Rethinking care: How ‘de-implementation’ can improve quality and reduce burnout

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In this episode of Well-Being at Michigan Medicine with Dr. Elizabeth Harry, Dr. Eve Kerr explores the concept of de-implementation—scaling back unnecessary tests, treatments, and administrative hurdles. Kerr shares how eliminating low-value practices can reduce clinician overload, lower patient costs, and improve overall health outcomes. Discover how both healthcare organizations and local frontline teams can foster a culture of high-value care by eliminating outdated processes.

Guests:

• Eve Kerr, M.D., M.P.H., MACP

Transcript

Elizabeth Harry: 

Welcome to the Well-Being at Michigan Medicine Podcast, the show where we dive into forward-thinking conversations that are reshaping the future of healthcare. I'm your host, Dr. Elizabeth Harry. And today, we're exploring a topic that affects every patient, clinician, and healthcare leader. The urgent need to de-implement low-value care, reduce unnecessary work, and support real well-being in our healthcare workforce.

Our guest is Dr. Eve Kerr, professor and division chief of general medicine at the University of Michigan Medical School, founder of the Michigan Program on Value Enhancement or MPrOVE, and a nationally recognized leader in healthcare value and workforce well-being. Dr. Kerr has devoted her career to building sustainable systems that prioritize high-quality care and the thriving of both patients and clinicians.

Join us as we discuss how eliminating unnecessary processes can drive both better care and a healthier, more resilient workforce. We'll talk about practical strategies, leadership insights, and what it takes to foster real change from the frontlines to the executive suites. Let's jump in and welcome Dr. Kerr. Thank you so much for joining us.

Eve Kerr:                             

Thank you for having me.

Elizabeth Harry:                

So, I am so excited for this conversation. And as we get started, can you just share a little bit about your background, particularly your research focus, and how you got interested in the areas that we're going to talk about today?

Eve Kerr:                             

So, I got into thinking about issues of de-implementation because I was thinking about issues of quality of care. And my research for the past 30 plus years has focused on improving quality of care for patients in the healthcare system, and especially for patients with chronic conditions. And so, I spent a lot of time measuring quality of care and measuring value in healthcare. And I began to realize that all the time we focused on doing more things, but that there were a lot of things in healthcare that we should actually stop doing because they didn't improve value for patients.

So, again, I was thinking about those types of things. And then there was a movement in healthcare called Choosing Wisely. And this was in around 2011, I think, when it started. And I started to get really interested in that because it was really about choosing the best healthcare approaches depending on the patient's situation. And that often meant not doing something. That often meant or stopping something, because it didn't improve outcomes for patients.

And so, a lot of my quality work then started to focus on how do we stop doing low-value care? And then, that actually led me to be thinking about, "How do we stop doing low-value everything in healthcare, not just clinical practices, but also administrative practices?" And that really got accentuated for me when I became vice chair for well-being in our very large department during the pandemic. And I saw how difficult it was for our clinicians in our department to navigate the pandemic, how much work was put on them, how much burnout.

And then when I became division chief in 2021 in the division of general medicine, our faculty, our clinicians were just really overwhelmed. They were really burnt out. And that became my calling. How do I apply all this research that I had done in quality and value to also support the healthcare workforce?

Elizabeth Harry:                

Oh, I love that. Well, let's start simple. So, we're talking de-implementation. So, what does that mean and why does it matter now?

Eve Kerr:                             

Yeah. That's a really great question. When I refer to de-implementation for patients, I'm really thinking about treatments, procedures, services that we should stop doing, or maybe we should do less of because those tests don't benefit patients or they may in fact harm them. So, for example, we can de-implement getting routine blood tests before lower surgeries like cataract surgery, because those tests don't help improve outcomes for patients, but they take patient time and they take money.

There's also de-implementation for clinical practices, like what we do in the clinic, like routine administrative functions that don't benefit patient care. So, another example, we can de-implement requiring pre-authorization for services that almost always get approved. Why do we put in pre-authorization requests for that? We can save doctors and staff time and we can limit frustration for patients. So, basically, de-implementation is stop or scale back, doing things that don't help patients, but they do cost money or time or potentially even cause harms.

