ACMPE Fellowship:

Sample Outline Submissions

Outline Examples - Exploratory:

Understanding Barriers to Physician Engagement: Learning from Other Industries

American College of Medical Practice Executives Professional Paper Topic and

Outline -EXPLORATORY

Paper outline being submitted in partial fulfillment of the requirements for election to Fellow

Exploratory Paper: Detailed Outline and Sources Physicians are key stakeholders in healthcare systems whose engagement is critical to the success of change initiatives yet who have been challenging to motivate and gain commitment from when developing clinical process improvement programs. The environment of healthcare has changed significantly over the past decade. It has moved from a one-on-one interaction in small or solo practices to one that requires integration with computerized systems and multi-disciplinary teams. This change reflects a substantial transformation of the care delivery model. To accomplish this, key stakeholder involvement is essential. Physicians are identified as the leader on healthcare teams and fill a key role in the transformative change that must occur. However, engaging this stakeholder group has proved to be challenging. Review of the barriers to engaging this group will help leadership understand their unique role on the team and develop strategies to enlist their talents in the transformation. This paper will briefly provide an introduction to the recent changes in the external environment forcing a change, the physician’s historical role on the care team and the expectations in the emerging system, and the barriers to engaging them to acceptance of the new role. Outline: Thesis statement: Physicians are key stakeholders in healthcare systems whose involvement is critical to the success of change initiatives yet who have been challenging to motivate and gain their commitment when developing clinical process improvement programs due to barriers in engaging them in the need for transformative change.

1. Introduction a. Review of the rapid change in clinical practice

environments over the past fifteen years. i. There have been regulatory changes based on

changes that define hospitals’ obligation to provide certain services and issues related to quality of care and patient safety.

1. There has been an increase in monitoring and enforcement of fraud and abuse. This was expanded more recently to include additional audits around RACs.

2. National patient safety goals have been established. 3. There is more measurement of clinical processes at the

organizational level with a push by payers to report publicly at the individual provider level.

ii. There have been changes to the reimbursement models. 1. Hospitals were moved to a payment system that utilizes Diagnostic

Related Groupings (DRGs) in the 1980s and Medicare Conditions of Participation.

OUTLINE WHAT METHODOLOGY WAS UTILIZED FOR THE 

OUTLINE. FOR EXAMPLE: “A review of various 

professional journals was completed” 

GOOD EXAMPLE OF SENTENCE STRUCTURE 

WITHIN THE SECTIONS OF OUTLINE. 

2. Payment reform with DRGs required hospitals to look at improvement in efficiencies and ways to maximize the ever dwindling reimbursement.

3. This increase competition for some types of patients and more demands from patients as they assume more of the cost of care.

4. Hospitals and physician groups have moved care into ambulatory settings to improve reimbursement. This creates additional competition between physicians and hospitals.

iii. The corporate structure of most hospitals is included a tripartite between the Board, medical staff and the administration. In spite of all the payment and care reform, this structure has been a relatively constant structure that has been protected from much of the other changes based on external regulating systems such as the Joint Commission.

1. The medical staff is a self-governing, independent group of physicians who has “control over matters touching the provision of medical care within the institution” (Blum, 2005, p. 4).

2. Historically this independent structure also provided the physicians, who were generally independent contractors and not employees of the hospital, a voice and associated power to maintain their autonomy (Blum, 2005).

3. Because of changing external pressures to improve efficiencies and reduce costs, some hospitals have considered closing medical staff membership or using other limiting criteria such as economic credentialing, or exclusive contracting. These decisions increase the tension between administration and the medical staff.

b. Discussion of the physician’s historical role on the health care team. i. The focus has been on the physicians many of the change initiatives

because it is estimated that they are responsible for 80-90% of the resource allocation decisions (Evans, Hwang, & Nagarajan, 1995).

ii. “The manner in which physicians relate to hospitals is changing, and even amid current battles to solidify the power of the medical staff, the structure in which that entity exists is eroding” (Blum, 2005, p. 1).

iii. “From a fundamental standpoint a hospital in which the medical staff is out of sync with the two other core parts, board and administration, is an organization whose effectiveness is compromised. Large current challenges, such as ongoing regulatory compliance, marketplace competition, and patient safety, cannot be dealt with efficiently in hospital environments in which the board/administration and the medical staff are working at cross purposes” (Blum, 2005, p. 12).

1. Economic credentialing and increase scrutiny of credentials and competency by the hospitals and payers increases physician frustration and mistrust in the vision to provide care.

