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Aligning our Efforts to Transform the System

Posted By Rob Cushman, Thursday, October 18, 2012

Dr. Cushman's post is the third in a 5-week collaborative series hosted by the blogs of

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As a long-time member of STFM and the incoming President of CFHA, I am both excited and a bit anxious about taking on this role at this time, because we are truly at a critical juncture. As healthcare providers and educators, we offer clinical services in a "system” that is about to either continue making important strides forward toward becoming a true SYSTEM achieving meaningful outcomes, or to slip backward into the free-for-all chaos that has complicated delivering good, patient-centered care for decades. We need to work together as members of STFM and CFHA to navigate through these twists and turns, or plow through some obstacles, so that we, our trainees, and our patients and communities, come out in better shape on the far end.

I want to share one of the "clinical pearls” I learned in my residency, which has served me well as a "compass,” and which I have quoted (with attribution!) many times to my own trainees as I precept them in the hospital and the office. I offer it now because it is applicable beyond the direct patient care process. I can still hear Tom Campbell saying, "When you’re stuck, expand the system.

He of course meant to explore more into the patient’s family and community context, gathering the perspective of some of those folks that make up that social network, or enlisting their assistance in changing parts of that context in order to achieve change for the patient. He also meant to ask for input and additional, new and different perspectives and suggestions from one’s professional colleagues, both diagnostically and for interventions. This approach has proved hugely valuable to me, repeatedly. And I think the current emphasis on team-based care is a result of a collective recognition that this systemic approach is valuable and more effective than "going it alone.” Rob Cushman
We need to invite others who are not yet fully aware of
the models we
are implementing
to join us and
learn along with
us as we change
our systems.

I want to challenge us all to continue to "Expand the System” in three ways. I want us to Expand our Concept of Teams, to Expand our Measurements of what we’re doing, and to Expand our Reach. Let me elaborate briefly on each of these.

First, Expanding our Concept of Teams. Too often we lapse into thinking of the team as the "clinical team”, those who are based in our practices and/or in other agencies. I would encourage us instead to remember that every patient needs to be at the center of the "team” that coalesces to address their physical and mental health needs. The person that is that patient/client/consumer should be thought of as a co-captain in setting the agendas for the team. Only then will our primary care practices have truly become Patient-Centered Medical Homes. I fear that label is currently thrown about far too liberally, and unconsciously shortened to "medical home” because being truly patient-centered is way harder!

Second, we need to Expand our Measurements. By this I mean that we need to more consistently, more systematically collect, track, and analyze meaningful data about what were are doing (our processes) and the impacts we are achieving with and for our patients and their families and communities (our outcomes). Some folks emphasize measuring outcomes over process, and that has some validity in the long run. However, while we are in the middle of striving to find the best ways to do things, collecting information about process may help us to determine more rapidly which aspects of different approaches we try may be the critical components in determining the success or failure of an approach. The outcomes measures are then important for making the case that that change is ultimately worth doing.

Finally, we need to Expand our Reach. By this I mean that, as CFHA and STFM members, we need to expand our conversations about collaborative, integrated care to others in our workplaces and communities. We need to invite others who are not yet fully aware of the models we are implementing to join us and learn along with us as we change our systems. We need to decide how we can best coordinate and partner with each other and other organizations who share many similar values and positions, in order to join our collective voices in advocacy, and even to undertake joint initiatives to help "make our case.” We need to share our success stories, and be able to provide the data coming from our own, and our collective, measurements and research about the value of this holistic model of care. This is what advocacy is, distilled down: telling illustrative stories, backed up by data. Each of us has a role in advocating for the continued expansion of collaborative, integrated care. Together, we can make this happen.

So, don’t just expand the system when you’re feeling stuck. Instead, let’s strive to Systematically Think (and Work) Systemically.


Robert A. Cushman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Connecticut School of Medicine and Saint Francis Hospital and Medical Center. He has been an active member of STFM since 1987. He was consistently active in the Group on Family and the Group on Community Medicine, and served on the Steering Committee for the Group on Family, including serving as Conference Chair for the STFM Conference on Families and Health in New Orleans in 2008. Since that time he has become increasingly involved in CFHA, as well, and joined its Board last year as Treasurer and President-Elect. The text above is adapted from his inaugural address as CFHA President.

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