The Robert Wood Johnson Foundation (RWJF) site visit team existed SETMA November 1, 2012 about 4:30 PM.  They had nothing but positive things to say about SETMA and they feel that they learned a great deal which will advance their project.  They plan to have a formal report to us by the first of January.  When that comes a number of SETMA’s team will be asked to review it and to comment on it.  Without doubt, SETMA was pleased with the outcome of the visit as we all had an anxiety that what we are doing might not be what the RWJF team wanted to see.

The over arching analysis is that the RWFF team was impressed that everyone they talked to said that they are constantly trying to improve what we are doing.  They were complimentary of all of our staff, addressing how insightful and bright they are and also how friendly.  They particularly commented on our front office staff that they felt really like people and try to make everyone feel welcome.

The team identified five areas which were most impressive to them:

1. The Care Coordination Department - they had never heard of such a department and had never seen one.  They were impressed at how the department is integrated with the clinical personnel through electronic communication and how critical they are to our mission.  Across the nation, transformative efforts in healthcare include what is referred to as “daily huddles” - meetings to discuss patient care and the days activities.  They were interested in SETMA’s concept of “electronic huddles” where there is continuous communications between departments and colleagues to strengthen, coordinate and improve care.
2. The Care Transition and Hospital Care Team --  The complex solutions for this critical area of practice is very impressive to them.  The integration of care with the admission hospital plan of care, the discharge Hospital Care Summary and Post Hospital Plan of Care and Treatment plan, the hospital follow-up care coaching call and other aspects of this care transition process, they identified as innovative improvements in the work force relationships among staff.
3. The I-Care team - they are very impressed with the electronic tools we have with which to support the work of the full time staff and the professional support staff for I-Care.  SETMA has worked in the long term residential care area for its entire existence and before.  But, they were impressed with how a group of SETMA providers built upon that foundation and organized an excellent integration of work flow innovations to improve that care.
4. Learning Team - they believe that the spontaneous and structured learning of SETMA allows us to continually and almost unintentionally learn and grow.  They understand that learning, as Senge says, is only distantly related “to taking in more information.”  They believe that we have incorporated “systems thinking” and “systems structures” into SETMA extremely well.  They think this is one of the most value aspects of SETMA’s work force and work flow innovations.  They were able to attend one of SETMA’s monthly training meetings and were intrigued by the enthusiastic and engaged participation by all of SETMA’s healthcare providers. 

The fifth area of uniqueness of SETMA identified by the RWJF team was a surprise to them; it was SETMA’s IT Department.  The team felt that SETMA has approached healthcare transformation differently than anyone they have seen.  They related that uniqueness to the decision we made in 1999 to morph from the pursuit of “electronic patient records” to the pursuit of “electronic patient management.”  They were surprised to see how centrally and essentially electronics are positioned into SETMA and how all other things are driven by the power of electronics.  They marveled at the wedding of the technology of IT with clinical excellence and knowledge.  The communication and integration of the healthcare team through the power of IT is novel, they concluded.

SETMA’s Response to the Team and Personal Mastery

I am very impressed with how much the team learned about SETMA in such a short time.  In the exist interview and at many other times in our conversations, we discussed Peter Senge’s concept of “personal mastery”. Senge declares: "All too often, teams in business tend to spend their time fighting for turf, avoiding anything that will make them look bad personally, and pretending that everyone is behind the team’s collective strategy - maintaining the appearance of a cohesive team."

The deception employed here is the illusion of competence. It is never popular to say, “I don’t know,” but sometimes it is the most creative approach to solving a problem. The admission that you don’t know, or that the “management team” does not know, often makes the team aware of possibilities which otherwise would be excluded.  This is the foundation of the last three characteristics of “personal mastery” which Senge addresses in The Fifth Discipline. People who have a high degree of personal mastery have the following ten characteristics:

• They have a special sense of purpose that lies behind their vision and goals. For such a person, a vision is a calling rather than simply a good idea.
• They see current reality as an ally, not an enemy. They have learned how to perceive and work with forces of change rather than resist those forces.
• They are deeply inquisitive, committed to continually seeing reality more and more accurately.
• They feel connected to others and to life itself.
• Yet, they sacrifice none of their uniqueness.
• They feel as if they are part of a larger creative process, which they can influence but cannot unilaterally control.
• They live in a continual learning mode.
• They never ARRIVE!
• (They) are acutely aware of their ignorance, their incompetence, and their growth areas.
• And they are deeply self-confident!

I think these elements of personal mastery describe the culture of SETMA and explain a great deal of our success.  They agreed. 