2. “Major efforts, such as pay for performance (P4P), try to create incentives for physicians to improve measures of quality. Evidence of this is the shifting focus of quality measurement and improvement from systems measures (ie, Health Plan Employer and Data Information Set [HEDIS] for health plans) to individual physician measures” (Holmboe & Cassel, 2007, p. 18)

c. Discussion of the proposed physician’s role on the health care team and review of the gap.

i. The physician may no longer be in the role of authoritarian. 1. “In recent years, many hospitals in the world have moved to a

professional management model from one of physician dominance” (Akbulut, Esatoglu, & Yildirim, 2010).

ii. The physician now must review and interpret data on the practice and integrate that data into improvement initiatives. This feedback is frequently delivered by non-clinicians.

iii. The physician must develop the skills needed to lead a multi-disciplinary team in a collaborative manner that is patient-centered.

2. Identification of barriers to engagement from the literature outside of healthcare a. There is a general need for engagement that is at the core of preventing change.

“All employees can make enormous contributions; and without the support and commitment of all employees, major change is impossible” (Axelrod, 2011, p. 9)

b. There are several references to engagement barriers identified in the literature. i. The common theme that was identified included lack of perceived benefit

to self or to the organization, low trust, low tolerance to change. (Kotter & Schlesinger, 1979)

1. Supportive evidence toward lack of perceived benefit to self or to the organization as examples of barriers to engagement include the following.

a. Expectance theory predicts some of the resistance that a change initiative might experience. “Expectance theory predicts that resistance will result if any of the following conditions hold: (1) the individual has expectancies that the relationship between a change in behavior and performance is uncertain; (2) that the link between performance and outcome is uncertain; and (3) the outcomes have negative

INCLUSION OF REFERENCES WITHIN 

THE OUTLINE 

value to the individual (Hope and Pate, 1988)” (Lines, 2004, p. 198).

b. “Changes that contain elements in conflict with dominating norms and values are more likely to be resisted unless the process by which they are conceived and implemented is capable of reducing this resistance. For example, changes that involve a tightening of control is likely to be more resisted in organizations where the culture emphasize autonomy than in organizations where control is part of the accepted norms” (Lines, 2004, p. 199).

c. “Changes involving reductions in job variety are likely to be evaluated negatively by change recipients, whereas changes not affecting or leading to an increase in job variety will lead to a neutral or positive evaluation of the change” (Lines, 2004, p. 200).

2. There is supportive evidence toward lack of trust as a barrier to engagement.

a. Paldo del Val provided results of a study on sources of resistance (Pardo del Val & Fuentes, 2003). This study identified the most significant factor to be related to the presence of deep-rooted values. She commented further that this is also “one of the sources that presents the highest differences between evolutionary and strategic changes. (Pardo del Val & Fuentes, 2003, p. 153)

b. Engagement is impaired with the individual perceives a lack of feeling heard. “The key is to ask the person you seek to influence, first for their thoughts, fears, and aspirations. If you can show you are genuinely interested, you begin to break down any barriers to change.” (Mayfield, 2014)

c. Lack of trust impacts an individual’s commitment to the organization. “Three related practices that are integral to successful trust building interventions in public organizations are: (a) participation in decision making, (b) employee empowerment, and (c) feedback from and to employees” (Nyhan, 1999, p. 64)

3. There is supportive evidence toward a low tolerance for change as a barrier to engagement.

a. Fear of the outcome of change can prevent engagement. Lazarus and Folkman wrote that “people fear and tend to

avoid … situations they believe exceed their skills whereas they get involved in activities and behave assuredly when they judge themselves capable of handling situations that would otherwise be intimidating” (Lazarus & Folkman, 1984, p. 20)

ii. Lack of affective versus calculative commitment can contribute to the barrier of engagement (Nyhan, 1999).

iii. Barriers identified in the educational literature are similar to those in other organizations and include uncertainty, concern over personal loss, group resistance, dependence, trust in administration, awareness of weaknesses in the proposed change (Lunenburg, 2010).

3. Review of barriers to physician engagement in the context of healthcare a. There is lack of a shared vision and understanding of the system

i. The development of the vision and organizational goals does not always include the physician.

ii. Physicians are not engaged in practice improvement efforts.

1. Feedback reports are frequently delivered in an impersonal manner and include data that may not be considered relevant to the provider (Forthman, Wooster, Hill, Homa-Lowry, & DesHarnais, 2003).