Elizabeth Harry:                

I just love this focus. It feels like so often we're having conversations about starting this new program or doing this new thing and not often pausing to say, "Wait a minute. What do we already have in place that we should stop doing, particularly as we're adding all of these things?" And I also really, really love the focus that you're bringing to this, that it helps the team because we're getting rid of waste, we're getting rid of administrative burden, and it really fundamentally helps our patients get better care. Can you tell us a specific example where our patients got better care because of something that was de-implemented?

Eve Kerr:                             

Yeah. Let me give you an example, actually, from our own research. This was research that Dr. Jeff Kullgren and I did together. And we did a study in our own clinics here at the University of Michigan to stop or scale back unnecessary tests and too many medications for older adults. So, we actually focused on decreasing the number of medications and the type of medications for patients with diabetes who are already in good control, but often they were on so many medications that their blood sugars might go too low.

And so, we were able to decrease the load of medications for these patients and decrease the risk of low blood sugar. So, it was really a win-win. And it was also a win for our doctors, because we helped patients. We gave them information, education. And a lot of times, the patients would then come in and ask their doctor, "Hey, do I really need medication X? Maybe I don't really need it." So, it helped the doctors. The doctors didn't have to remember it. They didn't have to explain these things to their patients either, because we had already done that. And the patients sometimes wound up having to take fewer medications and having better health.

Elizabeth Harry:                

Yeah. And I love this because it really highlights a win-win and that it is, it's easier for our patients, if they have fewer medications that they have to remember and better for our healthcare system, in general, from a cost standpoint, from a workflow standpoint, even just refilling those medications for our providers. And yet this isn't the norm. This isn't the behavior that we see people doing regularly, sort of thinking about, "What is it that we can de-implement?" And so, why is it do you think that de-implementation is either hard to do or it's not the first thing we think to do within an organization? What makes de-implementation hard?

Eve Kerr:                             

Yeah. I think that's so important, because it is really hard. And there isn't just one thing that makes it hard. So, as a doctor, when a patient comes to me, I don't always know the right thing to do. And I think it's most of us tend to err on the side of doing something. And in that maybe there's a concern about liability. Well, if I don't get this test or I don't start this medication? But sometimes what's best for the patient is not to do that thing, to actually wait to see how they're doing. Or maybe doing that thing might actually cause side effects. So, we have to think harder.

And in the moment, we sometimes don't slow down and take that time to think. We are on the side of doing something. It's also, there are system level incentives, you already alluded to that, to do more. Sometimes the system will get paid more for a test or a CT scan or what have you. And that gets integrated into the way that we teach healthcare and the way we practice healthcare. So, again, we have to think harder when not to do something or to stop doing something.

And once something becomes routine to say, "Oh, you don't need that medication anymore." We often, we just don't think about it. And so, it takes active brain power to say, "Oh, yeah. Maybe we can stop that. We don't need to screen you for this anymore, because it's been normal for so many years." That takes active thought. I think the other thing is we think we're doing what patients want. We think that patients always want more care. And that's actually not true.

We did a survey some years ago of patients asking them, "Do you think that your doctor sometimes orders too many tests?" And in fact, they do. Patients don't always think more care is better. And so, some of this is communication. We might be more on the same page than we think with our patients, but we're not always communicating about that.

Elizabeth Harry: 

Well, and it's so important, because currently, I think we all feel really overloaded. And there was that great recent study looking at if we were to do everything evidence-based for a primary care provider, it would take us 26 hours a day. And even if we have excellent team-based care, it would take over nine hours a day on an average patient panel size. And so, I often think folks are overloaded. They have so much going on that they're trying to manage. It feels like so much is coming at you. We know there's a relationship between being overloaded and feeling burnt out.

And my observation has been that sometimes when people are overloaded, to your point, there isn't that time or space to slow down and be thoughtful. And actually, sometimes you can go faster by going slower to create that time to say, "We don't need all of these extra pieces." And so, I'm curious, as you're looking at the value of de-implementation, as you're looking at this value of simplifying in a lot of ways, how do you measure that in a way that not only connects it to patient outcomes, but also to clinician well-being and identifies that this simplicity is truly a win-win?

