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Your Life Your Health - Continuity Creativity Consistency Part X: The Place and Spirit of Accreditation Activities for Improving Healthcare which is Sustainable
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James L. Holly,M.D.
February 23, 2017
Your Life Your Health - The Examiner

This is the final part of this 2017-ten-part summary of SETMA’s PC-MH pilgrimage.  The entire series consists of the following:

I.          The Less Initiative
II.         PC-MH
III.       Auditing for Quality and Safety
IV.       Team Work:  The Key to Excellence in Healthcare
V.        Organizational Philosophical Foundation
VI.       Producing a Sustainable Health Quality Model of Care
VII.      The Patient-Centered Conversation
VIII.     The Power of Story Tell
IX.       Care Coordination and Convenience
X.        Place & Spirit of Accreditation Activities for Improving Healthcare

This is a good summary of the crux of SETMA’s PC-MH.  Along with the over 150 articles at on PC-MH, SETMA’s journal is well documented.  The following links on SETMA’s website give further guidance to our understanding of PC-MH:

This last part of this most recent series on PC-MH addresses SETMA’s understanding of the value of accreditation in the PC-MH transformation process.  To that end, on November 18, 2015, SETMA had a conversation by e-mail with a member of a PC-MH accreditation body.  Because accreditation is an important part of excellence in healthcare organizations, in oversight, in compliance functions and in quality improvement, SETMA believes the spirit of accreditation surveyors should be collegial and collaborative.  If accreditation and/or oversight deteriorates into an adversarial dynamic, the positive effects of that oversight can and will be lost.  This is true for accreditation organizations and for compliance officers, whether governmental or other.

The Question posed by the accreditation executive was, “You note that ‘The provider must be an extension of the family. This is the ultimate genius behind the concept of Medical Home, and it cannot be achieved by regulations, restrictions and rules.’  Are you implying by this statement that there is no role for "regs, rules, and restrictions", or simply that they are insufficient to sustain long-term change?”

SETMA responded, “No doubt, as our accreditation efforts suggest, we believe that there is a key place for standards and guidelines.  The point of SETMA’s comment is directed at the government’s preoccupation with creating ‘change’ with demands and dictates.  SETMA has said to the Office of National Coordinator often, ‘if you demand that everyone must do the same thing, the same way, every time, you will eliminate creativity, generative thinking and transformation.  Tell us what you want done and let us demonstrate our unique way of doing it. Then evaluate and find the ‘best practice or best solution’ and promote that.’”

When change is driven only by external demands, it is not sustainable and will become dependent upon rewards to drive improvement.  But when change is driven by internalized values and vision, being self-sustaining and generative in nature, it is sustained not by financial or other rewards, but by the passion of the participants.  For change to be permanent, it must be driven by transformation rather than reform.  Transformation is driven by internalized value and vision.  Rules, regulations and requirements can be part of an external standard against which you can measure yourself, but they will never become a part of the energy which sustains change.

The executive’s second question was, “Also, would you consider ‘standards’ (such as those that certain accrediting bodies use) to be equivalent to “regs, rules, and restrictions’, or do you see them as having value because they offer a blueprint that describes a desirable future state that is worth attaining/maintaining?’”

SETMA responded, “As implied above, we think standards are important guideposts in starting us on our pilgrimage and in giving us guidance in what to do, and, often, even, in how to do it.  Remember Lincoln’s famous quote in his 1858, “House Divided Address” to the Republican National Convention.  He said, “If we can first know where we are and whither we are tending; we can better judge what to do and how to do it.”  A healthcare GPS must tell you where you want to go - that is often expressed in standards, evidenced-based goals and quality outcomes - but if the GPS does not also tell you where you are - how far you are from where you want to be -- you can never get to where you want to be. 

Standards are what we measure ourselves against, as we create our future.  Remember Peter Senge’s great comment in The Fifth Discipline as he addresses “creative tension,” which is the difference between your “reality” and “your vision.”  The “tension,” which cries out for resolution is created by standards which you have not yet met, but which you embrace as “the good.” 
Yes, we believe in standards, that is why we sought _____ ___________accreditation and why we will renew it.  That is why we objected to the original spirit of the surveyors as they announced in their first sentence, “If you are doing something wrong, we will find it.”  It was a threat, when in fact that is why we sought _______ __________accreditation in the beginning - to tell us both what we are doing wrong but more importantly to tell us what we are not doing right.

We WANTED to be measured by the _____ __________ standard; to discover we needed improvement was not a threat, it was an expectation.  The worst experience of bringing in a practice consultant is that after you have paid him/her $10,000, you are told, you are doing everything perfectly and we can recommend no improvement.  You have just wasted your consultation fee.  If, however, you are told, we can show you how to really improve.  That has great value.

In Senge’s work, the interesting thing about  “creative tension,” as it drives you from your “reality” to your “vision,” is that as you approach your “vision,” and as your “vision” increasingly becomes your “reality,” you discover that your “vision” expands and when you “arrive” at your former “vision,” it having become your “new reality,” is challenged by a new and larger and more comprehensive “vision.”  That should always be the goal.   I would hope that when we are reaccredited by the _____ _______ that we will have corrected the very few things which you pointed out before but that you will find subtler and perhaps even more important things we can improve. That is not failure; that is progress and that is a dynamic for success.

Because SETMA believes in Accreditation, we have sought and achieved accreditation and/or recognition from the following:

SETMA’s Recognitions and Accreditations

  • NCQA - PC-MH Tier III
  • NCQA - Diabetes Recognition
  • NCQA - Heart And Stroke Recognition
  • NCQA - Distinction in Patient Experience Reporting
  • AAAHC - Ambulatory Care
  • URAC  - PC-MH Advance Certification with EMR
  • The Joint Commission - PC-MH
  • The Joint Commission - Ambulatory Care
  • The Joint Commission - Clinical Laboratory Services
2014-2016, 2016-2018

Any organization serious about transformation needs the stimulation and evaluation of multiple accreditation experiences.  However, achieving these benchmarks was not the end of our journey but only the end of the beginning.  The dynamic process of PC-MH transformation continues.  Daily, SETMA recognizes the value of our journey.  We recognize that this was the right course to take.  We realize how far we have come but we also recognize that we will always be “becoming a PC-MH” and never finally reaching the end point.  This is not frustrating nor discouraging; it is challenging and encouraging.

Other Articles in the Continuity, Creativity, Consistency Series

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