2. There is a need to optimize the use of feedback as opposed to providing general information (Forthman, Wooster, Hill, Homa-Lowry, & DesHarnais, 2003).

iii. The physician workday is focused on taking care of the patients on the schedule for that day. The environment is chaotic and orientated toward getting the work done rather than strategic planning (Chesluk & Holmboe, 2010).

b. There is lack of trust and empowerment, which contributes to the lack of engagement.

i. Engagement requires mutual trust and trust requires participation in decision-making.

ii. Empowerment is considered a prerequisite to establishing trust (Nyhan, 1999). An un-empowered physician cannot effectively engage.

1. “Empowerment means an organization ensures that (1) employees receive information about organization performance, (2) employees have the knowledge and skills to contribute to achieving the organization goals, (3) employees have the power to make substantive decisions, and (4) employees are rewarded based on the organizations’ performance. This concept of empowerment

DISCUSSION OF NEGATIVE 

IMPLICATIONS. 

is rooted in practice and management” (Chen & Chen, 2008, p. 281).

iii. The roles within a practice are frequently ill defined. 1. The physician continues to fill an independent role in caring for

patients while the systems are asking for more collaboration in decision-making.

2. “In a more recent study, the attributes of physician champions working to improve AMI care were as follows: personal commitment, professional credibility, active participation in a quality improvement team, skills in quality improvement, and an effective relationship with other groups (eg,administration) in the hospital” (Holmboe & Cassel, 2007, p. 19).

c. Physician autonomy contributes to the barriers for engagement. i. “Autonomy makes people feel responsible for their work results” (Chen &

Chen, 2008). ii. Defined during their years of training and the personal accountability that

is prioritized during that time, many physicians believe that the quality of care provided to their patients is completely dependent on their individual knowledge and hard work (Reuben, 2007).

iii. There is implied entitlement to a physician-centric work environment. 1. “In the 1990s, some markets experienced tremendous and rapid

growth in demand. To attract physicians, organizations offered “sweet” deals” (Kornacki & Silversin, 2012, p. 3).

2. Requests to change the environment are considered assaults on the prior agreements.

iv. There are relationship issues between specialties that create a hostile environment for improvement. Many of these issues are related to turf battles and protecting one’s practice preferences.

v. “Physicians will oppose changes that threaten their livelihood, sense of competence, autonomy, and delivery of quality patient care” (Forthman, Wooster, Hill, Homa-Lowry, & DesHarnais, 2003, p. 182).

d. Physician time limitations due to workload contribute to the difficult situation. i. With the changes in the healthcare environment, physicians are expected

to see more patients and complete more documentation than before. This creates what Chesluk and Homboe described as a frantic bubble (Chesluk & Holmboe, 2010).

1. This hectic schedule requires physicians “to work in a manner that inhibits reflection and collaboration” (Chesluk & Holmboe, 2010, p. 878).

2. When the care team is able to come together, it is generally based on the physician’s schedule, which creates tension for the other team members.

ii. Many physicians are not trained to work within an interdisciplinary team. 1. “The move to interdisciplinary care has important implications for

physician champions. First, physicians will need to relinquish some of the autonomy they have closely guarded for decades. Second, they will need to empower others to improve quality and share success. Finally, physicians must lead by example, willing to do what they ask of others“(Holmboe & Cassel, 2007, p. 19).

2. “The majority of the physicians had never received any training in quality improvement principles and methods, and their definitions of quality improvement varied widely. This group of physicians also noted that their staff lack skills in quality improvement and that time was a major barrier in acquiring skills and bringing about improvement” in (Holmboe & Cassel, 2007, p. 20).

e. There is uncertainty related outcome of change. i. Physicians are concerned they will not be able to provide quality care to

their patients. “Researchers also found that the nonadopters wanted more assurance that quality improvement efforts will benefit their patients and that their practices will be financially rewarded before implementing changes in their practice” (Holmboe & Cassel, 2007, p. 20).

ii. Physicians are concerned about their role in the new structure and if they will be valued. “Bodenheimer et al’s study of larger group practices found that lack of resources, misaligned payment incentives, physician unfamiliarity, resistance, and overwork all were barriers to the adoption of effective care management practices” (Holmboe & Cassel, 2007, p. 19).

iii. Physicians are concerned with the payment structure. 4. Summary of findings and conclusions related to the barriers to

physician engagement and the value of addressing them to move healthcare’s transformation forward.

a. “Payers, such as CMS and private insurance companies, and accreditors, such as the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations, all are actively involved in trying to engage the physician community to develop meaningful quality measures. However, in the end, significant improvement will occur only if physicians get involved at the local and regional levels.20,21 in (Holmboe & Cassel, 2007, p. 19)”

CLOSING PARAGRAPH PREFERRED VERSUS BULLET POINTS. 

b. While there are barriers to physician engagement, the barriers are similar to what is seen in other industries. Healthcare can learn from the experiences of other organizations to break down the barriers and improve care.

