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AANS Neurosurgeon | Volume 28, Number 2, 2019


Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations – A Review

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Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations

by Ezekiel J. Emanuel, MD 

Public Affairs, New York

Zeke Emanuel, MD, has done it again with his latest attempt to predict the future of health care. This effort derived from studying organizations that have made a difference specifically by improving quality, while lowering cost and remaining patient-centered. The result is 12 steps that will transform health care and the way we practice.

The premise of the book hinges on the fact that he declares the present status of the U.S. healthcare system an embarrassment. The United States has the highest cost of health care but mediocre outcomes that compare badly with other developed countries. Therefore, our health care system is underperforming and unaffordable.

As one of the architects of Obamacare, the author feels that the stage is set for further transformation. Dr. Emanuel studied 19 organizations from which he derives 12 action items. Transformation will not happen without the right culture, including six requisite components: vision, values, practices, people, narrative and place.

The Four Highest Priority Practices to Produce Transformation

  • Scheduling
  • Performance Measurement
  • Chronic Care Coordination
  • Site of Service

Scheduling relates to patient appointments. Physicians need centralized scheduling that allows patients to be seen on the day they call, if needed. Then every physician’s performance must be measured. Annual reviews are worthless. Performance measurements and physician feedback must be constant. Chronic care is critical. Eighty-four percent of the health care dollar is spent managing chronic care. Chronic care coordinators are essential to proper management. Finally, Dr. Emanuel feels strongly that health care must be delivered in the right place. More than half of cost-saving strategies are associated with changing the site of service, meaning using lower-cost settings. Prices of physicians and facilities vary tremendously and must be taken into consideration.

Second Tier Priorities for Practices

  • Registration and Rooming
  • Standardization of Care
  • De-institutionalization
  • Behavioral Health

The digital process of registration must be done effectively before the patient is seen. Rooming simply means a medical assistant getting the patient from the waiting room into an exam room. Standardization of care is possible, because there are now many useful guidelines, pathways and protocols that should be adopted for patient care. De-institutionalization implies moving patients out of hospitals and rehabilitation facilities and into in-home care. Improving behavioral and mental health care for patients with depression, anxiety and substance abuse disorders represents an opportunity for quality improvement and cost savings.

The Third Tier of Transformations

  • Shared Decision-making
  • Palliative Care
  • Community Interventions
  • Lifestyle Interventions

Shared decision-making means that patients must be educated about treatment alternatives. Palliative care has been a great development in the spectrum of health care. Successful community health care workers are particularly effective when a practice has a large number of low-income, socially stressed patients. Finally, every practice has patients that need to exercise more and eat differently.

Dr. Emanuel closes with some common sense recommendations: Transformation does not occur over night, so patience is required. Change takes time and the transformation of health care is an on-going process, not a one-time event. His program is moveable and adoptable. He suggests that if we start now we will make a difference by 2030. Let’s go for it!

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