Eve Kerr:                             

Yeah. I really love this question because it allows us to talk about like, "What really is value in healthcare?" When we're thinking about healthcare value, the classic teaching is that we think about outcomes and how much it costs to get a good outcome. And so, it's really outcomes is on the numerator, cost is in the denominator, and that's it. But there's so much more to healthcare value. And you already alluded to some of those things. There's how patients experience their healthcare. And that is a huge component of healthcare value.

And there's also how clinicians experience their jobs and the work that they do and whether they take joy in their work. And that is a huge component of healthcare value. Those are all things we can measure. We can measure patient outcomes and we can measure costs, but we can also measure patient experiences and we can also measure clinician experiences. And we should be doing that, because they're all linked together.

So, physicians who feel professionally engaged and not overwhelmed by administrative burdens, they can spend more time with patients. And then they can have those important conversations that we just talked about, and they can have the ability to make better decisions. And then that leads to better healthcare outcomes. And it often also leads to lower costs, because maybe we aren't doing those unnecessary tests, procedures, or treatments. So, really looking much more holistically at what healthcare value means and measuring it along the way is really important.

So, this focus on quality and value, that's one of the reasons that I founded the Michigan Program on Value Enhancement, which is a collaboration between the Institute for Healthcare Policy and Innovation and the health system and particularly the quality department. And we really focused on a program that was designed to help us de-implement and right size care within our health system.

One of the initiatives, for example, was to decrease doing blood tests before low-risk surgery. So, patients don't have to come in and get their blood tests. Sometimes they don't even need to come in to get a physical exam for low-risk surgeries. That's a waste of their time and resources if we already know that they're healthy in general. And because for low-risk surgery, like cataract surgery, it doesn't improve outcomes. So, the Michigan Program on Value Enhancement is a great program that helps leaders really focus on these issues.

Elizabeth Harry:                

And that's the MPrOVE.

Eve Kerr:                             

MPrOVE. Yeah.

Elizabeth Harry:                

Yeah. That's amazing. And it sounds like measuring that is a really important, almost temporizing measure to this feed forward cycle of the complexity, increasing and increasing and increasing. And then it feeds on itself. Because as the complexity increases and we're more overloaded, we're less likely to pause, we're less likely to check, we're less likely to have the conversations with our patients that might identify this alignment around wanting fewer interventions or fewer testing and that sort of thing.

So, if someone's listening to this now and they're like, "Ah, this is what my day feels like. This is what my clinical experience feels like. I really feel like there's a lot of opportunity for de-implementation for my team." What could an on the ground frontline team do to start a project that would address burnout, pushing forward high-value care, maybe by de-implementing? What would be something they could do on Monday after listening to this that you would advise?

Eve Kerr:                             

Yeah. I think I'm going to give two levels of answers to that question. So, one is, what can the organization do as a whole? And then the other is, what can teams do? And because I think we need both those pieces and really be able to make a dent. We actually did this at Michigan Medicine a couple of years ago. We tried a program that was called Choosing Wisely to Preserve the Clinician Workforce. And it was loosely tailored after a American Medical Association program called Stop Doing Stupid Stuff, which I love. I know you've heard of it too. And it makes so much sense. We know in our administrative practice, there's a lot of things that are just stupid. We don't need it. Let's get rid of those things.

So, for example, fix automatic order sets that are outdated. Or remove ordering options for tests that shouldn't be routinely ordered. Shorten or eliminate learning modules. All the learning modules that clinicians have to do. Some of them are no longer relevant. But again, they don't get removed. And we have removed a lot of them at Michigan Medicine over the last couple years. So, removing stupid stuff, that goes a long way towards helping physicians and teams be able to focus on important stuff. That's the patient.

And in the long game, we also, I think, need to socialize the fact that we don't always need to order tests and procedures to get the best outcomes for patients. And we don't necessarily do that enough when we teach our medical students and our residents about these kinds of things. So, I think organizations at a high-level have a really important role here.

But what you asked specifically is what can teams do? And I think we need to think about what teams can control. And a lot of what teams can control is how they work together. And so, I think one of the things that I know Michigan Medicine is working on is making sure that the right person is dealing with the right issues at the right time.