References: Akbulut, Y., Esatoglu, A. E., & Yildirim, T. (2010). Managerial roles of physicians in the

Turkish healthcare system: Current situation and future challenges. Journal of Health Management, 12(4), 239-251.

Axelrod, R. (2011, May). Dealing with change: Engage your people or die trying. Leadership Excellence, 9.

Blum, J. D. (2005). Symposium on health care: Beyond the bylaws. Hospital-physician relationships, economics, and conflicting agendas. Buffalo Law Review, Rev. 459, pp. 1-21.

Chen, H. F., & Chen, Y. (2008). The impact of work redesign and psychological empowerment on organizational commitment in a changing environment: An example from Taiwan's state-owned enterprises. Public Personnel Management, 37(3), 279-302.

Chesluk, B. J., & Holmboe, E. S. (2010). How teams work-or don't-in primary care: a field study on internal medicine. Health Affairs, 29(5), 874-879. doi:10.1377/hlthaff.2009.1093

Evans, J., Hwang, Y., & Nagarajan, N. (1995). Physicians' response to length of stay profiling. Medical Care , 1106-1119.

Forthman, M. T., Wooster, L. D., Hill, W. C., Homa-Lowry, J. M., & DesHarnais, S. I. (2003, September/October). Insights into successful change management: Empirically supported techniques for improving medical practice patterns. American Journal of Medical Quality, 18(6), 181-189. doi:10.1177/106286060301800502

Hayes, J. (2014). The theory and practice of change management (4th ed). New York: Palgrave Macmillan.

Holmboe, E., & Cassel, C. (2007). The role of physicians and certification boards to improve quality. American Journal of Medical Quality, 22(1), 18-25.

Kornacki, M. J., & Silversin, J. (2012). Leading physicians through change: How to achieve and sustain results (2 ed.). Tampa, FL: American College of Physician Executives.

Kotter, J., & Schlesinger, L. (1979). Choosing strategies for change. Harvard Business Review, 57(2), 106-114.

Lazarus, R., & Folkman, S. (1984). Stresss, appraisal and coping. New York, NY: Springer. Lines, R. (2004). Influence of participation in strategic change: Resistance, organizational

commitment and change goal achievement. Journal of Change Management, 4(3), 193-215.

Lunenburg, F. C. (2010). Forces for and resistance to organizational change. National Forum of Educational Administration and Supervision Journal, 27(4), 1-10.

Mayfield, P. (2014). Engaging with stakeholders is critical when leading change. Industrial and Commercial Training, 46(2), 68-72.

Nyhan, R. (1999). Increasing affective organizational commitment in public organizations: The key role of interpersonal trust. Review of Public Personnel Administration, 19(3), 58-74.

Pardo del Val, M., & Fuentes, C. M. (2003). Resistance to change: A literature review and empirical study. Management Decision, 41(1), 148-155.

Reuben, D. B. (2007). Saving primary care. American Journal of Medicine, 129(1), 99-102.

Outline Examples - Focus:

Political Influence: Why and How Healthcare Leaders Must Get Involved

American College of Medical Practice Executives Professional Paper Topic and

Outline

FOCUS PAPER

Paper outline being submitted in partial fulfillment of the requirements for the election

to Fellow

PoliticalInfluence:WhyandHowHealthcareLeadersMustGetInvolved Advocatingforpositivechangeinthehealthcarearenaisoneofthemostimportantjobsoftoday’shealthcareleader.Becausehealthcareisahelpingprofession,manyplayerswithintheindustryarereluctanttowieldpowerandgetinvolvedinpolitics.Althoughtheprocessmayfeeluncomfortableatfirst,properpreparationandpracticecanhelponefeelcomfortableinthisimportantrole.Withtherightknowledgeandtools,anyhealthcareleadercanandshouldusehisorherpowerandpositiontoinfluencechange.ThispaperwillinformthereaderaboutthehistoryofadvocacyandlobbyingintheUnitedStatesandprovideimportantbackgroundinformationneededtobeaneffectiveadvocate.Additionally,thepaperwillreviewmultiplestrategiesandprovideimportantdetailstohelpleadersinhealthcarefeelcomfortableintheroleofapolicyinfluencer.Purpose:Thepurposeofthispaperistohighlighttheimportanceforhealthcareleaderstoengageinadvocacyeffortsandtoprovidestrategiesforsuccessintheseroles.1) BackgroundinformationaboutadvocacyandlobbyingintheUnitedStates

