Crabtree Regenstreif October07

Transformation is Hard Work: Lessons from TransforMED’s National Demonstration Project Presented by Benjamin F. Crabtree, PhD October 3, 2007

Disclosure
Dr. Crabtree is the co-PI of the TransforMED NDP Evaluation
Supported by grants from the American Academy of Family Physicians and 2 grants from the Commonwealth Fund

Agenda
Background on collaborative research and organizational change perspectives of team
Review the components of an ideal primary care practice
Describe the TransforMED National Demonstration Project (NDP)
Highlight the evaluation of the NDP
Early findings from qualitative analyses
Questions and answers

Center for Research in Family Medicine and Primary Care Kurt C. Stange, MD, PhD Carlos R. Jaén, MD, PhD Benjamin F. Crabtree, PhD Paul A. Nutting, MD, MSPH William L. Miller, MD, MA

Background
Collaborative team has conducted a series of descriptive and intervention projects over a 15 year period.
Funded by NCI, NHLBI, NIDDK, NIMH and American Academy of Family Physicians (AAFP)
Results from these projects have informed an evaluation of the AAFP’s National Demonstration Project (TransforMED)

Observation I ntervention DOPC STEP-UP IMPACT D irect O bservation of P rimary C are (1994-97) S tudy T o E nhance P revention by U nderstanding P ractice (1996-2000) Insights from Multimethod Practice Assessment of Change over Time (2001-2004) P&CD P revention & C ompeting D emands in P rimary C are (1996-99) ULTRA Using Learning Teams for Reflective Adaptation (2002-07)

First insights into role of complexity in understanding practices
Practices could not be described in mechanistic terms, such as non-linear relationships among events
All the parts and people of a practice are interconnected and interdependent in terms of both relationships and functions.
Any change in one part of the practice will have ripple effects through the other parts of a practice. Those ripple effects will create tension and problems that can be barriers to change.
Changes don’t occur in a linear fashion. Small changes can have dramatic effects at times, large changes can produce small results at others.
What works in one practice may not work in another---many different ways of achieving good outcomes

Properties of Complex Adaptive Systems (CAS)
CAS consist of ‘agents’ with capacity to learn and freedom to act in unpredictable ways.
Agents are often individuals, they may be teams, organizational processes, technical components
Agents are connected in non-linear ways--one agent’s actions changes the context for other agents.
The quality of the interactions among agents is more important than the quality of the agents

Properties of Complex Adaptive Systems (Cont.)
Self-organization: systems generate new structures and patterns over time as a result of their own internal dynamics. Order emerges from patterns of relationships among agents.
Emergence: process by which non-linear interactions among agents results in new patterns of behavior. The system that evolves over time is more than the sum of its parts.
Co-evolution : process of mutual transformation of the agent and the environment in which it exists.

“ All models are wrong. Some are useful.” - George Box, 1979 Box, G.E.P., Robustness in the strategy of scientific model building, in Robustness in Statistics, R.L. Launer and G.N. Wilkinson, Editors. 1979, Academic Press: New York.

IMPACT CHANGE MODEL

Change Is Challenging

Implications for Practice Change
Patterns of relationships among staff (‘agents’) are critical determinants of practice change. (The quality of the interactions is more important than the quality of the staff.)
From high quality interactions, process will emerge to create high quality change
Emerging processes will not be the same in every practice.

Capacity to Change Model Reflection Action Trust Miindful Respect Heedful Diversity Social/ Task Rich/Lean STORIES Learning CULTURE Teamwork Sensemaking Improvisation Build Memory Dynamic Local Ecology Inquiry-Centered LEADERSHIP

According to CAS principles, successful practices will:
Move from an ‘organization as machine’ paradigm and begin to understand their practices as complex adaptive systems.
Pay more attention to the quality of the interactions among staff than on the quality of the staff.
Focus on staff learning rather than on what they know today.
Encourage cognitive diversity among staff (and teams) and leverage diversity to foster learning and emergence
Recognize that the practice is a social entity, and foster sense-making, learning, and improvisation
Expect and celebrate surprise as opportunities to learn and grow
Begin to understand the interdependence between the formal and informal organizations rather than making everyone conform to the formal organization

National Demonstration Project
Proof of concept of a new model of care for family medicine
Quality of care
Practice finances
Determining the best process for transformation
Facilitated
Self-directed

Components needed
Access to care
Access to information
Team approach
Point of care services
Information services
Redesigned offices
Management
Quality and safety
Whole-person orientation
Medical home
Patient-centered care
Continuous relationship

