Advancing Transformational Science Doebbeling Cpmrc 1.22.11

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Outline of ideas to advance the science of transforming health care organizations. 81. “Advancing Transformational Science”, Bridges to Sustainable Healthcare Transformation Through Evidence, Partnerships & Technology: 19th International Conference San Francisco, CA, January 19-22, 2011.

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  • Reveals communicative patterns of complex groups and teams Identifies the strength and frequency of the connections between members (e.g., with whom and how often do you communicate about reducing MRSA)Describes the current social network for work in general and the MRSA Bundle implementation in particular
  • Advancing Transformational Science Doebbeling Cpmrc 1.22.11

    1. 1. Bridges to Sustainable Healthcare Transformation Through Evidence, Partnerships & Technology: 19th International Conference San Francisco, CA, January 19-22, 2011 Brad Doebbeling, MD, MSc Professor of Medicine, Epidemiology, & Biomedical Engineering, Indiana University School of MedicineSenior Scientist, IU Center for Health Services Research, Indianapolis VA COE, Regenstrief Institute, Indianapolis Award Number: HHSA290200600013I, Task Order No. 4
    2. 2. Frameworks
    3. 3. Socio-technical Systems FrameworkSocial Subsystem Technical Subsystem• Key stakeholder views • Usability• Patient barriers/facilitators • Functionality/scope• Organizational buy-in • Computer/IT support• Leadership support Joint Optimization •Flexibility in IT tools• Training • Integration of CDS - •Iterative design• Unintended social for CRC screening - • Unintended technicalconsequences into clinical workflow consequences External Subsystem (Context) • PERFORMANCE MEASUREMENT • Workload • Financial factors • Unintended external consequences Westbrook et al., JAMIA, 2007; Harrison et al., JAMIA 2007
    4. 4. Panarchy or Ecocycle Model of Change Renewal Maturity Creative Birth DestructionFor more information on the ecocyle go tohttp://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html
    5. 5. Institutional level A change in culture A change in laws A change in resource distribution/availabilityOrganizational levelA change in strategiesA change in proceduresA change in resourcedistribution/availability Network or group level A change in conversation A change in routine A change in resource commitment or influence Individual level ―Getting To Maybe: How the World is Changed‖ A change of heart Frances Westley, Brenda Zimmerman, Michael A change of habits Patton, 1996, Random House Canada A change of ambition
    6. 6. Implementation & Spread
    7. 7. Social Network Analysis Reveals communicative patterns of complex groups and teams  Identifies the strength and frequency of connections (e.g., with whom and how often do you communicate about reducing MRSA)  Describes current network in general & MRSA Bundle implementation in particular  Tool for Implementation & Spread
    8. 8. Example – Before – Montana Hospital Obvious clusters, not well integratedCore not denseenough Core not diverse – too small
    9. 9. Example – After – Montana Hospital Core is much more denseCore is more Still room fordiverse – more improvement…departments androles present
    10. 10. Strategy
    11. 11. Transformative Change:7 Effective Strategies Fostering Change Communication & Collaboratives Local, Focused Implementation Frontline Staff Engagement Organizational Learning Support, Resources & Accountability Feedback & Reinforcement Qualitative Thematic Analysis, Healthcare Associated Infections (HAI) Initiative Assessment Program , AHRQ ACTION, HHSA290200600013I , 2010
    12. 12. Strategies from Regenstrief ConferenceComplex Adaptive Systems -Conceptual framework of complexity dynamics and complexFramework adaptive systems. -Ground quality improvement strategies in a theoretical perspective that views primary care practices as dynamic complex adaptive systemsFostering Organizational -Conceptualize organizations as a series of conversations.Redesign -The creation of healthy work cultures depends upon communication, teamwork, trust and partnerships. -Enhance the quality of listening, to foster openness and trustAppropriate Performance -Develop new approaches to evaluation of the performanceMeasures and Incentives measurement system. -Develop new measures to identify and address gaps in the current system.Continuous Learning -End-users need to make the research ―right‖ for their context—Organizations customize guidelines for local use. -Continuous learning organizations set measurable targets for change, assess progress and provide feedback to stakeholders.Integrating Health Information -The implementation of evidence-based tools, resources andand Communication information systems at the point of care.Technologies -The use of telemedicine/Personal Health Records to improve access to care and improve health outcomes. Doebbeling & Flanagan, Medical Care (in revision, 2011)
    13. 13. Related Research QuestionsComplex Adaptive Systems Framework -What organizational change strategies are based on complexity science principles? -How do they create and sustain change? -What characteristics foster using a complexity science perspective in transformation efforts?Fostering Organizational redesign -What organization redesign strategies facilitate the creation of healthy work cultures? -How can implementations be tailored to suit different organizations and patient populations?Appropriate Performance Measures and Incentives -What performance measures/incentives encourage collaboration and coordinated care among providers? -How can performance measurement be more dynamic to continually adapt to healthcare changes?Continuous Learning Organizations -What barriers and facilitators exist for end-users to customize guidelines for use? -What strategies and investments work best for continuous learning organizations?Integrating Health Information and Communication -What type of health information promotesTechnologies collaboration between patient and provider? -What health information innovation development implementation strategies influence uptake? Doebbeling & Flanagan, Medical Care (in revision, 2011)
