Summer Institute 2010Deep Dive into CommunityF. Daniel Duffy, MD, MACP

July 31, 2010

Why are we here?

Present

OK

Why are we here?

Present Future

School of Community Medicine

OK

Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in care

How do we do it?

OK

Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in care

Plan & design

Present Future

School of Community Medicine

YES, BUT…Community Medicine Moves from isolated and self-interested silos

to connectedness and care for the whole

Shifts from problems to be solved to our community’s positive potential

Encourages collaboration in creating the future that cares for the whole

Theory U

The way in which we attend to a situation determines how a situation unfolds: I attend this way, therefore it emerges that way.

Principles and practices for collectively creating the future that wants to emerge.

Otto Sharmer, 2009

How does the “U” Journey Work?

LISTEN to others and to what life

calls us to do

SENSE Go to the places of most potential, observe and listen with our minds, hearts and wills wide open

CREATE Prototype a microcosm of the new to explore the future by

doing

EVOLVE ecosystems by acting from

the emerging whole

PRESENCE Retreat and reflect to allow inner knowing to emerge

Present Future

Social activities Anchoring lectures Stakeholder dialogues World-Café: discover the whole Professional meaning groups Prototyping the future Evolving Community Medicine

Co-Sensing: Listen, Discover, Connect

Dialogue GroupsDialogue Groups

Appreciative InquiryAppreciative Inquiry

Shadowing PatientsShadowing Patients

Poverty Simulation Poverty Simulation

PhotoVoicePhotoVoice

Observe, observe, observe; suspend voice of judgment, cynicism, fear

Dialogue, listen deeply, connect with mind, heart, and will wide open

Allow the system to see itself

Learning journeys into community

World Café World Café

Anchoring LecturesAnchoring Lectures Learning from the past

Appreciative Inquiry Interviews

Dialogue focuses on the individual’s or group's most positive potential – not on problems!

We inquire to learn with an open mind, open heart and open will.

Our conversations appreciate rather than criticize and judge

World Café practice Hospitable Café-like

setting Hosts Travelers

Meaningful questions Everyone contributes

Cross pollination Diverse perspectives

Listen together for deeper insights

Harvest discoveries

Co-Presencing: Professional Meaning

Professional Meaning “Presencing” Conversations

The call to service, to give ourselves to something larger than ourselves, and to become what we were meant to become.

Our public self is shaped by life experiences and masks the authentic self beneath rationalizations, excuses, and resentments that stem from fear, blame, and sorrow in our relationships with each other.

Our authentic self is in touch with truth, generosity, and love and is the source of inspiration, compassion, and creativity

Co-Creating: Prototype 0.8

Create prototype 0.8 microcosms

Explore the future by doing rather than by analyzing

Quickly build an experiential microcosm of the future that needs you to come into being

Present ideas or work in progress before they are fully developed

Get feedback to improve it and make it useful

Co-Evolving: Act as Ecosystem Part Grow innovation

ecosystems by seeing and acting from the

emerging whole

Systems governed by: Markets Hierarchy (regulation) Networking

New governing system: Seeing from “presencing”

the emerging whole Acting from our crystallized

vision of the future

What Have We Learned from Summer Institutes?

Summer Institutes2008

Rationale & Vision for School of Community Medicine

Plight of Uninsured Vulnerable people need us Developing knowledge Moral imperative

2009 Dr. Clancy’s story Health & community structure Determinants of health Behavior change Ethics & social justice Crystallize a better future

Tulsa’s history full of violence and community separation Social agencies are eager to help – but are uncoordinated Low density, separated, low social capital, auto, poor air, accidents Poverty is not a choice, can happen suddenly, is a hard lifestyle Health care institutions somewhat isolated from community needs Uninsured patients appreciate access to low cost care

Prototypes 0.82008

Take it to the streets Electronic portal Center for behavioral health Connecting care – Tulsa HIE Fewer patient more

professionals Go forth and multiply No senior left aside Community research

infrastructure Science of cultural

competency

2009 Yo-Yo 96 Frequent flyer – ER clinic CANDLe3 HUB Spanish Immersion Healthy Hornets CHAMP Service-Share Foundation AH-AH i-Volunteer app Life Skills – you can do it Shock Aah, Hugs

Healthcare Ecosystem

Complex adaptive system integrating human biology economics, socio-political organization, psychological factors, and health care delivery to produce health.

