The document discusses strategies for transforming healthcare through evidence-based practices, partnerships, and technology, presented at the 19th International Conference in San Francisco. Key themes include fostering organizational change, the importance of communication and collaboration, and integrating health information technologies to improve patient outcomes. It emphasizes a complex adaptive systems approach and continuous learning to enhance healthcare quality and efficiency.

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 Medicine
Senior Scientist, IU Center for Health Services Research,
Indianapolis VA COE, Regenstrief Institute,
Indianapolis
Award Number: HHSA290200600013I, Task Order No. 4

2. Frameworks

4. Socio-technical Systems Framework
Social 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 technical
consequences 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

5. Panarchy or Ecocycle Model of Change
Renewal Maturity
Creative
Birth
Destruction
For more information on the ecocyle go to
http://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html

6. Institutional level
A change in culture
A change in laws
A change in resource
distribution/availability
Organizational level
A change in strategies
A change in procedures
A change in resource
distribution/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

7. Implementation & Spread

8. 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

9. Example – Before – Montana Hospital
Obvious
clusters, not well
integrated
Core not dense
enough Core not diverse
– too small

10. Example – After – Montana Hospital
Core is much
more dense
Core is more Still room for
diverse – more improvement…
departments and
roles present

11. Strategy

12. 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

13. Strategies from Regenstrief Conference
Complex Adaptive Systems -Conceptual framework of complexity dynamics and complex
Framework adaptive systems.
-Ground quality improvement strategies in a theoretical perspective
that views primary care practices as dynamic complex adaptive
systems
Fostering 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 trust
Appropriate Performance -Develop new approaches to evaluation of the performance
Measures 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 and
and 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)

14. Related Research Questions
Complex 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 promotes
Technologies collaboration between patient and provider?
-What health information innovation development
implementation strategies influence uptake?
Doebbeling & Flanagan, Medical Care (in revision, 2011)

15. Needed R&D

16. Collaboration Negotiation
Strategy
Difficult
Conversations
Innovation
Conflict
Management
Facilitation

17. My Conclusions
My Analysis
Relevant Data
DATA POOL
DATA POOL
From Argyris & Schon

18. The Publication

19. SHARE
My Conclusions Their Conclusions
ASK
SHARE
My Analysis Their Analysis
ASK
SHARE
Relevant Data Relevant Data
ASK
DATA POOL
DATA POOL
From Argyris & Schon

20. Collaboration

21. Collaboration = Communication+ Skill +
Context (Leadership x Culture)

22. 1. (Communication) Tools
 Wikis: our work
 Blog: my thinking
 Twitter: peripheral awareness
 Email: specific question

23. Relationship Communication
Interests
Options
Legitimacy
If “No” If “Yes”
Alternatives Commitment
Harvard Negotiation Project

24. Needed R&D

25. DELIVERY SYSTEM FOAs
1. 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 policy
2. 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 redesigns
3. 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.

26. Delivery System Evaluation FOA
10-012. 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

27. ARRA Delivery System FOA Grantees: Impacted Sites of Care
(1-2 sites per study)
14
13
12
11
13
10
9
8
7
6
5
4 7
3
2
3
1
0
Hospital Other Specialty Primary Care

28. ARRA Delivery System FOA Grantees:
Primary Health Conditions
Chronic Kidney
Disease, 1 Cardiological
Pediatric Health, Asthma, 1 conditions +
1 hypertension, 2
Orthopedics, 1
Mental Health +
substance abuse,
Multiple Chronic 4
Conditions, 6

29. ARRA Delivery System FOA Grantees: Geographic Spread
1 1
11
1
2 3
2
2
1
1 1
1
1 1
5 2
2
1
2
1
2
1
National =2

30. Needed R&D

31. 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

32. SHARP program
Fill 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

33. 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

34. ―Process Improvement Through Participatory
Design 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

35. Care-centered design
As-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

36. 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

37. ―Collaboration‖ – What does it
mean?
 ―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

38. Thank You!
 Questions?
 Contact
 Brad Doebbeling
 bdoebbeling@gmail.com