I am particularly pleased to be able to offer you this issue’s cover story by Leif I. Solberg, MD, both because it carries a message that is vital to family physicians today and because it articulates clearly a major theme of Family Practice Management – that systematic practice is better practice (see “The KISS Principle in Family Practice: Keep It Simple and Systematic,” page 63).
As Solberg is careful to point out, systematic practice is not mechanical practice, it is not necessarily computerized practice, and it is certainly not cookbook medicine. Rather, systematic practice is intelligently consistent practice. It is practice where nothing important is overlooked and where what is done is done for good reason.
To oversimplify Solberg’s message considerably, the way to systematize a process is, first, to get general agreement on how the process should function and, second, to make sure that it does function that way without fail. The first step is clearly important in cases where strong evidence supports one way of doing something – where there is obviously a right way and a wrong way. Hence, in clinical care, the starting point is usually to agree on an evidence-based guideline as the way to go. But even where there is no one right way, having everyone agree on one way to do something is beneficial, if only for simplicity. In even a small group, if each physician wants the appointment system to accommodate one or two special appointment types that only he or she uses, the result can be confusion, conflicts and chaos. The practice needs to decide as a whole which side of the street to drive on, so to speak. Simplicity and standardization are fundamental to the systems approach. (And yes, the value of the systems approach is not limited to clinical care. Every part of your practice can benefit, including the bottom line.)
Together with simplicity and standardization, Solberg lists reminders, redundancy and teamwork as components of the systems approach. All three are important in the second step I mentioned above: making sure that what you’ve agreed should happen does happen. How important are they in your practice? Think about questions like these: What percentage of your post-MI patients are actually on beta-blockers? What percentage of smokers in your practice do you ask about quitting at every visit? What percentage of your patients with diabetes are up-to-date on foot exams, eye exams and HbA1c levels? Is it difficult to cover for colleagues because you all document differently? How many of your rejected claims are rejected because they lacked information they should have included in the first place?
You are the only one who can decide how important the systems approach is to you. I ask only that you base your decision on a review of your charts and claims and other objective evidence, not on your own sense of how consistent you are. Your seat-of-the-pants sense of how you’re doing is likely to be less trustworthy than you think it is.
That brings me to what I consider another important component of the systems approach: monitoring. You don’t need to collect exhaustive data; you need just enough to know whether your system is actually working. If you’re not measuring your operation, you are not operating systematically.
The FPM system
I said that the systems approach is an important theme of FPM. That’s because it seems clear that the more systematic your practice, the better you’ll serve your patients, the happier they will be, the easier your life will be and the more you’ll bill and collect. No wonder the theme runs through most of the content of the journal – from major efforts, such as the special issue on preventing errors that appeared exactly a year ago, to individual articles, such as the one by Peter A. Cardinal, MD, MHA (see page 35), which provides tools to help standardize preventive exam documentation, and the one by Brian S. Alper, MD, MSPH (see page 49), which introduces several online resources for evidence-based information. FPM can’t deliver off-the-rack systems for your use, because you – and your practice – need to implement what works for you. We do what we can in presenting advice from authors like Solberg, providing examples of practices that have systematized one facet or another of their operation and giving you tools that can become elements of the systems you construct. You need to take it from there. Good luck.