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Roxanna Gapstur: On this episode of Inspiring Health, we're going to dig a bit deeper into a subject that we introduced during our last episode, the six value-based competencies needed to generate value and improve health. These are the capabilities that each of our physicians and APPs can steward to provide the highest quality care best experience at the most affordable cost.

So today, we'll take a look at our 2025 promise to lead the region in value. We'll talk about these six value-based competencies that will align our journey to value. And lastly, we'll consider next steps for building our competencies internally. Joining me today is Dr. Steve Flack, who's the Medical Director for Primary Care in Franklin County, part of our West region, and also a patient-centered medical home champion.

Dr. Flack, thanks for being here. Even though we're recording remotely during this time, I appreciate you being on the podcast.

Dr. Stephen Flack: Well, thanks for having me. I'm really privileged to be here.

Roxanna Gapstur: So Steve, on our last episode, we defined value as providing care of the best quality, exceptional experiences at an affordable price. It's when we do every part of the value equation right consistently, that we generate real value for our patients and customers. On this journey to value, we have guideposts to align our physicians and APPs. And you're here with us today to help us explore these competencies in greater detail. But first, I'd like to get your perspective on our value transformation. As a practicing physician and a leader in our West region, what does value mean to you?

Dr. Stephen Flack: So for me, most things come back to the patient-centered medical home philosophies. So I think that of course value means the right test at the right time for the right cost. But you have to also put that through the lens of the patient outcome and patient goals specifically.

So we do a lot of work with our goal setting in primary care, uh, to understand where the patients are coming from, to understand what they find valuable. We have worked a lot on our quality metrics. And we see that there are people that have all the quality metric boxes checked, but unfortunately have bad outcomes. And when you look at that, the value part really comes did we explain exactly where the need for the treatment was? Did we explain why it's important to have a statin? Did we assess whether or not the patient was willing to do that or willing to take the medication? And did they understand why it was helpful to them?

Roxanna Gapstur: Gotcha. Well, thanks for sharing that perspective. That is so important for us to be in touch with our patients and understanding their goals and what value means to them. So thanks for that. Your perspective is insightful and I think our listeners will get a lot out of hearing about how you think about the first of the six value-based competencies, quality and patient experience. How do you think about those as a physician in generating value for patients that you're caring for?

Dr. Stephen Flack: So I think that the patient experience really starts with understanding of all of our patients. What legacy WellSpan would call Know Me. And what the patient-centered medical home would call Knowing and Managing My Patients, listening to our patients, understanding their goals for their treatments, uh, understanding their frame of reference, their social determinants of health is really important.

Our role as the medical home is to limit barriers to care and to empower patients, to be advocates for their own health. We have done a lot of work related to Perfect Patient Experience. Jenny Smith is our Director for Primary Care in Franklin County, and she's done awesome work in our Shippensburg office around patient experience.

So she had worked on a number of projects that had to do with watching patients as they flowed through our office, watching the experience of the patient, doing timing, finding out what the patients need, talking to people. So I think that is the most important thing that we hear from our patients on how we can make things better.

Examples of things that we learned from the Shippensburg practice, uh, had to do with things like if someone has an ambulatory problem and they can't walk all the way to the back of the office, maybe we should have them roomed at the front of the office. Some of the patient's self-rooming work that had been done there then was able to be shared at other offices. That work also was done to share to our Greencastle office where multiple specialties were in the same office building. We heard from our patients that it would be helpful for our team members, both primary care and specialty to be able to share care along a continuum. And so we have the opportunities for them to be seen by the primary care and specialty care at the same time.

Those are great points, Steve. Just knowing our patients, understanding what could make the experience a while for them, uh, and really listening to concerns. That's really great. So when I think about quality and safety, I consider our key metrics like patient experience, you know, CMS and Leapfrog scores, our Medicare shared savings, quality metrics, and some of our metrics in our ambulatory settings.

Roxanna Gapstur: When we're also leading in quality and experience, we're disrupting the status quo as well. So we have some examples like Madeline RX or Babyscripts, or the fact that we did 400,000 remote visits during the last nine months in the pandemic. How do advanced analytics, the second competency, help us in our journey to value, Steve?

