Practice in a networked health care system

David Patrick Ryan, Ph.D. C.Psych. Director of Education, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto

Objectives

Situate practice as a networked phenomenon

Consider the continuum of tight and loosely coupled networks

Provide an overview of concepts from network and systems theory

Review network analytic tools

Reflect on the implications of networked practice for the knowledge to practice process

The ubiquitous ‘network’ concept

National health networks (see Mur-Veeman et al 2003)

Multisite hospital networks

Research networks

Disease/population focused networks

Primary Care Networks

Family Health Networks

Local Health Integration Networks

Some of Disease/Population Networks in Ontario Network Name Focus Clinical

ServicesFunding Role

The Child Health Network  

population no no Plan, collaborationstandard setting

Cancer Care Ontario 

disease yes base Service, research, leadership

Ontario Family Health Networks 

population yes base A managed care network

The Cardiac Care Network  

disease Wait list mgmt project Monitor analyze and advise MOH

Northern Diabetes Health Network 

disease yes base Assess needs, contract services, evaluate, educate

GTA Rehab. Network  

population no no Plan, research, educate, advise

ABI Network 

population data base mgmt

mixed Lead, advocate educate collaborate

RGP Network  

population yes and no mixed Advocate educateleadership, service

Dementia networks disease no startup   Advocate educate collaborate

Network studies and related themes

Intraspeciality medical networks (Coleman et al. 1966)

Networks within practices (Scott et al. 2005) (Miller et al 2001)

Comparisons of discipline specific networks ( West et al 1999)

Primary care research networks (Mold & Peterson, 2005)

Shared care (Hickman et al. 1994)

Coordination versus continuity (Pinkerton et al 2004)

Inter-teamwork (Ryan, 1996)

Communities of practice (Parboosingh, 2002 )

Practice collaboratives (Mittman, 2004)

What a difference a decade makes or maybe not

“Despite the ubiquity of the network concept in planning programs, the issue of how networks of health care facilities affect the delivery of services has not been intensively studies. Although there are references in the organizational literature . . . very few studies have documented the effects of these programs. . . . Further, the value of network programs in actually improving the dissemination of new treatment technologies or disease management has not been adequately explored on either a theoretical or an applied level” (Fennell & Warenecke, 1988 p.12)

“Ever since the seminal work of Coleman et al (1966), networks have been seen as important in the process by which clinicans adopt (or fail to adopt) new innovations in clinical practice. Yet very little is actually known about the social networks of clinicians in modern health care settings” (West et al., 1999 p. 633)

Do we need the network concept?

Convergent validity – is it different from other organizational forms e.g. are networks different from teams?

Heuristic validity - is the network concept rooted in a body of knowledge that has led to useful theory?

Operational validity – are there standardized and validated measures?

Predictive validity – does the theory and measures predict behavior?

On teams and networks Dimension Team Network

Level of analysis fixed agnostic

Goals prescribed organic

Development intentional emergent

Relationships narrow ties multiple ties

Sample sizes Small n Medium to large

Theoretical origins Social Psychology Sociology

Output Process gains social capital

Strength of ties Strong Weak

Participation mandated self-selected

Causal models linear non-linear and recursive

Boundaries Fixed Flexible

Authority Formal Informal

The collaboration prerequisite

When environments require complex interdependency the quality of collaborative alliances may predict outcomes better than the internal processes of individual teams (Pfeiffer, 86)

Just as simply putting health professionals together to work in teams seldom leads to effective teamwork so simply putting teams to together to work seldom leads to effective inter-team collaboration (Ryan, et al. 1996)

Words of advice for young people

Minimizing variation to reduce error and increase the quality of health care through the use of standardized guidelines “has not been as successful as traditional logic might suggest” (Miller et al 2001)

There seems to be little relation between the quality of the evidence and its diffusion into practice (Fitzgerald et al 2002)

The ways people actually work usually differ fundamentally from the ways organizations describe that work (Mintzberg & Vander Heyden,, 1999)

Our beliefs to the contrary, a great deal of human behavior is illogical (Kruger & Dunning, 1999) (Tversky & Kahneman, 1967)

Beneath each espoused culture lies another that is implicit, informal and unacknowledged (Argyris,

Social Network Theories

Structural holes (Burt)

Resource mobilization and connectedness (Lin)

Peripheral participation (Wenger)

Strength of weak ties (Granovetter)

Trust and strong ties (Uzzi)

Networked individualism (Wellman)

A network analysis diagram (Burt, 1999)

Social Network Diagram of a Family Practice (from Scott et al 2005)

Social Network diagram of another family practice (from Scott et al 2005)

What does this mean for practice networks

Practice networks should be construed as a local complex adaptive systems with the high levels of uncertainty, contextual uniqueness and surprise.

Like other complex adaptive systems, practice networks self-organize, reveal emergent behavior, and co-evolve.

Successful practicse networks minimize errors, make good sense of what is happening, and effectively improvise

In this context variation rather than standardization is to be expected and a good coach is essential

from Miller et al (2002)

Health Professional Advice Network ( from Coleman et al 1966 p. 75)

Health professional discussion network (from Coleman et al 1966 p.76)

Health professionals friendship network ( from Coleman et al

1966 p. 78)

Network character, type of change and prescriptive interventions (McGrath & Krackhardt, 2003)

Change Model

Type of change

Network character

Mechanism Where to intervene

External ties

Network wide

Strong dense ties exist with many external ties across subgroups

Trust and social identity

The people with strong external ties (structual holes)

Viscosity

Adoption of controversial innovations

Strong, dense internal ties but few external ties across subgroups

Individual commitment within a subgroup

Introduce change in one group at periphery (strength of weak ties)

Structural leverage

Innovation clearly superior

When the networks formal structure is low

Creating buzz (contagion)

Introduce change to a friend of a network member (opinion leaders)

Network stages of development

Adapted from Brown et al (2001) Strategic Planning in Rural Health Networks available online at www.academyhealth.org/ruralhealth/ strategicplanning.pdf

   Forming

 Evolving

 Maturing

 Growth 

Joint planning Program evaluation

Joint marketingExpanding service line

New servicesProgram integration

 Efficiency

Benchmarking Standard setting

Administrative consolidation

Shared services Service relocation

 Value  

Resource manualsPeer networks Member directory

Grant writingShared investments

Common budgetingResource planning

 

Please find a copy of the reference list for this talk online at the url below

http://rgp.toronto.on.ca/article.pl?sid=05/08/30/1936247