Coach, Patient Advocate, and CMO
Two women sitting across a small conference table from Glenn Focht, MD, looked ready for his next remark. They had just delivered an update on two of Boston Children’s Hospital’s 85 office practices that Dr. Focht oversees as Chief Medical Officer of the hospital’s primary care network.
His gentle, smooth voice began, “This is really great stuff, and it’s going to help us do better with our kids and ultimately save lives.” Looking up from their notes, Amy Armata and Farah Jooma glanced at each other, smiled slightly, and continued their report.
The moment encapsulates Dr. Focht’s mission in medicine and his philosophy of working with people. Nobody leaves a meeting he runs without a compliment, and most meetings—like most of his work—address ways to improve patient care.
It is a mission that has taken him from a life as a minister’s son in rural, impoverished Pennsylvania, to leading primary care practices at one of the premiere children’s hospitals in the world. An internist, he shifted his focus from direct clinical care to patient safety and quality more than ten years ago.
His career has been driven in part by a personal tragedy that unfolded in front of his eyes, on the bedroom floor he shared with his older brother growing up. In the 1970s, his teenage brother started showing signs of serious mental illness. During one difficult night, Dr. Focht woke to see his brother on the floor seizing.
“He suffered permanent brain damage because the medicine that he had received was one of the early tricyclics and somewhere between the prescription pad and the dispensing from the pharmacy, there was an unintended overdose. He had received a dose that was about 10 times higher than he was supposed to. So this kid, who was a trumpet player and pianist and a very skilled high school athlete, came home months later unable to tie his own shoes, with permanent motor defects, short-term memory gaps, and his life changed forever and so did my family’s.”
Dr. Focht’s brother is leading a productive life today, but the family’s experience is one of the drivers of his patient safety work at Boston Children’s, as he strives to prevent other families from having a similar experience.
The work may not look like what he first imagined. No one in his family’s circle were medical professionals. When he was three years old, after a bee sting sent him to the hospital, a very young Glenn Focht decided to become the first doctor in his family. His brother’s later medical mishap further solidified his goal, despite the skepticism of even some school counselors. Medical school at University of Pennsylvania, residency at University of Massachusetts Medical Center, and eventually senior leadership roles at Central Maine Medical Group and Cooley Dickinson Hospital in Massachusetts followed.
Over time, while he loved directly caring for patients, Dr. Focht also discovered a talent for looking over the horizon—seeing how care comes together more globally and how cascading events are linked. When Boston Children’s Hospital offered him the chance to apply his skills to patient safety work, he jumped at the opportunity to have a greater impact. He now serves as CMO of Pediatric Physician’s Organization at Children’s (PPOC), the hospital’s affiliated primary care network, with 280 physicians, 120 NPs and PAs, and about 400,000 patients at practices from Nantucket to the New Hampshire border.
The settings range from “micropractices” with a single physician and one medical assistant for 300 patients, all the way to practices with 26 providers caring for 40,000 children. Their populations vary widely as well, representing nearly 200 languages used by patients receiving care.
Improving Ambulatory Care and Patient Advocacy
Dr. Focht sees a major function of his job is to marshal resources to help each of these practices develop ways to improve and evaluate their performance.
“I honestly believe that every one of us who works in health care should have a two-part job description. One is to provide great care today and the second is to be part of providing safer, more effective care tomorrow.”
Ambulatory care has become an increasingly hot area for patient safety research and interventions, due in part to a shift in care from predominantly in-patient to mostly out-patient.
Professional liability suits have followed that trend. A grant from CRICO, a group of companies providing MPL coverage and services to its members within the Harvard medical community, is helping Dr. Focht’s organization collect data and understand how harm occurs in ambulatory settings.
“There’s a growing awareness that we don’t know or appreciate all the ways that harm can occur in an outpatient setting. They’re pretty well described now in places like operating rooms or emergency departments or chemotherapy infusion suites. But they’re not known in a three exam room practice that’s caring for a couple of thousand kids.”
At Children’s, that has meant a philosophy of working locally to test improvements, then sharing lessons in “communities of learning.” Each practice uses a performance improvement tool that is geared to its setting and helps identify practice-specific gaps in performance and establish priorities.
Even in very small, under-resourced practices, coming together for five or 10 minutes a week can make a difference in the lives of children. If something goes wrong at one practice, the case is discussed more widely, and every PPOC practice can benefit from the lessons learned.
“We view sharing those stories as a form of patient advocacy, that if we can create an expectation that there’s a safe place to talk about when things go wrong in care, people are willing to share and distribute their learning and even tell their stories in ways that make all of us more likely to provide safer and more effective care. There’s no need to hide this under the cloak of darkness or for people to feel like sharing their story is a form of being beaten up. People working in healthcare now understand viscerally and intellectually that when they share events like this, they’re advocating for their patients and patients across a network of 400,000 children. That’s a powerful opportunity to make a difference, and I think that’s really at the core of what I’m trying to do.”
Working with the Local Community Improved the Patient Experience
One early win: finding out that 50 percent of his practices couldn’t achieve well visit rates consistent with the American Academy of Pediatric standards, because the practice schedule didn’t have enough slots for well visits. A PPOC staffer built a computer application to calculate how many well visit slots they needed.
Now the 85 PPOC practices are seeing 10,000 more children each year for well visits—a much improved rate. Some practices added Saturday and evening well visit hours, or even turned routine sick visits into well visits for children who were behind in their check-ups.
“In one case we found a practice whose patients couldn’t get to their appointments because they were dependent on a bus line, and they were either an hour early for their appointment or 20 minutes late. So they had a high no-show rate and a high reschedule rate. They changed the hours in their schedule that they provide well visits. The well visit rates have gone up.”
Other examples of community of learning victories include ensuring the receipt and review of all newborn screens as well as building workflows to track patient referrals to completion and incorporation in the patient’s plan of care.
Dr. Focht summarizes his focus at Children’s as case-based learning, working locally, sharing across communities, applying basic safety principles to enhance closed-loop communications, and doing important things reliably.
Importance of a Strong and Dedicated Team
But to do this work well, he needs motivated, dedicated team members behind him. There are too many measures and projects and practice sites to attend to otherwise. And this turns out to be one of Dr. Focht’s chief skills.
“You lead, I’ll follow,” he says to Jean Santangelo, RN, his Director of Quality Improvement, as they start a weekly check-in.
Despite his powerful position and big responsibility, Dr. Focht’s staff tends to be more impatient than he is. But he sees the big picture and makes sure everyone else does too—and their important place in it for saving the lives and health of children.
“If you leave a meeting that I’ve had a chance to be in and you feel better about your experience and you leave that meeting believing that you can make a difference, then that’s been a really successful meeting. And if you can continue to have experiences where you can see through the work you’re doing to how it impacts patients, you’re going to start approaching this work with more fervor and with more effectiveness… and if I can help people believe each day that they are competent and able to effect change, they’ll do that in every part of their work and that’s extremely powerful.”