So we use lot of advanced analytics. We look at a lot of programs. We have the Highmark quality program that the West scored a 4.51 last year. Uh, we also have Capital BlueCross programs. And so we take a look at the information, the data that comes in. We have to put that back into the frame of reference on what does it mean to a patient.

Uh, so it's great to have an awesome score. However, how does that improve the patient's life? How does that prevent disease? Can we look at it in the frame of reference of how many colon cancers that we've prevented? How many people has gotten immunizations? So it is very important that we look at that as a team and we share information. Closing gaps is one thing, but making certain that we help people so that they stay as healthy as possible, of course, is the goal.

So we also use Press Ganey scores to review how we're doing. As part of our patient-centered medical home model, each office has a core team that's made up of staff members, both clinical and front desk, as well as providers and patients. So we look at our Press Ganey scores and we see how we're doing and we ask the patients how we're doing. We can then dial down into how does that make a better experience for our patients. Uh, and we've had many conversations in our office where patients had some challenges with the way that things were done or the way that things have been done in the past. And when we want to make an innovation, we want to make a patient experience better, who better than to give us input than the patients?

We have a number of rising risk scores as well for patients. So patients that are going to go on to develop problem, we really need to focus on those people. We spend a lot of time and effort on the most complex people, but those that are getting into problems, those are the ones that we really need to focus on. So someone that is going to go on to develop diabetes, if we can prevent them from getting diabetes in the first place, they will be much healthier in the long-term.

That's great, Steve. Yeah. And so advanced analytics and using data to help point us in the right direction with our patients is critical to our success in the future under value. Let's switch gears to access. We know we can and retain and grow market share by ensuring that our patients are seen in the most convenient way possible. And this may look like same-day walk-in service. It might look like urgent care sometimes. It might look like, you know, online urgent care. Using our facilities appropriately into capacity and, of course, continuing to develop those digital front doors.

Dr. Stephen Flack: So I used to think of access strictly in terms of patients' ability to get onto my schedule. So I have a limited number of patients slots per day and a large number of patients. And so previously, I would think of that in frame of reference, "How many people could be put on Dr. Flack's schedule?" However, I think that team-based care, which is another one of the patient-centered medical home pillars in addition to access to care, go hand in hand.

So I am blessed with a team of people that are helpful to provide contact with our patients. So my front desk person, Mary; my clinical staff flow manager, Emily. I have two care coordinators in my office, Sonya and Kathy. I have a counselor in my office, Samantha; a triage nurse, McKenzie. So these are all people that are providing access to our patients.

In the big scheme, patients oftentimes don't need to see me directly just to get an answer to their question. If they can reach out to any of the team members, um, they can answer their needs. The team members then can communicate and to develop a plan.

My job as the provider is to come in and to try to provide my expert level input into the needs of the patients. But if my front desk talks to my flow manager and determines that someone needs to be seen, they'll make an adjustment on my schedule to make certain that someone can get in. That way, we can make certain that we're seeing the most complex people and the people that need to be seen in the office at a time, uh, that they can come in prior to getting ill and end up in the hospital.

Roxanna Gapstur: Yeah, absolutely. It's so important that we're all working together as a team to understand, you know, who's the right person to see that patient and meet their needs. So that's a great point on access. Certainly having digital tools and different types of bricks and mortar, including urgent care and primary and specialty offices, all make a difference for access. But access means different things to different patients. And so I think the more options that we have, the better.

Dr. Stephen Flack: We need to establish the most appropriate site of service for the type of care patients need. This might mean an ambulatory setting over a hospital or an outpatient practice over a surgery center.

For me, the most important way to prevent extra days in the hospital is to prevent the admission in the first place. From a medical home standpoint, patients are taught to reach out to their patient-centered medical home team, the best way to prevent extra days is to prevent admission and prevent emergency room visits.

We have a lot of examples in the West, including our COPD program, which has been led by Dr. Peter Jablin and our CHF program, which is led by Shani Gadwaw. We also have done a lot of work with complex care plans for our really complicated patients that are at risk for going to the hospital. If they can reach out to us, we can coordinate care among our team members among our medical neighborhood, uh, and hopefully prevent them from going to the emergency room in the first place.

Roxanna Gapstur: Oh, that's great, Steve. What great work that helps benefit our patients, not going to the hospital at all is definitely the best thing. Well, that's great work in the West. We've also seen in the central region, we've re-imagined surgical procedures that were historically conducted at WellSpan York Hospital, and that work's now underway to move many of those procedures into the outpatient setting at our local surgery centers.

