Dr. Andy Lee knew there was a better way to treat diabetes patients. His new model of care was already succeeding at LAC+USC Medical Center, where he serves as medical director for specialty services. What the doctor didn't know was how much resistance he would face when trying to expand the model to the rest of the county.
"It was relatively new, and people couldn't see how we can entrust primary care physicians to manage diabetes," said Lee, an endocrinologist at LAC+USC's outpatient specialty care center, the largest in Los Angeles County. "Even when we achieved it, people just couldn't believe that it was happening."
Lee's approach aims squarely at reducing the fragmented care so commonly received by patients with chronic disease. His model enables primary care physicians to manage diabetes patients with the help of in-depth education and guidance via e-consultation with endocrinologists.
When it was time for the 43-year-old doctor to develop a California health improvement project (CHIP) for his CHCF Health Care Leadership Program fellowship, it was natural for him to focus on the diabetes care model that had been his passion. Like many of the more than 400 California clinicians who have been leadership fellows over the past 17 years, Lee set out to find ways to spread an innovation that was working so well.
A Shift in Focus
Working on his CHIP forced Lee to reflect on his experiences in new ways. He had to acknowledge the internal resistance he encountered at his own medical center when he first proposed his innovation. He realized that other good ideas were likely dying on the vine because they faced similar resistance to change. If he could solve that problem too, he thought, the impact would be far greater than focusing on spreading only the diabetes program. "I went back and I completely pivoted my direction and said I want to create an incubator so that others within the county . . . can take an idea from the back of a napkin and actually form a program," Lee said. "This is where it's so critical, so serendipitous, that I was part of this fellowship, and that I had the right mentors."
Empowered by the information and significant resources provided by the fellowship, Lee decided to build a medical innovation incubator (MII) at LAC+USC. The MII is embedded within a newly renovated hub for seven subspecialty services.
With support from Dr. Mitchell Katz, director of the Los Angeles County Department of Health Services, Lee was given the opportunity to redesign specialty clinics within one unit that replicates systems and processes used across LAC+USC's 168 clinics. The goal is for the ideas generated in the MII to be adopted throughout the medical center, around Los Angeles, and across the nation.
"We can actually simulate models of care that we think would apply to other clinics," Lee said. "We started establishing standards of access, standards of how physicians and nurses and teams should be built."
Where People Feel They Can Make Things Better
A major aim of the MII is to overcome what Lee views as three main pitfalls associated with medical innovation:
- The failure to include line staff in efforts to innovate
- The pursuit of innovations that fail to be disruptive
- The inability to bring new ideas to scale
Soon after the MII launched in June 2016, great ideas started pouring in from clinics in the medical center. "They were immediately applicable to the [patient] population they were serving, and it created a culture of inclusiveness," Lee said.
The MII is a unique project, and Lee's diabetes care idea is a standout result that reflects the culture change Lee is pursuing, said Katz. Thanks to Lee's vision, patients once thought to require direct care from a diabetes specialist are now being served as well or better by the primary care doctor getting a specialist's advice through e-consultation on a secure electronic communication platform.
"Often an organization will have a director of innovation or an innovation center, but the difference is that what Andy is doing is trying to figure out a way to align staff who best understand the work, to get support for innovating within the system. And I'm not aware of anyone else who does that," Katz said. "Andy has figured out that he can provide ongoing assistance to primary care doctors electronically in managing their diabetic patients. I think that's a new implication because diabetes is in epidemic proportions in LA, and it's a devastating illness."
The MII project also addressed clinic workflow issues with an eye toward decreasing the time needed for a patient visit. A major challenge was that each of the seven specialty clinics operating within the MII had unique workflows, making it difficult to figure out how to implement a change that would be applicable to each. The team ultimately devised a way to share three key indicators online each hour with the clinics' clerks: the number of patients who checked in, how many patients' vital signs were recorded, and how many patients were seen by providers. This transparency required no intervention, no staff training, and no promotional effort, but it was enough to make a huge difference in the elapsed time of patient visits.
"They just report this through the Internet, and it's widely visible," Lee said. "The impact tracked was tremendous."
The duration of patient visits dropped immediately in the three departments that implemented it.
"We've shown throughout the three sites a specifically significant reduction in cycle time that was maintained over six months," Lee said. "It's incredible."
Since introducing the MII, other novel ideas like Lee's have been tested and scaled throughout more than 100 clinics.
Of all the lessons learned during the year since the MII launched, the most valuable, said Lee and Katz, relate to the importance of creating an environment in which people feel comfortable sharing their ideas.
"This is as much or more about empowering people as it is about the ideas themselves," Katz said. "To me, the ideas are secondary. What really matters about the innovation center is whether you're running the kind of organization where people feel they can make things better."
Links to other CHCF pages for further information:
CHCF Health Care Leadership Program
How CHCF's Leadership Program Reinvigorated Two Stellar Careers
How California Can Meet the Challenge of Accurately Diagnosing Autism
Rural Pregnant Women with Opioid Addiction Find a Doctor, Not a Judge
How One Doctor Realized He Was His Own Biggest Management Problem
Artificial Intelligence Eases Burden of Blindness in Diabetes