Assignments Week 3
Improving Value at the Bedside
Syllabus
Monday
Tuesday
Wednesday
Thursday
Friday
VBHC: Mod 6 & 7 (2˚)*
Rx-Lowering Activity (complete before class) (1˚)
Order Wisely Exercise* (1˚) // Optional Mini-Pres Opp
Class (2˚)
Mini-Reflection
Watch the Costs of Care video series (40')
Class (2˚)*
Click here for May 2020 recorded talk with Dr. Richard Wardrop
ACP Module: High Value, Effective Testing
Opt: Creating a Positive Culture for High Value Change*
Work on Final Project
Peruse Rx-Financial resources *
Further Instructions & Resources:
VBHC Module Instructions:
Focus on M6S9, where students simulate lowering costs for a theoretical patient. Have students be prepared to share what they came up with.
RX-Lowering Activity
Instructions: Please complete the prescription cost-lowering activity prior to the group discussion. Students will be asked to report on their findings from the activity. It's encouraged that students work together to divide the workload and discuss; however, please make sure each student looks at each resource presented in the assignment.
Session 5 - some instructions
Facilitators can optionally create opportunities during the class discussion to group up students so they can practice high value communication strategies. This activity was very well-received by the UNC SOM students -- they wished we had devoted more time to it during the session. This activity has been pulled from the MedEd portal. Included is a pre-/post-survey for students to do on their own for their own self-enrichment, or class facilitators may choose to collect the responses to review. To read more about this activity and access the other resources, click here.
Order Wisely Activity
First, this video provides a short overview on how to determines at one's own institution what is a high- versus low-value lab practice and ways to potentially address over-ordering.
Request that students pick 4 videos (2 imaging and 2 Hospital Medicine) that interest them. They should be prepared to discuss what they watch.
Optionally, facilitators can choose to assign a component of this exercise as a Mini-Prez (note, students in the UNC SOM elective highly rated mini-presentations!)
Opt: More on Pharma
This NYT piece highlights the "pharmacy" side of the HVC prescribing discussion, as well as some of the challenges faced by pharmacists trying to meet the demands of their employers (e.g., quotas on refills, etc.). There have been some unfortunate consequences to quota-driven corporate policies.
Our Generic Drug Problem
Not to complicate things, but not all that's generic is gold. Out of some scandals surrounding generic drug production came Valisure. You can learn more in two podcast episodes featured in The Peter Attia Drive.
Interview with Katherine Eban on Widespread Fraud in the Generic Pharma Industry
More on Katharine Eban, journalist, & author of "Bottle of Lies"
Interview with David Light, CEO of Valisure, on Zantac Recall
Note: This interview is provided for the sake of completeness; it discusses the recall of Zantac due to its inherent molecular instability - not because of any foul play or fraud by pharmaceutical companies.
Peruse Financial-Rx Resources
Ideally, students should become familiar with 1 - 2 of these resources and identify the ones that can be their “go-to” when in clinic.
Beers Criteria Medication List (resource for prescribing in a geriatric population)
STOPP/START criteria (resource for prescribing in a geriatric population)
MedStopper: Deprescribing Tool
Costs of Care Affordability Accelerator (learn how Costs of Care is convening experts to improve patient affordability)
Opt: Creating a Positive Culture to Influence HVC Change (follow-up from Dr. Wardrop's talk)
This article identifies organizational culture as a potential barrier to healthcare quality improvement. It provides several examples of why this might be true. Key themes addressed include patient safety, interprofessional communication, respect, and workplace diversity.
Residents' Self-Report On Why They Order Perceived Unnecessary Tests
Turns out that we have a lot of self-insight! This article highlights that residents recognize the moments their care decisions are not fully high value and what types of barriers contribute to the perpetuation of such action.
Harnessing Motivation
The authors delineate between intrinsic/extrinsic motivation and then describe the factors that help make those motivators successful. This article is included to emphasize how important it is to create environments that motivate physicians to perform. Additionally, it explains that these motivators can be unique to physicians and/or physician-groups. Featured vignettes illustrate how easily one could perceive that some change or another is a great idea and will bring about improvement, when the reality is the exact opposite. We must consider that context and reference points contribute to motivation; and if we don't keep these ideas in mind, we won't be able to set up systems that adequately support physician wellbeing and performance, as well as patient care.
Does Peer Pressure Increase the Rate of HVC in the Clinic?
This report shows how policy makers can harness the power of psychology to influence physician behavior. Specifically, this RCT demonstrates how peer comparisons helped improve the quality of care delivery by clinicians.
Taking action on overuse: Creating the culture for change
Again, organizational culture matters. Why? Culture is comprised of the shared values and norms within a group that can influence decisions made by a person, a team, or a health care system. Changing behavior is hard; and it's especially difficult without paying attention to and addressing culture. This article outlines an action plan for how one might begin to change organizational culture that results in medical overuse.The authors convened a multidisciplinary stakeholder advisory committee, reviewed social science theory and literature, studied both successful and unsuccessful attempts at improving high value care, and interviewed innovators from 23 organizations across the U.S.; and they decided upon four conditions for change that foster collegiality and collaboration across providers, providers and patients, and healthcare system leaders.
At the heart of the framework are conversations that lead to action and behavior change that slowly begin to shift the culture of how medicine is practiced. These conversations occur between clinicians, patients and team members and focus on evidence about the potential for patient harm, current rates of overuse, and patient stories about the consequences from delivery of an unnecessary service.
Four catalysts that support these conversations were identified:
Ensure consistent communication about low-value practices and how to address them
Build a culture of trust, innovation, and improvement -- foster a space that supports non-judgmental non-punitive conversations that are welcoming to innovators
Establish a consensus around shared language and purpose when discussing overuse. Our language carries emotional baggage; to bring about change, we might need to re-examine the ways we are talking about change. For example, perhaps this means we move away from the term "high value" and work towards "reducing medical overuse" instead.
Commit resources to measurement
How will providers know they are contributing to overuse? We need to present data that's meaningful and actionable.
You can assess your own organization's culture here, the accompanying website built from the work of these innovators.
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