a) AdvocacyandlobbyingintheUnitedStates

i) Lobbyingandadvocacyofteninterchanged

ii) Protectedasafirstamendmentright

iii) Occursatalllevelsofgovernment

iv) USvs.othercountries

b) Howabillbecomesalaw

i) Itisimportanttobefamiliarwiththeprocess

ii) Billsstartasideasthatcomefrommanysources

(1) Alegislator’sexperienceandexpertise

(2) Issuebroughtforthbyconstituents

(3) Issuesbroughtforwardbyspecialinterestgroups

iii) Billiswritteninproperformat

iv) BillisintroducedbytotheHouseortheSenate,dependingonwhichchamber

thelegislatorwhoisintroducingitbelongsto

IF USING a, I, i, 1 TO SEPARATE THOUGHTS, KEEP IN MIND THEY SHOULD BE FOLLOWED BY A SECOND OR THIRD: b, II, ii, 2.  

v) Billisassignedtoastandingcommitteeformoreconsideration

(1) Thestandingcommitteeshaveafocusonparticularsubjects

(a) Billsabouthealthcaregotoahealthcommittee

(2) Theremaybesubcommittees

(3) Thebillismarkeduporamended

(4) Chairofthecommitteehasalotofinfluence

vi) Thebillgoestothefloor

(a) Thebillisargued,debated,andvotedon

vii) Ifthebillpassesinthechamberwhereitwasintroduced,itgoestotheother

chambertorepeattheprocess

viii) Thebillmovesontoaconferencecommittee

(a) ThedifferencesbetweentheversionsofthebillpassedbytheHouseand

bytheSenateareresolved

ix) Finally,thebillissignedintolawbygovernororpresident

c) Threelegsoflobbying

i) Professionallobbyists(firstleg)

(1) Usuallyrepresentspecialinterestgroups

(2) Expertswhoareimportanttolawmakers

(3) Membershipinprofessionalorganizationssupportprofessionallobbyists

(4) Over11,000registeredlobbyistsinWashington,DC

ii) Grassrootslobbyists(secondleg)

(1) Effortsattheconstituentlevel

(2) Oftenreferredtoasadvocates

(3) Grassrootslobbyistsmustbeorganizedandwell‐informed

(4) Importanttolawmakers

(5) Passingalawmaytakealongtimeandalotofcompromises

(6) Collaborationincreasesabilitytoinfluence

(7) Somegrassrootseffortsareoutsidethepoliticalarena

iii) Money(thirdleg)

(1) Thereareregulationsaboutmoneyinpolitics

(2) Lobbyspendingiswellover$3billion

(a) Nearlyhalfofthespendingisfromhealthcarelobbyists

(i) Pharmaceuticalandhealthproductscompaniesarenumberone

spendersat$230,693,261in2015

(ii) Hospitalsandnursinghomesarenumbernineat$92,893,765in2015

(iii) Healthcareprofessionalsarenumber11at$89,751,202in

2015

(iv) Professionalduessupportlobbyingefforts

2) Strategiesandtacticsforeffectiveadvocacyefforts

a) Healthcareleadersoftodaymustbestrongadvocates

i) Goodleadersarepassionateandactiveinpursuingthevisionfortheir

organization

(1) Animportantpartofhealthcareleadershipintoday’sworldis

understanding,influencing,andnegotiatinginthepoliticalarena

(a) Mustbuildrelationships

(b) Mustbemastersofinfluence

(c) Mustworktowardhavingastrongpowerbase

b) Therearemanywayshealthcareleaderscaninfluencepolicy

i) Vote

(1) Voteforcandidateswhosupportpoliciesthatyouareinfavorof

(2) Voteonmeasuresthatsupportyourpoliticalphilosophy

ii) Joinprofessionalorganizations

(1) Theyorganizelobbyingefforts

(2) Theyengageprofessionallobbyists

(3) Theyprovidememberswithinformationtohelpthemstayinformedabout

issues

(4) Theycreateopportunitiesforyoutobuildimportantrelationships

iii) Lookforwindowsofopportunitytotimeyoureffortsforthebiggestimpact

(1) TheKingdonModelexplainshowissuesappearonthepoliticalagendaand

howsolutionsareintroduced.

