sustaining and spreading medical home transformation · medical home transformation . 8 change...
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Moderator: Nicole Van Borkulo, MEd, Qualis Health Speakers: Mindy Stadtlander, MPH, CareOregon Robert Reid, MD, PhD, Assoc. Investigator, Group Health Research Institute
Sustaining and Spreading Medical Home Transformation
8 Change Concepts for Practice Transformation 1. Foundational Changes
Engaged Leadership
QI Strategy Empanelment
2. Changing Care Delivery
Continuous, Team-based
Healing Relationships
Patient-Centered Interactions
Organized, Evidence-based Care
3. Changing Patient Experience
Enhanced Access
Care Coordination
Spread and Sustainability in Medical Home Transformation
Mindy Stadtlander, MPH
Clinical Systems Innovation Program Manager, CareOregon
Provide framework for thinking about spread and sustainability
Offer tips and tricks from clinics on methods for spread and sustainability
Share a few stories from the field
SPREAD
To distribute widely To expand the impact of an
intervention/workflow
SUSTAINABILITY
Ability to maintain/ hold the gains
Ensure continuity in improvement
Source: Nolan et al (2005). Using a Framework for Spread: The Case of Patient Access in the Veterans Health Administration. J on Quality and Pt Safety, 31:6, 339-347.
Responsibilities of leadership Identification of better ideas Communication Strengthening the social system Measurement and feedback Knowledge management
Source: Nolan et al (2005). Using a Framework for Spread: The Case of Patient Access in the Veterans Health Administration. J on Quality and Pt Safety, 31:6, 339-347.
Shift to interactive trainings
Add communication and change management training Add post-
implementation collaborative
meetings
Add Sustainability
Team
Have teams that have gone before provide training
Provide Providers-
Only session
Cross-Clinic Teams Measure so you know
what’s working Have staff share their
experiences Define standard work Keep things flexible for
site differences, provide support
Track and advertise new improvements
Frequency: Once per month Goal: Share learnings between teams and roll
out new initiatives to clinic Membership: A representative of each team
and each role within the clinic
Identify key strategic measures
Identify positive outliers
Use them to understand best practice
Pilot Clinic
Source: Multnomah County Health Department, Portland OR
Source: Multnomah County Health Department, Portland OR
Top FEW things that everyone needs to do the same way to make a process successful
Developed during organizational pilots Should be simple to communicate Auditable
Source: Multnomah County Health Department, Portland OR, Open Access Policy
Have standard work when success can be demonstrated
Honor site/team/population differences Can use a push system or a pull system
depending on organizational culture
Process Benefits (beyond patient care) Credibility Adaptability Ability to monitor progress
Staff Involvement in training Attitudes towards sustaining the change Senior and Clinical leadership engagement
Organization Alignment with strategic aims Infrastructure
Helpful resource: NHS Sustainability
Guide
Standard Work Visual Management Orientation and Training
Implementation Monitoring Training Can also be applied to
leadership Rounding Checking
A simple written (or photo-based!) description of the safest, highest quality, and most efficient way to perform a particular process or task
The only acceptable way to do the process it describes
Expected to be continually improved Reduces variation, increases consistency
Do Don’t Keep it very simple Use photos where possible Create one document for each part of a process Use it regularly, train from it, and follow up with it
• Create it in an administrative conference room • Put it in a binder! • Make it difficult to change/ improve
Allows you to detect quickly what is normal and what is abnormal
Teams develop and
maintain visual boards
Leaders “go and see” and ask questions
Visual Management
Use simple graphics Focus on clear, actionable information Maintained by those doing the work Needs to be linked to high level
organizational objectives – it’s a way to see how the work that is done every day contributes to the goals of the organization
Visual Improvement Board
Outcome Measures
Current Improvement
Projects / Process
Measures
Staff Engagement
Clinic Vision/ Aim
Customer Service
Visitor Comments
Source: Multnomah County Health Department, Portland OR, Telephone Improvement Kaizen
Source: Old Town Clinic, Portland OR, Leadership Improvement Board
How will you communicate with new staff the process?
What training materials and needed? Should core competencies be updated? Who will train new staff?
Ongoing training and development Role group meetings Updates at staff meetings Collaborative meetings
Job descriptions Competencies Employee evaluations
Goal Summary
Provide framework for thinking about spread and sustainability
There are a few papers out there that are really helpful to spur your thinking… IHI and NHS
Offer tips and tricks from clinics on methods for spread and sustainability
Take what is useful and resonates with your clinic culture
Share a few stories from the field
You are not alone!
