Sue Stableford - What happens when policy hits the ground? The diffusion of innovation meets complex adaptive systems


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Presented by Sue Stableford, MPH, MSB, on September 27, 2013 at the fourth annual Center for Health Literacy Conference: Plain Talk in Complex Times.

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Sue Stableford - What happens when policy hits the ground? The diffusion of innovation meets complex adaptive systems

  1. 1. What happens when communication policies hit the ground? Sue Stableford, MPH, MSB, Director University of New England Health Institute September 2013 The Diffusion of Innovation meets Complex Adaptive Systems
  2. 2. Assumptions • Communication focus: Terms and 2 major strategies • Moving strategies into practice = CHANGE • Core issue for better health and public health outcomes
  3. 3. What’s Ahead 1. The challenge of change 2. Context: Policy and history 3. What happens when policy hits the ground? 4. How change happens: Interweaving theories 5. Opportunities to improve practice
  4. 4. The Challenge of Change [Atul Gawande. Slow Ideas. New Yorker, July 29, 2013] • Adopted quickly: Anesthesia – Ether introduced 1846 and universal in 7 years • Adopted slowly: Antiseptic techniques – Lister report 1867: Carbolic acid – Generation(s) passed; still challenges • Public health example: Limes on British ships Relationship to plain language and teachback?
  5. 5. Context: Policies, Guidelines, Standards, Tools Triple Aim
  6. 6. More Policies, Guidelines, Standards, Tools
  7. 7. Context of Change: History in 1 Slide 2013 1985 Doaks and Root publish “Teaching Patients With Low Literacy Skills” All major national policy and accreditation bodies recommend/require clear health communication 1999 AMA ‘White Paper’ 2003 2nd National Assessment of Adult Literacy (NAAL) 1992 1st National Adult Literacy Survey (NALS)
  8. 8. Policy hits the ground
  9. 9. Healthcare and public health: Stormy environments • Complex • Many players • Multiple stakeholders • Limited resources • Competing agendas
  10. 10. Competing for Attention • External forces – Finances – Politics – Regulations – Safety & quality • Internal agendas
  11. 11. Time pressures acute
  12. 12. Impact on improving communication? More like this Than this Results
  13. 13. How can we get to better communication practice? • Not easily! • Change theories converge – Public Health: Diffusion of Innovation – Medicine: IHI Model for Improvement – Business: Kotter’s 8 step action model – Popular press: Switch Tipping Point
  14. 14. Core Concepts of Change • Establish need – Engage head and heart (data and stories) • Engage trusted leaders • Show the way/Start small • Clear obstacles • Measure and celebrate • Spread, build, and anchor
  15. 15. What promotes broad-scale change? • Relative advantage • Compatibility • Simplicity • Trialability • Observability (visibility) “Diffusion of Innovation” (Everett Rogers)
  16. 16. Lacks 4 of 5 key elements of easy diffusion • Visibility • Simplicity • Relative advantage • Compatibility with ‘usual care’ Barriers to Communication Change
  17. 17. Another Framework for Understanding Change – Nonlinear – Self organizing – Emergent – Dynamic – Adaptive Healthcare and public health as Complex Adaptive Systems (CAS)
  18. 18. The CAS framework and communication practice change “Health care providers, patients, officials and the many other stakeholders in a health system interact with each other through a web of complicated relationships, influenced by communities of practice, neighborhoods, and social networks. Scaling up health services involves intervening in these networks and engaging in dynamic, health system relationships.” Paina L & Peters D. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy and Planning, 2012: 27.
  19. 19. Diffusion of Ideas and Behaviors Core Concepts of Change Complex Systems in Complex Environments Common theme: Social Relationships Policies, Guidelines, Standards, Tools
  20. 20. Showing the way: Models of Success • IOM Health Literacy Roundtable, April 2013 – Focused on organizational change – Care systems using change frameworks and systems thinking to integrate plain language and teachback • Public health: ecological paradigm
  21. 21. So, what does it take to change communication practices? 1. Core concepts – Prioritize, Invest, Measure 2. Diffusion of Innovation –  Compatibility and simplicity – Emphasize advantage 3. Systems & social theory – Flexibility and creativity – Points of leverage
  22. 22. Support for Improved Communication Practice • ACA payment reforms • Links to high-profile issues e.g. Cultural Competence • Accreditation requirements • Academic changes • Links to proven programs e.g. TeamSteps and Choosing Wisely
  23. 23. What about technology solutions? • Technology: A supporting player, not the star • Change – A social process – Person to person • Gawande: “People talking to people is still how the world’s standards change.”
  24. 24. Will it make a difference? Yes! Evidence on communication impact: • Patients • Providers and care systems • Public health
  25. 25. Finale Atul Gwande referencing Everett Rogers: “Every change requires effort, and the decision to make that effort is a social process.”
  26. 26. Selected Additional References • Foster-Fishman P, Nowell B, Yang H. Putting the system back into systems change: a framework for understanding and changing organizational and community systems. Am J Community Psychol, 2007. 39:197-215. • Hawe P, Shiell A, Riley T. Theorising Interventions as Events in Systems. Am J Community Psychol, 2009. 43:267-276. • Hibbard JH and Greene J. What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs. Health Affairs, 2013. 32(2):207-214. • Langley GJ et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Francisco: Jossey-Bass, 2009. • Meadows D. Thinking in Systems. Vermont: Chelsea Green Publishing, 2008. • Patton MQ. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: The Guilford Press, 2011. • Rogers E. The Diffusion of Innovation. New York: Simon & Schuster, 1962. • Sterman JD. Learning from Evidence in a Complex World. Am J Public Health, 2006. 96(3):505-514. • Trickett EJ et al. Advancing the Science of Community-Level Interventions. Am J Public Health, 2011. 101(8):1410-1419.