During the Taking Action on Overuse project, we partnered with three diverse health care organizations that used the Taking Action on Overuse Framework to address overuse topics. The partner sites are UCLA Medical Group, Swedish Medical System, and Missouri Primary Care Association. Much was learned about the challenges and opportunities of addressing overuse.
- Reducing overuse is challenging and takes time, perhaps more so than traditional QI projects.
- Sustained leadership engagement is necessary to the success of overuse reduction efforts.
- In addition to leader support, front-line engagement is critical to succeed – one cannot be prioritized over the other.
- Ongoing conversations about overused services are key to engaging providers and having front-line teams take ownership of the work. Trusted data and evocative stories as both necessary.
- The human side of change should be attended to. Behavior change is often hard and conversations about overuse can be emotionally challenging.
- Unintended consequences are not uncommon: efforts to reduce overuse in one area (e.g., test ordering) may result in compensatory increases in another area (e.g., referrals).
- Competing priorities exist at both at the organization and local level, especially if volume is more important than value due to traditional reimbursement practices.
- Leadership and staff turnover, which can disrupt projects and affect buy-in and credibility.
- Difficulty obtaining needed data, which often unnecessarily delays starting the conversation with providers, patients and teams about overuse.
- Difficulty creating a shared understanding of and commitment to overuse reduction work.
- Individual and organizational resistance to change, which may be influenced by other internal/external pressures and priorities.
- Continuous, consistent, direct communication across the organization from leadership at multiple levels about the importance of preventing patient harm by reducing utilization of overused services can slowly shift the organizational culture to one of doing less with an emphasis on patient safety.
- Emphasize potential for patient harm, it is central to the work of engagement.
- This harm can be financial, emotional, or physical, and can occur as part of the service itself or the clinical cascade it initiates.
- Potential patient harm from overuse resonates with providers and can help obtain buy-in, so always be prepared with stories about harm, even when you have reliable data about rates of overuse, they are critical to facilitate these conversations.
- Data should be credible and transparent, but need not be “perfect” to support necessary conversations about overuse Leadership needs to provide support for data gathering, reporting and regular meetings.
- Start with an area where there is a high rate of overuse and/or when there is little controversy that overuse occurs.
- Local clinical champions who are trusted members of the team can often serve as a broker to help open doors, facilitating access to sites and local teams.
- Be attentive to language, not all terms (such as emphasizing “value”) resonate with all clinicians and staff.
- Make sure physicians who specialize in the specific area of overuse are on-board and supportive
- Don’t leave clinicians empty-handed. Develop scripting for talking with patients about the three areas of harm. Whenever possible, create a replacement service or pathway that is evidence-based and doesn’t cause harm.