    14. 14. Needed R&D
    15. 15. Collaboration Negotiation Strategy DifficultConversations Innovation Conflict Management Facilitation
    16. 16. My Conclusions My Analysis Relevant Data DATA POOL DATA POOLFrom Argyris & Schon
    17. 17. The Publication
    18. 18. SHARE My Conclusions Their Conclusions ASK SHARE My Analysis Their Analysis ASK SHARE Relevant Data Relevant Data ASK DATA POOL DATA POOLFrom Argyris & Schon
    19. 19. Collaboration
    20. 20. Collaboration = Communication+ Skill + Context (Leadership x Culture)
    21. 21. 1. (Communication) Tools Wikis: our work Blog: my thinking Twitter: peripheral awareness Email: specific question
    22. 22. Relationship Communication Interests Options Legitimacy If “No” If “Yes”Alternatives Commitment Harvard Negotiation Project
    23. 23. Needed R&D
    24. 24. DELIVERY SYSTEM FOAs1. RFA 10-012 -- Comparative Effectiveness Delivery System Evaluation Grants – R01 (Michael Harrison) Research on existing designs or redesigns (interventions) in payment, reporting, and organization of care delivery CER= compare alternative designs or redesigns; compare one redesign to status quo accepted as current policy2. RFA 10-013 Comparative Effectiveness Delivery System Demonstration Grants – R18 (Michael Harrison) (A) Demonstration of redesigns in  primary care  care continuum  payment and reporting (B) Research on implementation and effectiveness of these redesigns3. RFA 10-014 -- Accelerating Implementation of Comparative Effectiveness Findings on Clinical and Delivery System Interventions by Leveraging AHRQ Networks – R18 (Dina Moss)  PURPOSE: Spread of CER findings by leveraging the capacities of multi- stakeholder or multi-site networks: Goal is implementation of existing evidence, not creation of new evidence  Reporting of progress in achieving project goals is required – evaluation is not; Evaluation to be conducted by external contractor.
    25. 25. Delivery System Evaluation FOA10-012. Delivery System Evaluation Grants – R01 (a.k.a. ―Evaluation grants‖) (Harrison) Evaluate ability of alternative system designs, change strategies, and interventions to enhance system performance (quality, efficiency, etc.); evaluate applicability of change strategies across diverse settings. 3-year projects with no extensions $7 million allocated for 6-10 awards Support Contractor -- Econometrica with sub to Booz Allen for portal 6 funded
    26. 26. ARRA Delivery System FOA Grantees: Impacted Sites of Care (1-2 sites per study)14131211 1310 9 8 7 6 5 4 7 3 2 3 1 0 Hospital Other Specialty Primary Care
    27. 27. ARRA Delivery System FOA Grantees: Primary Health Conditions Chronic Kidney Disease, 1 Cardiological Pediatric Health, Asthma, 1 conditions + 1 hypertension, 2Orthopedics, 1 Mental Health + substance abuse, Multiple Chronic 4 Conditions, 6
    28. 28. ARRA Delivery System FOA Grantees: Geographic Spread 1 1 11 1 2 3 2 2 1 1 1 1 1 15 2 2 1 2 1 2 1 National =2
    29. 29. Needed R&D
    30. 30. Nation-wide Adoption of EHR  There is critical nation-wide need to improve health care services while reducing cost  Federal goal is 50% EPR adoption by private clinics and hospitals by 2016  Current adoption is ~ 14% for private hospitals and clinics  Private providers have serious concerns about:  steep start-up cost  rejection by physicians  unknown, sustained overhead for training, tech support, etc.  disruption of health care workflows
    31. 31. SHARP programFill technology gaps for nation-wide, meaningful use of electronic health records (EHR) Awardee Research Focus Area University of Illinois at Security of Health Urbana-Champaign Information Technology (#10510624) The University of Texas Patient-Centered Cognitive Health Science Center at Support Houston (#10510592) Healthcare Application and Harvard University Network Platform (#10510924) Architectures Mayo Clinic College of Secondary Use of EHR Medicine (#10510949) Data
    32. 32. Long-term Approach to Meaningful Use Stage 3 – 2015 Stage 2 – 2013 Improved outcomes Advanced oStage 1 – 2011 clinical processes Data capture and information sharing http://www.cms.gov/ehrincentiveprograms/ Rtn
    33. 33. ―Process Improvement Through ParticipatoryDesign of Health Information Systems‖ Tools and methods to make health care improvements integral to the way HIT systems are created Keith Butler, U Wash, SHARP-C
    34. 34. Care-centered designAs-is care process model Improved process models Sensitivity analysis Value to care Better care Trade-off process analysis Information usage Cost-effective S/W HIT system Risk & cost implement ation models Information architectures Technology-centered design Keith Butler, U Wash, SHARP-C
    35. 35. Acknowledgements  Funding from AHRQ  Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria HHSA2902006000131 (Completed)  Healthcare Associated Infections (HAI) Initiative Assessment Program HHSA290200600013I (Current)  Implementing and Improving the Integration of Decision Support into Outpatient Clinical WorkflowHSA2902006000131(Current) Funding from AHRQ and CDC  Testing Spread and Implementation of Novel MRSA-Reducing Practices HHSA290200600013 (Current) Thanks to our collaborators, partners, providers, patients! Thanks to Michael Harrison, PhD, AHRQ and Keith Butler, PhD, U Washington/SHARP-C
    36. 36. ―Collaboration‖ – What does itmean? ―Alone we can do so little; together we can do so much.‖ – Helen Keller ―Strength is derived from unity. The range of our collective vision is far greater when individual insights become one.‖ – Andrew Carnegie
    37. 37. Thank You! Questions? Contact Brad Doebbeling bdoebbeling@gmail.com

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