Home sleep studies is another way that we've re-imagined site of service here at WellSpan. So that takes us to our final two competencies of reducing care variation and removing waste. These two go hand in hand, don't they, Steve?

Dr. Stephen Flack: Yes, they sure do. We've done a lot of work with our Lean efforts to help our primary care offices functions more similarly. We have processes that are the same for check-in, check-out, nurse rooming for each office. We've also done a lot of work with our Lean daily management philosophies in the offices themselves. As far as waste, we have done lots of 5S work, which has to do with making the rooms appear more similar and have similar materials available for providers to see patients.

We also have done work with our Kanban cards, uh, which is where you have a card that allows you to order materials before you run out of them. So you can estimate the amount of things that you need on a monthly basis and have an order put in before you run out.

As far as our care variation goes, we've done a lot of work with hypertensive guidelines. One of our primary care providers and one of the cardiology providers were real champions for this. So we have hypertension care plan package that was developed. That also included education for staff about how to check blood pressures and that included primary care and specialty offices. If a patient's blood pressure was elevated, then they were planned to sit for a period of time and the staff would recheck the blood pressure. If the blood pressure remained high, they reached out to the patient-centered medical home team. This hopefully prevented them from going to the hospital or being sent to the emergency room so that the primary care provider could adjust the blood pressure and schedule a follow-up visit in the office.

Roxanna Gapstur: That's great, Steve. I love those examples because the focus is on being patient centered during that journey to value. You hit on something earlier that I'd like to circle back to, I know you have a deep appreciation for continuous improvement and Lean thinking. And I'm eager to spread that throughout our culture.

So in January, we're going to be launching some consistent pathways for education for all of our team members through WellSpan's continuous improvement institute. The system approach to Lean where we'll empower, really our entire WellSpan system and all of our 20,000 team members to be problem solvers. I'm curious about your perspective on Lean as a physician and a leader.

Dr. Stephen Flack: I was blessed to come to Summit about eight years ago. And it was just at the time that they were starting in on their Lean journey. So the first week that I was here, we actually had a three-day conference that was managed by Virginia Mason. They talked a lot about a number of Lean terms and Lean philosophies. But the thing I learned most from those three days had to do with I could make my day better. So after we got back from the conference, my nurse and I came back to the office and we started experimenting with PDSA cycles on things that might make our day better.

So some days, we did things and it made the day worse. And so we tried not to do those things again the next day. Sometimes we did things and it made our day much better. And so we built on those. We would do additional timings. We would develop some standard work. And the great thing was that we were then able to share information with other people to benefit from the things that we had learned.

We also had a 3P which stands for production, preparation and process, which was a primary care redesign. This was another Lean methodology that really was meaningful to me. What did it allowed us to do was to understand that the 10 different primary care offices that I'm responsible for were acting very differently. And so the concept was to redesign the primary care experience so that each office was acting more similarly. In that way, we could then share the good things that were going on at the offices amongst the office and benefit the patients.

Each office still had their own flavor, and I equate that to the analogy of ice cream. So everyone could have very similar attributes. However, everyone could be a different flavor of ice cream. We also worked a lot on innovation and probably the most important thing that I've learned in my Lean journey has to do with innovation.

So Taiichi Ohno, who is the father of the Toyota Production model, says, "Without standards, we cannot have innovation." What that means to me is that you have to have standards so that people can start on a similar base. After we are all agreed on the standard and that probably is the most difficult thing that we've had experience with, then we can start to innovate and we can make things better. So then we can share information and we can share amongst our offices and we can share amongst the regions so that we are doing things in the best possible way for our patients.

Roxanna Gapstur: Oh, that's a really great note to close on, Steve. Thank you so much for sharing that information and that perspective as a physician and a leader. Let's recap our discussion today. We reviewed our 2025 promise to lead the region in value, delivering highest quality care, exceptional experiences at an affordable cost. And we explored the six value-based competencies that support our journey. We also recognize the power of Lean and continuous improvement as necessary tools in our value transformation. Thank you for being with me today, Steve.

Dr. Stephen Flack: Thanks for having me.

That's all the time we have for today. We hope you'll join us for the next episode of Inspiring Health.