Perspectives on Sustaining & Spreading PCMH Transformation
Rob Reid MD PhD Group Health Research Institute December 19, 2012
Sustainability & Spread
It’s not the innovation that matters most;
it’s what happens after the innovation.
Sustainability & Spread
• Improvement is never complete
• After transformation, 2 natural questions: • How to “hold the gains” & continue to improve?
• How to export strategy to other sites & teams?
• Deliberate planning needed from outset
• Need to think beyond improvement period
Deciding what to sustain?
National PCMH Curriculum
Identify the features to institutionalize
D
S A
P
Ideas
Improvement
Holding the gains through standard processes and routine work
National PCMH Curriculum
D
S A
P
Ideas
Improvement
Wedges signify making the work routine, no
backsliding!
Improvement is continuous
National PCMH Curriculum
Continually build upon the institutionalized
improvement
Spread exports the essential components…
National PCMH Curriculum: Module 6 DRAFT
Site 1
Site 2
43
…but leaves room for customization
National PCMH Curriculum
Site 1
Site 2
Site-specific features
44
Spread can happen in different ways
Adapted from Greenhalgh T et al. 2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 82(4):581‐629.
Spread mode implications for coaching
Technique Watch for: Natural, passive Slow pace of change and lack of fidelity
Social Dependence on existing channels of communication and on the popularity and energies of the champion for the work
Technical CMEs and how-to manuals don’t change behavior. Buy-in by all staff and leadership support need to be attended to.
Managerial Reinforce the need for flexibility in implementation while adhering to core concepts
Roger’s Theory of Diffusion 47
Factors that make spread successful
The new way is broadly perceived to have relative advantage over other interventions
It is compatible with existing norms and values. Risks are manageable.
The innovation may be complex, but it can be broken down into manageable parts.
Users have some opportunity to try it on a limited basis before adopting.
Users see benefits in a reasonable timeframe Appropriate knowledge and training are present
National PCMH Curriculum Sources: Damschroder L, e al. Implementation Science. 2009;4(1):50. Greenhaugh T et al. Milbank Q 2004;82(4) 581-629
External environment: factors that influence spread
Innovation aligned with patient needs and desires?
External incentives or mandates?
Political and policy climate?
Are competitors doing similar things?
Does organization work closely with other organizations?
Is the external environment stable?
National PCMH Curriculum:
Sources: Damschroder L, e al. Implementation Science. 2009;4(1):50. Greenhaugh T et al. Milbank Q 2004;82(4) 581-629
Internal environment: factors that influence spread
Is leadership informed, supportive, and actively engaged?
Is the innovation ready to spread, and is the system ready for the innovation?
Is the organization small and nimble, or large and regimented? Change may be easier, but less lasting in the former
What is the innovation “climate”? Are staff up to the challenge or at their capacity?
National PCMH Curriculum
Spreading the PCMH at Group Health
National PCMH Curriculum
51
Spread Properties – the Group Health Experience
Relative advantage? At Group Health the advantage was compared to the current state, no alternatives to the PCMH were considered.
Compatible with existing norms and values? What are the risks? It was consistent with the values of primary care and the value of having manageable work lives. Risks were assessed -- particularly the risks of both doing the intervention (losing the money invested), or not doing it (losing the workforce, becoming less competitive).
National PCMH Curriculum:
Can users try it on a limited basis before adopting? Three clinics trialed all the spread interventions to refine them before it was spread to all clinical sites
How quickly are the benefits seen? Through visual display systems, all users were able to see the results right away
National PCMH Curriculum
Spread Properties – the Group Health Experience
Spread Properties – the Group Health Experience (cont.)
Is the innovation complex? Can it be broken down into manageable parts? At Group Health this was key, the intervention was divided into four parts and spread sequentially.
National PCMH Curriculum
Project Funders We would like to thank the following for the generous support:
The Commonwealth Fund (Project Sponsor)
Co-Funders:
Colorado Health Foundation Jewish Healthcare Foundation Northwest Health Foundation
Partners HealthCare The Boston Foundation
Blue Cross Blue Shield of Massachusetts Foundation Blue Cross of Idaho Foundation For Health
Beth Israel Deaconess Medical Center