(a) Policystream

(i) Beattentivetoemergingpoliciestoattachyourselfandyourideas

(b) Problemstream

(i) Bealerttoproblemsthatcorrelatetoasolutionyouwanttopromote

(c) Politicalstream

(i) Beawareofpublicattitude,campaigns,electionresults,partisan

distributionincongress,andchangesinpoliticaladministration

iv) Network

(1) Engagelocalbusinessesandothercommunitymembers

(a) Buildrelationships

(b) Collaboratewithotherstakeholders

(c) Getinvolvedwithyourlocalchamberofcongress

(d) Beactiveinyourcommunity

(2) Makeyourselfavailabletoparticipateinfocusgroupsandcommittees

workingonissuesthatimpacthealthcarepolicy

(a) Bevocalaboutyourdesiretoparticipate

(b) Reachouttomeetingorganizers

(c) Reachouttoheadsoforganizationsthatwillbeparticipatinginthe

meetings

(d) Participateinanysurveysorrequestsforinformationasorganizers

prepareforthemeeting

(e) Ifyoucannotparticipateintheprocess,staywell‐informedabout

progressandprovideregularfeedbacktoorganizersandparticipants.

v) Reachouttolegislators

(1) Writeletters

(a) Havethebiggestimpactearlyinthelegislativeprocess

(b) Usestationarythatincludesyournameandaddress

(c) Canbeviaemail,fax,orpostalservice

(i) Postalservicemayhavethebiggestimpact

(d) Besuccinct

(e) Makeitpersonalizedyetprofessional

(i) Avoidformlettersforgreatestimpact

(2) Hostacongressionalsitevisit

(a) Showslegislatorstheimpactofpolicyonhealthcaredelivery

(b) Buildsrelationshipswithmembersofcongress

(i) Schedulethroughthedistrictoffice

1. Invitestaff,too.–preferablyahealthcarelegislativeaide

2. Allowflexibilityinscheduling

3. Beclearaboutthepurposeofthevisitandwhatyouwanttotalk

about

(ii) Prepareforaconciseyetmeaningfulvisit

1. Befamiliarwiththecongressperson’spositionsonhealthcare

issues

2. Selectareasofthepracticethathighlightyourpositionandbe

preparedtotalkaboutitduringthetour

3. Prepareaone‐pagedocumenttogivetovisitors

4. Offeryourselfasaresource

(iii) Otherthingstokeepinmind

1. Knowrulesaroundtheethicsregardingofferingmealsorsnacks

tomembersofcongress

2. Trytogetapicturewiththecongresspersonduringtheirvisit

3. Followthevisitwithathankyoucard

a. Reiterateyouroffertoserveasaresource

(3) VisitlegislatorsonCapitolHill

(a) Spendtimefocusingonthehealthcarelegislativeassistant

(i) Prepare–Beclearaboutwhatyouwanttoachieveandwhoyouneed

tomeetwith

(ii) Scheduleanappointment

(iii) Bepromptbutalsobepreparedtowait

(iv) Bringmaterialstosupportyourposition

1. Onepagesuccinctinformationsheetor“ask”letter

(v) Beclearthatyouhaveanissuetodiscuss

1. Relateyourpersonalexperience

2. Offertoserveasaresource

3) Conclusion

a) Advocacyeffortsareoneofthemostimportantthings

healthcareleaderscandotobringaboutpositivechange

inhealthcare

b) Understandthatyouhaveexpertisethatisvaluable

i) Growanduseyourpowerbase

c) Choosingnottoparticipatesendsamessagetolegislators

d) Alleffortstoinfluencehealthcareaddup

i) Eventhesimplesttaskofvotinghasanimpact

e) Healthcareleadersmustcollaborateforthegreatesteffect

f) Beingastrongadvocatetakepreparationandpractice

i) Worththeeffort

ii) Itisourresponsibility

NEED TO DISCUSS THE IMPLICATIONS IF WE DON’T BECOME INVOLVED IN THE LEGISLATIVE PROCESS. 

CONCLUSION NEED TO BE PRESENTED IN A PARAGRAPH, NOT 

BULLET POINTS. AUTHOR NEEDS TO ADDRESS 

WHAT THEIR PEERS WILL LEARN / ACT UPON FROM THIS PAPER 

ReferencesAbood,S.(2007).Influencinghealthcareinthelegislativearena.OJIN:TheOnlineJournal

ofIssuesinNursing,35(2),Manuscript2.doi:10.3912/OJIN.Vo;12No01Man02AMA.(n.d.).HowtomakeyourvoiceheardinCongress.Retrievedfrom

https://savegme.org/sites/default/files/communicating‐with‐congress.pdfBolster,C.J.,&Larrere,J.B.(2012).Thenextgreatexplorers.Trustee,65(2),19‐21.