So, teams are composed of members with various expertise, but sometimes we don't allow some of the team members to work to the top of their abilities while other team members, like physicians who should be focusing on the patient and being a doctor are dealing with filling out forms. Like, "So, how can we get the right person to be dealing with the right issues at the right time?" And communication is also key to that. And being able to define roles and work together is really key to that. So, that I think is something that all teams can work on in real-time.

Elizabeth Harry:                

Yeah. And what I love about that model is a couple things. One, I've actually heard Christine Sinsky, our former VP of professional satisfaction from the AMA often say that it's actually, we have this though that it's safest to have physicians do every task, but it's actually not safer because then we're overloading them and they can make a mistake in the critical tasks with the medical decision-making that we're asking them to do. And they are not actually best qualified to do a lot of the tasks.

And so, making sure that we have the member of the team that is best qualified to do the tasks. And some of the cool work I've seen recently is even looking at how many times does a message get touched by a member of the team and which member of the team is it that's doing that? And does it go around and around in circles or do we really have a clear process there? And what I love about what you're saying, too, is this idea of controlling the controllables. A lot of times it can feel like all these decisions are made out there and they're far away from us and we have no agency, but we are humans working together on teams that can talk to one another and make decisions to work differently together.

And I've seen such local variability in the way teams work together, because some really do take it upon themselves to say, "What's the very best way we can do this?" And really empowering and championing those local teams I think is huge. I love that. And so, let's say you do have ... You gave an example of some order sets that maybe aren't being routinely pruned. Part of this is having systems in place to reevaluate and re-look over things and make sure that we're regularly pruning things.

Let's say we have entrenched practices that are, "This is how we've always done it. And maybe because of new technology or because of new medical knowledge or whatever, that's not the way we need to do it anymore." How do you help people retire in entrenched practices without tanking morale or helping them feel supported through that process?

Eve Kerr:                             

Yeah. It's so important to implement anything new in a way that people embrace. And sometimes it is harder when you're pulling back on things, but it actually depends on what it is. If we're stopping to do stupid stuff, I think everybody can get on board with that. Everybody can go say, "Oh, my God. I'm so glad we don't have to deal with that order set anymore." So, usually, that improves morale.

But if we're really changing ... So, we haven't even talked about the in-basket. And of course, the in-basket is huge for the amount of time it takes for teams, clinicians, physicians to respond to all the volume of in-basket messages. So, one of the things, in fact, members of our team have tried to do is figure out how to get messages to the right person. And that person isn't always the doctor first. It might be a medical assistant, it might be a clerk, it might be a nurse. And you need those processes to standardize those processes. And that has really helped.

But some physicians might say, "But wait a second. There are messages I'm not even going to see. I'm used to seeing all my messages. I want to be sure I get the right answer to the patient." And even though they know that they're flooded with messages, it's hard for them to give it up.

Elizabeth Harry:                

Yeah.

Eve Kerr:                            

So, I think also having processes that let them know that, "Hey, if something's really complicated, you're going to see it. If there isn't an easy protocol for it, you're going to see it. It's going to be okay for your patients." So, we really have to think about the unintended consequences also and how to address those when we're making these new processes.

Elizabeth Harry:                

Yeah. To get to your earlier point on teamwork, it's about teamwork and trusting your team. It's really about a high-functioning team where there's high trust. And so, you trust the other team members to do their job. And so, in order to do that, we can't have any one member managing everything. It's not sustainable, I think, anymore, given the volume and the complexity that we're dealing with.

And so, it strikes me that you're talking about things that need really intentional structure and oversight to make sure there's a regular looking at our processes and pruning. There's these complex interdisciplinary team dynamics that we need to be tracking and thinking about how are we cultivating these teams that work really well together and that understand their roles. These are really strong leadership competencies. And I'm curious, as you've watched this go well or not go well in different areas, what specific behaviors or leadership behaviors do you note that really seem to be most effective to move the needle on these system changes that can drive clinician experience and care team experience in the positive direction?