The Patient is at the Center of the Health Care Ecosystem

The structure and function of community government and services

affects the health of everyone

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

An individual’s genetics, family, culture, education and society affect health

Spiritual

School

Friends

Family

Money

Home Food

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

Personal Lifestyle choices and access to healthy options affects everyone’s health

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

Health care begins with a Medical Home

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

Medical Home

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

…and a network of services

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

Medical Home Pharmacy

Specialist

Lab Tests

X-Ray

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

…and more services

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

Medical Home Pharmacy

Specialist

Lab Tests

X-RayHospitalNursing Home Surgery

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

Medical Home Pharmacy

Specialist

Lab Tests

X-RayHospitalNursing Home Surgery

Emergency

Rehab

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

Medical Home Pharmacy

Specialist

Lab Tests

X-RayHospitalNursing Home Surgery

Emergency

Rehab

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

Spiritual

School

Friends

Family

Money

Home FoodChild Care

Leisure Yoga

Fitness

Fat

Habits

Support

Medical Home Pharmacy

Specialist

Lab Tests

X-RayHospitalNursing Home Surgery

Emergency

Rehab

Research

SafetyLaw & Order TransportationAgenciesCitizenship UtilitiesPublic Health

Innovations that Improve the Health Care Ecosystem

Supplier Process Process Customer

Disruptive Technology (LEAN) Disruption – makes simpler and more

affordable Technology – a way of combining inputs of

materials, components, information, labor and energy into outputs of greater value.

Business Model – work that creates value someone will buy

Value Stream MapValue to patient

Value Stream MapValue to Patient

Check-In1.-------2,-------3.-------

Nurse1.-------2,-------3.-------

Clinician1.-------2,-------3.-------

Wrap-Up1.-------2,-------3.-------

Scheduler1.-------2,-------

Report1.-------2,-------

Triage1.-------2,-------

Check-In1.-------2,-------3.-------

Nurse1.-------2,-------3.-------

Clinician1.-------2,-------3.-------

Wrap-Up1.-------2,-------3.-------

Triage1.-------2,-------

Scheduler1.-------2,-------

Report1.-------2,-------

Check-In1.-------2,-------3.-------

Nurse1.-------2,-------3.-------

Clinician1.-------2,-------3.-------

Wrap-Up1.-------2,-------3.-------

Triage1.-------2,-------

Scheduler1.-------2,-------

Report1.-------2,-------

Process Step That Can Be

Improved

Check-In1.-------2,-------3.-------

Nurse1.-------2,-------3.-------

Clinician1.-------2,-------3.-------

Wrap-Up1.-------2,-------3.-------

Triage1.-------2,-------

Scheduler1.-------2,-------

Report1.-------2,-------

Bright Idea For Improvement or Innovation in a

Process Step In the Work

Prototype 0.8 Solution PosterIssue: Patient repeats history multiple times

Background/Measures• Patient survey 50% poor history• Nurse/doctor delays, patient waits

Root Cause AnalysisWhy? – Tradition Why? – Training students

Why? – Habit of practiceWhy? – Forms in EMR Why? – No time to

develop

Repeated questions

Current Condition

Future ConditionPatient

generated form

Title: Patient INFO to EMR Quickly

Team: JB.CD. RK. SW. FG HO

Countermeasures: Patient Questionnaire

Implementation Plan:Task Who When OutcomeForms J.B. 8/1 New formEMR C.D. 8/15 TemplateTraining RK 8/30 “can do”

Cost $600 Benefit Save time

Rapid Cycle Test of ChangeIM Clinic Team 1, SW, 9/1-10

Follow-up – Expected MeasurePatient wait time drops 50%

A small group of committed people can change the world.

In fact nothing else ever has!Margaret Mead

Enjoy your deep dive into shaping the future of community medicine