Retrievedfromhttps://www.researchgate.net/publication/223994010_The_next_great_explorers_only_the_bravest_most_skilled_leaders_will_discover_health_care's_new_world

Demko,P.(2014).Howhealthcare’sWashingtonlobbyingmachinegetsthejobdone.ModernHealthcare[onlineedition].Retrievedfromhttp://www.modernhealthcare.com

Glabman,M.(2002).Lobbyiststhatthefoundersneverdreamedof.ManagedCare[onlineedition].Retrievedfromhttp://www.managedcaremag.com

Hacker.(2016).InMerriam‐Webster.com.RetrievedApril26,2016fromhttp://www.merriam‐webster.com/dictionary/advocacy

Kovner,A.R.&Knickman,J.R.(Eds).(2011).HealthcaredeliveryintheUnitedStates (LaureateEducation,Inc.,customed.).NewYork,NY:Springer

MADD(n.d.).Acasestudyon“grassroots”lobbying:HowMADDfixedtheflawinHawaii’sdrunk‐drivinglaw.MADDpublication.Retrievedfromhttp://www.innonet.org/resources/files/MADD.pdf

Madden,M.(2013).Top10skillsofhigh‐performinghealthcareleaders.B.E.Smith[online].Retrievedfromhttps://www.besmith.com

MGMA(n.d.‐a).CapitolHillvisit:Aguidetograssrootsadvocacy.MGMAResources [online].Retrievedfromhttp://www.mgma.comMGMA(n.d.‐b).Hostingacongressionalsitevisit:Aguidetograssrootsadvocacy. MGMAResources[online].Retrievedfromhttp://www.mgma.comMGMA(n.d.‐c).MGMAadvocacycenter:Togetherwecanmakechangehappen. MGMAResources[online].Retrievedfromhttp://www.mgma.comMilbreth,L.(n.d.).Lobbying.Encyclopedia.com.RetrievedonApril28,2016from

http://www.encyclopedia.comMilstead,J.A.(Ed.).(2013).Healthpolicyandpolitics:Anurse'sguide(Laureate

Education,Inc.,customed.).Burlington,MA:Jones&BartlettLearning.Milyo,J.(2010).Mowingdownthegrassroots:Howgrassrootslobbyingdisclosure

suppressespoliticalparticipation.InstituteforJustine[online].Retrievedfrom https://www.ij.orgOpenSecrets.org(2016).Lobbyingdatabase[online].RetrievedonApril26,2016from

https://www.opensecrets.org/lobby/index.phpOMA(2015a).Protectingthedeliveryofqualityhealthcareisonallofus.Medicinein

Oregon8(4),6.OMA(2015b).SGRmakesexitstageright–andanewactbegins.MedicineinOregon8(3),

14‐16.OMA(2015c).TheOregonMedicalAssociation’s2015legislativereport. OMA[online].Retrievedfromhttp://www.theoma.orgReimer,M.E.(2011).Thevoiceofdemocracy:Grassrootsadvocacy.[Professional

manuscript].Retrievedfromwww.mgma.com

Taylor,R.G.,&Lynham,S.A.(2013).Systematicleadershipforsocio‐politicalstewardship.SouthAfricanJournalofBusinessManagement,44(1).Retrievedfromhttp://thoughtprint.usb.ac.za/sajbm/Journals/ 

Outline Examples- Historical:

Title: The Emergence of the Quadruple Aim and the Need To Address Clinician Burnout As A Critical Strategic Initiative

Submission Date: June 2, 2017

American College of Medical Practice Executive Professional Paper Topic and Outline – HISTORICAL

Paper outline being submitted in partial fulfillment of the requirements for election to Fellow

American College of Medical Practice Executives

Professional Paper Topic and Outline: HISTORICAL

Title: The Emergence of the Quadruple Aim and the Need to Address Clinician Burnout As A Critical Strategic Initiative

In October 2007 the Institute for Healthcare Improvement (IHI) launched the Triple Aim

initiative, designed to help health care organizations improve the health of a population, improve

the patients' experience of care, while lowering—or at least reducing the rate of increase in—the

per capita cost of care. The premise was that pursuing these three objectives at once allows

health care organizations to identify and fix problems such as poor coordination of care and

overuse of medical services. It was also intended to help them focus attention on and redirect

resources to activities that have the greatest impact on health.