Eve Kerr:                             

Yeah. I would say I think if leaders continually think about right sizing the work, that's an automatic question. How do I right size this work? How do I make sure that the right person is doing the right work at the right time? So, whenever a new piece of work comes in, "Oh, now we need to change the way that we do vaccinations. Or now, we need to change the way that we administer something in the clinics." Ask that question. How do I right size this work? Because otherwise, it winds up just getting either randomly put on somebody or just nobody's thought about it and it may not get done efficiently. So, I think if we're thinking about that front and center, we'll put that into our workflows. And I think often that's what gets missed.

Elizabeth Harry:                

Yeah. And it's this intentionality that you're really speaking to, being mindful and intentional as we're building these systems and leading people. And it reminds me a little bit. I remember a study I saw where they had a Lego figure and then a bunch of Legos. And there was a Model A and a Model B, and the task was to make Model B look like Model A. And they gave the Lego figures to a bunch of kids. And it was very obvious to the kids that in order to do that, you just popped a couple Legos off of Model A, and it would look like Model B.                                   

But for these adults, they kept trying to add pieces to Model A to make it look like Model B. And there was something about the way that we had learned or been enculturated where we just couldn't see that the solution was actually taking things away and that it would make it work better. And what I love about this whole message is maybe the answer is not in more. Maybe it's in less. And maybe it's not in a new program or a new system, but maybe it's in looking at the people we already have and how they're working together. And is there something that we can take away there or make it more efficient?                     

And so, as we see this proliferation of organizations adding programs and adding technology and adding systems or adding apps, how do you make this case to think about, "Well, maybe the answer is in removing or maybe the answer is in simplifying or maybe the answer is in focusing on the people?"

Eve Kerr:                             

I actually think we need to ask the people doing the work. Because I think the people doing the work, if we crowdsource, like, "What should we stop?" They'll tell you. They know what's redundant. They know why have I touched this message four times and the patient still doesn't have an answer? And I think that when we ask the frontline providers and then listen and take their opinion seriously and then start to implement and evaluate and say, "Okay. Look, we did it. We saved patient's time. We saved clinician's time. We improved outcomes. Let's do it again. Let's do it for something else." And so, kind of build on those successes.                 

Often, we do really good things, but we don't broadcast that we did it and then nobody knows. And I think that is also a mistake. And I know we don't like to necessarily talk about, "Oh, we did this great thing. But maybe we should be. We should be doing that more."

Elizabeth Harry:                

I love that. And I am aware both at the system level of some crowdsourcing that went on to ask people about these administrative burdens and efforts to address some of them. And then I've seen, we have a couple of our departments standing up programs around this, asking the frontline. In fact, I know of one that opened recently that got, I think, eight submissions within the first week it was open of, "Here's a stupid thing that you could get rid of."     

And getting back to one of your earlier points, I do think this is one of those things that local teams could do, too. Just really crowdsourcing their teams, even at the clinic level. What are the top three things that we could focus on getting rid of or reducing and really empowering local areas to do this so that it can scale? Because I think so much of this is so local. So, as we look ahead ... I mean, this is really exciting work and it's very needed. I mean, I think as things just feel more overwhelming and more overloaded, just this idea of simplicity and de-implementation, it's almost soothing. It's soothing to think of like, "Let's just make it a little bit calmer."                                      

But it's also really challenging. This is hard work and hard change management and operational work. What keeps you in this work and what are the moments that give you energy to keep wanting to look at new projects and tackle new ways to make the systems better?

Eve Kerr:                             

Yeah. Sometimes it does sap your energy, for sure. But as a primary care doctor, and I'm also chief of a division with amazing faculty, amazing staff, they show up for their patients every day. And I want the system to work for them. I want the system to work for our patients. And when I see the tremendous pressure that they're under, they work nights, they work weekends, I know there's ways to make this better. And it's make it better for everybody. So, that's really what keeps me going.

Elizabeth Harry:                

Yeah. You can see a better state for them. Yeah. And I really feel that, too. I have a similar feeling where it's just you know how much people are struggling and that can be really motivating, because it is hard to even watch sometimes, especially when you see that data of how many hours people are putting in. So, if we were to think about some trends we're seeing or some new things we're seeing or maybe even policy shifts, what makes you optimistic about care value and workforce well-being moving forward?

