Lessons Learned

What we learned from the Taking Action on Overuse project across our 3 partner sites

We partnered with 3 diverse health care organizations that used the Taking Action on Overuse Framework to address overuse topics: UCLA Medical Group, Swedish Medical System, and Missouri Primary Care Association. Much was learned about the challenges and opportunities of addressing overuse.

Key takeaways

• Reducing overuse is challenging and takes time, perhaps more so than traditional quality improvement 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).

Common barriers

• Competing priorities exist at both at the organizational and local levels, especially if volume is more important than value due to traditional reimbursement models.
• Leadership and staff turnover can disrupt projects and affect buy-in and credibility.
• Obtaining the needed data can be difficult, which often unnecessarily delays starting conversations about overuse with providers, patients, and teams.
• Creating a shared understanding of and commitment to overuse reduction work can be challenging in our current health care environment.
• Individual and organizational resistance to change is common and may be influenced by other internal/external pressures and priorities.

Recommendations

• Commit to 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. This can slowly shift the organizational culture to one of doing less with an emphasis on patient safety.
• Be prepared to share stories about harm. 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. Even when you have reliable data about rates of overuse, real patient stories are critical to facilitate these conversations.
• Utilize credible and transparent data, though it does not need not be “perfect” to support necessary conversations about overuse.
• 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.
• Elevate local clinical champions, who are trusted members of the team, as brokers to help open doors and facilitate access to sites and local teams.
• Be attentive to language: Not all terms (such as emphasizing “value”) resonate with all providers and staff.
• Ensure providers who specialize in the specific area of overuse are on board and supportive.
• Prepare providers for conversations. Develop scripting for talking with patients about the 3 areas of harm. Whenever possible, create a replacement service or pathway that is evidence-based and doesn’t cause harm.

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