National Demonstration Project Evaluation Team Center for Research in Family Medicine and Primary Care Carlos R. Jaén, MD, PhD (PI) Benjamin F. Crabtree, PhD Paul A. Nutting, MD, MSPH William L. Miller, MD, MA Kurt C. Stange, MD, PhD & Elizabeth Stewart, PhD (analyst) Reuben R. McDaniel, EdD (consultant)

Domains of Evaluation
Discovering what the transformed model looks like in the real world
Effect of the transformed model on the practice
Effect of the transformed model on patients
Understanding the process of practice change
Understanding transformation

Sample Hypotheses
Practices that have motivated leaders that promote patterns of frequent opportunities for reflection with internal and external partners and are patient-focused will be more likely to integrate the components of the TransforMED.
Practices that have a more participatory decision making style and frequent opportunities for conversations about practice improvement will have higher levels of quality of patient care as measured by the chart audit and patient questionnaires.

Design
Volunteer practices selected by technical advisory committee from over 300 applicants
Randomly assigned to two change approaches:
Facilitated
Self-directed
2 year follow-up (Possible extension)
Mixed method assessment
RCT with pre/post and inter-group comparisons
Comparative case study

NDP Practices 18 4 5 2 4 3 Facilitated 18 Total 4 Large (7 or more clinicians) 5 Medium (4-6 clinicians) 2 New 4 Small (3 or less clinicians) 3 Solo and Solo +1 Self-directed Number of Sites Practice Description

Facilitated Practices
Each practice assigned one of 3 facilitators with each facilitator having a panel of 6 practices
Intervention included site visits, learning sessions, opportunities for sharing via conference calls and webinar, and connecting to consultants
Overtly focused on TransforMED “bubbles”

Self-Directed Practices
The self-directed group has a very minimal intervention that will still allow this group to be a valid comparison group
Have resources from TransforMED web page, but not facilitated
Practices self-organized and created their own retreat
Being in the national spotlight was a motivator
Site visit by evaluation team

Data Sources
Key informant & informal interviews
Contact logs
Email strings
Ethnographic observation
Clinician/staff surveys
Online discussions
Medical record review
Patient surveys

Qualitative Learning Emerging themes one year into the NDP

How are we learning?
Facilitators field notes
E-mails logs, webpage postings
Logs of phone conversations
Notes of facilitators huddles, other meetings
Weekly conference calls between members of the evaluation team.

NDP Early lessons
The most successful practices seem to have shared leadership systems rather than an individual physician leader
Despite being highly motivated some practices had serious dysfunctional problems within the relationship infrastructure that required significant time and energy on the part of the facilitator

NDP Early lessons
A practice's capacity for change at baseline is a huge determinant for that practice's progress, and equally important is the facilitator's ability to increase that capacity
Technology in the New Model, while shining with possibilities, is not by any means an easy " plug and play " interface for the practices

NDP Early lessons
Due in part to the ongoing challenges of technology, even the most successful practices are experiencing change fatigue

NDP Early lessons
Depending on initial practice capacity assessment, may need one or more:
Targeted consultation – e.g. Advanced Access, EMR, finances, specific operations, etc.
Coaching – e.g. leadership, finances, etc.
Facilitation – e.g. relationships, reflection, leadership, etc (different intensity of joining practice and/or system, ranging from just being there to active facilitation).

More information www.transformed.com

Questions?

References
Organizational Change & Complexity Science
Cohen D, McDaniel RR Jr, Crabtree BF, et. al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004 May-Jun;49(3):155-68.
Miller, W.L., Crabtree, B.F., McDaniel, R.A., and Stange, K.C. Understanding Primary Care Practice: A Complexity Model of Change. J Fam Pract, 1998 46(5):369-376.
Miller WL, McDaniel RR, Jr., Crabtree BF, Stange, K. Practice Jazz: Understanding variation in family practice using complexity science. J Fam Pract 2001; 50(10):872-878.

References
Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective practice improvement process. Joint Comm J Qual and Patient Safety. 2005; 31(8):438-446.
Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. J Gen Intern Med 2006; 21: S9-15.

References
Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR. Delivery of Clinical Preventive Services in Family Medicine Offices. Ann Fam Med. 2005; 3(5): 430-435.
Miller WL, Crabtree BF. Healing landscapes: Patients, relationships and optimal healing places. J Complementary and Alternative Med. 2005, 11 Suppl 1:S41-9.
Crabtree B. Primary Care Practices are Full of Surprises! Health Care Manage Rev, 2003, 28(3):279-283.

References
Tallia AF, Lanham H, McDaniel R, Crabtree BF. Seven Characteristics of Successful Work Relationships Family Practice Management 2006 Jan; 13(1):47-50.
Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: Case study of an exemplar small medical group. Ann Fam Med. 2006 Mar-Apr;4(2):109-16.

Crabtree Regenstreif October07

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