Is This a Contradiction?

But, how can you be “deeply self-confident” and yet be “acutely aware of your ignorance and incompetence?” It is that very contradiction which is the foundation of a learning organization. If we are going to move forward in medical informatics, we will have to be part of such a team. We will move confidently, but in that we have a degree of incompetence, we move forward to create a future of our own design.  If the health care industry is going to design its own future by solving "the" problems, it means that we must develop a collaborative, learning team.

In 2000, speaking of electronic patient records transformed into electronic patient management, we wrote:

• How can this powerful tool be used to change and to improve provider behavior?
• How can this tool be used to improve communications among providers, which is one of the essential elements of changing behavior?
• How can the tool help providers monitor themselves, which is ultimately the best way of changing behavior?

I have never met a physician or a health care provider who would admit to wanting not to provide excellent care. Now, I have met many who would not admit that they could improve, but none who would say, "Well, I know that I am not giving the best of care, and, quite frankly, I don't care!" I have never heard that. How can we "tap" in to that desire to do "good" which most providers have?

And, if these goals are achieved, inevitably the quality of patient care and the cost of that care will go up and down respectively. The elements of that task are at least the following (remember, we wrote these in 2000):

1. Establish a national standard of care, or a "best practices" which confronts a provider EVERY TIME a patient is seen, no matter where the patient is seen.
2. Establish a methodology for auditing the providers’ compliance with "best practices."
3. Enable that methodology to adapt dynamically to "changes" in those "best practices," as such changes are not only possible but inevitable.
4. Create an environment, so much as is possible, where the provider is a partner in the process and not the victim of it legally or administratively

SETMA’s Principles of Growth

The following are the principles of SETMA’s building of our EMR solution which we described in 1999.  Remarkably, many of these reflect the ideals of patient-centered medical home which we did not hear about until 2009 but which we had obviously been pursuing for ten yeas before that.  The principles which have guided Southeast Texas Medical Associates' development of a data base which supports these requirements are that we wanted to:

1. Pursue Electronic Patient Management rather than Electronic Patient Records
2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows.
3. Make it easier to do it right than not to do it at all.
4. Continually challenge providers to improve their performance.
5. Infuse new knowledge and decision-making tools throughout an organization instantly.
6. Establish and promote continuity of care with patient education, information and plans of care.
7. Enlist patients as partners and collaborators in their own health improvement.
8. Evaluate the care of patients and populations of patients longitudinally.
9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets.
10. Create multiple disease-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health.

The Impact of the RWJF Study on SETMA

We shall continue this analysis when we receive RWJF’s formal review.  Over the next three years and forward, the intent of this study is to create a “learning community,” where medical practices which are intent upon excellence and upon improving the care they deliver can share their ideas and their efforts.  The intent is to produce a “tool kit” which can be used by practices to join this community and to establish a “learning team” in their service areas. 

I think the RWJF study has already been a big success and it will provide motivation to all of us at SETMA to press forward to excellence, relentlessly.  As SETMA said to the RWJF team, there can be two responses by SETMA to our having been selected for this study: pride or gratitude. The first and the least productive is pride.  While there certainly is satisfaction in that after an extensive process through a prestigious national advisory committee SETMA was selected, the effect of pride is seldom positive. 

Pride stifles the generative, i.e., creative power, of an organization, as it often causes an organization to sit back and enjoy its accomplishments rather than to work diligently to discover new and valuable innovations.  Typically, the product of pride is the arrogance of thinking you deserve more, for less, than you have received.  Focusing upon expectations of what should have been received, organizations often cease to work hard and become more attentive to what they believe they deserved and didn’t receive.

On the other hand, and this is what SETMA told the RWJF team, when an organization responses to recognition with gratitude, which really is a product of humility, the organization is pushed to higher and higher achievement.  As pride expects more and feels slighted no matter how much it gets, humility appreciates what has been received, recognizing that others are equally worthy of recognition which was not received.  Pride results in slothfulness, doing less, while humility, birthing as it does gratitude for what has been received, generates diligence, hard work and the desire to prove the organization worthy of what it has already received.

In addition to being a “learning organization,” SETMA is, I think, a grateful organization.  The effect of being selected by the RWJF for this study has made us refocus and increase our efforts to transform the care we are delivering and that gratitude with its associated humility will cause us to work harder and more relentlessly to continue to improve.  This effort will not be a furious effort to change things for the appearance of change, but it will be to find ways of fulfilling the ten goals identified above.  And, the effect of this work will be the creation of a future for which we will all be grateful, which none of us can imagine but which all of us will be excited to see.