Eve Kerr:                             

Yeah. I guess I always think about, like, "Well, what if I had a magic wand?" If I had a magic wand and there are some movements towards this, but I think it is still going to take a little bit of magic. I think there will be a better payment system, especially for primary care physicians so that primary care receives more recognition for the work that primary care doctors do. I also hope that will mean better staffing, for example, in our clinic so we can really build these teams that we've been talking about and better access to care for patients.                        

But fundamentally, some of that comes from our payment system. And there's a lot of discussion about that now in national policy. So, I do keep hoping that that will move forward.

Elizabeth Harry:                

Yeah. Yeah. I agree. And I also, I'm hopeful about some of our innovations around AI and things like that, that even though it's a program we added, I do think it's de-implementing in some ways, because it's taking away some of the administrative burden of writing the notes. Although, obviously, there's always a human in the loop and the need to edit the notes and review it. So, it's a different skillset, but I think we are seeing some decrease in cognitive burden associated with that and I'm hopeful about that.

Eve Kerr:                             

Yeah. I think you're really right. The doctors in my division that I've been speaking to, a lot of them have said that implementing the AI scribe has been life-changing, because they can leave the office and most of their notes are done. And yes, of course, they read the notes, they edit them. It's not just done because AI has said it's done. But it saves them so much time. And some of them have said it saves them a couple of hours a day that they can leave the office and actually be present for their families when they go home.

So, there's a lot of good things like that happening on the horizon and the fact that Michigan Medicine has invested and it is an investment in this for the whole system now. That's huge. Not a lot of medical centers have done that. And I know that there's other great things on the horizon that hopefully will also streamline work.

Elizabeth Harry:               

Yeah. I'm also very hopeful. So, we're going to do a couple quick hits. So, a myth to ditch. What is one widespread myth about de-implementation that you would love to retire?

Eve Kerr:                             

So, I don't know if it's about a myth about de-implementation per se, but I think what I would love to retire is the more is better myth. And sometimes I think in visuals and Canada had this great campaign in healthcare that was more is not always better. And they showed this visual of a washing machine with just like suds coming out of it. Just a lot of soapy foam streaming. And you can just say that like, "Okay. We need laundry detergent, but we need just the right amount. We don't need too much of it. More is not always better."

Elizabeth Harry:                

Yeah.

Eve Kerr:                             

And so, I think we need healthcare tailored to patient needs and preferences. And we need the right treatments for the right patient at the right time. Not more. More is not always better. So, that is a myth I'd like to really retire, which allows us to get to de-implementation.

Elizabeth Harry:                

I love that. I love that. You think about your house. You can't just infinitely bring things into the house. You would be in trouble if that were the case. And so, being judicious about that. So, if we were to think about a digital playbook, if you will, a tool, a template, a metric, or something that you'd share with every clinical leader tomorrow, if you could, what would it be?

Eve Kerr:                             

So, I'm going to go back to one that we've already talked about, which is crowdsourcing. And I think if every clinical leader went to the frontline and said, "How can we help you? What can we stop doing that isn't needed?" And implemented that.

Elizabeth Harry:                

Yeah. Yeah.

Eve Kerr:                             

One thing a month. That also, I think, will have the staff and clinicians at the frontline feel like they're being heard. And it also is a way to improve communication in the team, because you can even get the team to decide and prioritize together. So, I think I would focus on that.

Elizabeth Harry:                

Yeah. I love that. The sort of nothing about me without me mantra. And if listeners try one sort of stop doing experiment this month, what should it be, do you think?

Eve Kerr:                             

Well, what I would like is if health plans did a stop doing experiment and focused on which pre-authorization they could get rid of.

Elizabeth Harry:                

Oh, I love that.

Eve Kerr:                             

So, which pre-authorizations always get approved 90% or really shouldn't be there? And let's take that burden off our clinicians and our staff to put in these pre-authorizations that they don't need. So, it's not always on us. There's also others in the healthcare system that can stop doing experiments.

Elizabeth Harry: 

Yeah. And really sharing this mindset across all key stakeholders. Yeah. That we want to be judicious with our resources, including our time and our attention, which are really valuable resources, and we want to make sure that we're respecting them. So, thank you so much, Eve, for your vision and dedication to building a healthcare system where value, well-being are possible for everyone, patients and professionals and care teams alike.

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