Quietly being present with Physicians as they care for their patients helps remind me that “care” as the Institute of Medicine defines it is fundamentally “the transfer of knowledge” and that requires Time. It also helps reframe the quality question from “How can we develop enough date to engage Physicians in Quality Initiatives” to “How can we engage in the Physician’s Quality Initiatives by transforming our exchange of knowledge.”

Presence also allows us to recognize the eco-system or community that surrounds not only the provision of health care but the importance of the receipt of it and the powerful role that consumers can play in designing new models of care. In addition to studying the latest LEAN process methods it is critical to listen to the patients voice and recognize that the real improvements in health care will require a new boundary of where health care is delivered when we realize that patient/consumers spend 99% of the time addressing their health care needs occurs outside of the office or hospital. Patients and Physicians need to be involved from the beginning as designers, motivators and in positions of Governance.

It is in this space, that cross boundaries, a community - where cultural and social factors play a major role and where the most dramatic solutions are possible. Recently in Whatcom County, WA there was a Robert Wood Johnson Pursing Perfection demonstration project for people with Chronic Conditions - in which the patients designed a shared care system to meet their needs. The outcomes were so dramatic (over $3,000 in cost savings per patient per year) and better outcomes (even though the project targeted those with multiple complex medical problems) that local specialists complained about the loss of income and the failure of the payment system to compensate providers who are able to keep their patients out of the hospital.

Now if we could all have someone as visionary and supportive as Ted in our organizations (hi Ted) there is no question that we would be able to provide high quality, patient centered health care to the entire community.