The Triple Aim has become an iconic moniker for where healthcare strives to be and it’s hard to

argue against their merits. However, ten years later it may be time to modernize the concept. As

first brought to light by Drs. Bodenheimer and Sinsky in 2014 in an Annuls of Family Medicine

article, they proposed replacing the Triple Aim with the more appropriate and realistic title of

Quadruple Aim, and proposed that without improving clinician and caregiver experience the

original three goals of the triple aim aren’t likely to happen. (Bodenheimer, Sindsky, 2014)

In addition, a growing amount of research is highlighting alarming levels of burnout of

physicians and other clinicians, and its implications for diminishing the ability of individuals to

provide optimal levels of quality, further emphasizing the need for organizations to incorporate

improving the clinician environment though recognizing the need for a Quadruple Aim.

After a brief summary of the history of the Triple Aim and introduction of the Quadruple Aim,

the author will provide a review of the current healthcare environment, most notably the growing

published evidence that clinician burnout is reaching epidemic levels and beginning to impact

patient care. This will include exploration of the drivers of clinician burnout and what

organizations are doing to recognize and address it. At the conclusion of this paper the author

will provide recommendations for how organizations can incorporate the Quadruple Aim as one

of their key strategic initiatives.

OUTLINE:

I. Introduction and Background

II. Review of the Triple Aim A. Definition

1. Improve population health 2. improve patient experience 3. Lower medical costs / slow the increase

in medical costs B. Its genesis

III. Review of the literature regarding the Quadruple Aim from 2014 to today A. Drs. Bodenheimer and Sinsky paper B. Additional articles and editorials

1. “Quadruple aim: care of the provider” 2. “Burnout and satisfaction with work-life balance among US

physicians relative to the general US population” IV. The Emergence of the Quadruple Aim Concept

A. Definition: Improving physician and caregiver experience B. Why the Triple Aim must turn into the Quadruple Aim C. Scope. Is the 4th aim only for physicians?

V. The growing challenge of physician and nurse burnout A. Drivers and contributors of burnout B. Implications of burnout C. Reduction in physicians in work force

VI. How organizations are addressing clinician burnout A. Measuring burnout and engagement B. Common strategies to address burnout

1. Flex hours

THE BULLET POINTS SHOULD BE EXPANDED TO INCLUDE A MORE 

IN‐DEPTH DISPLACE OF THE TOPICS TO BE DISCUSSED IN THE 

MANUSCRIPT.  THESE SHOULD BE COMPLETE SENTENCES. 

2. Reduced hour work weeks 3. Reduced on-call 4. Stress management

VII. The association of the Quadruple Aim and organizational strategy

A. Why it should be a strategic priority B. How to incorporate the Quadruple Aim into strategy

VIII. Conclusion A. Do the initial conclusions/recommendations of

Bodenheimer and Sinsky still hold true? B. Ways to further awareness of the Quadruple Aim

concept throughout the health care industry C. Lessons learned

1. Importance of addressing provider and caregiver stress 2. Return on investment in addressing the Quadruple Aim

THE CONCLUSION SHOULD BE IN PARAGRAPH 

STRUCTURE. ADDITIONALLY, WHAT LESSONS SHOULD THE AUTHOR’S PEERS LEARN FROM THIS DOCUMENT? 

Bibliography The IHI triple aim initiative. Institute for Healthcare Improvement. http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx Accessed May 1, 2017. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs (Millwood). 2008; 27:759-769. Build joy in work and prevent burnout. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/AudioandVideo/WIHIRaisingJoyintheHealthCareWorkforce.aspx Published July 9, 2009. Accessed May 1, 2017. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Annuls of Family Medicine. 2014; 12:573-576. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine. 2012; 172:1377-1385. MedScape lifestyle report 2016: bias and burnout. Medscape. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview Published January 13, 2016. Accessed May 10, 2017. Patients or paperwork? The regulatory burden facing America’s hospitals. American Hospital Association. http://www.aha.org/content/00-10/FinalPaperworkReport.pdf. Accessed May 10, 2017. Keefe B, Katz M. Quadruple aim: care of the provider. Healthcare Leadership Blog. https://hcldr.wordpress.com/2015/07/18/quadruple-aim/ Published July 18, 2015. Accessed May 10, 2017.