research so far. We will put up project updates as we get more information. We invite anyone interested to go to the website and give us feedback; we will be using that feedback to improve the framework.
To learn more about the Taking Action on Overuse model and their latest project updates, visit their website here. And don’t miss their hands-on workshop on day 2 of the Lown Conference, coming to Boston on May 5 – 7.