week 1 introduction translating evidence into practice: system-centered implementation strategies...
TRANSCRIPT
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Translating Evidence Into Practice: System-Centered Implementation Strategies
Week 1Week 1IntroductionIntroduction
Laura Schmidt, Ph.D, MSW, MPHJim Kahn, MD, MPH
Philip R. Lee Institute for Health Policy Studies
Clinical and Translational InstituteTraining in Clinical Research Program
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Roadmap for today’s introductions
• This Course
• T2 Translational Research
• Organizational Theory at the Systems Level
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Introduction: PART 1Introduction: PART 1
THIS COURSE
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Your Fearless Leaders
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PART ONE:Introduction to systems change
TODAY: Introduction to T2 Research Organizational Environments
WEEK 2: Policy Implementation
WEEK 3: Changing Systems
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PART TWO :Selected tools for systems-level change
DATE SPEAKER TITLE
4//21 Hal Luft Redesigning Benefits Structures: Health Coverage
4/28 Michael Cabana Changing Practice Patterns: Practice Guidelines
5/5 Adams Dudley Changing Organizations via Feedback on Quality
5/12 Diane Rittenhouse Restructuring Organizations: Medical Homes
5/19 Helen Lipton Redesigning Benefits Structures: Drug Formularies
5/26 Molly Cooke Influencing Providers via Professional Societies
6/2 Chris Millet Pay for Performance
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COURSE REQUIREMENTS
• SHOW UP, DO READINGS, ENGAGE
• THINK ABOUT WAYS TO APPLY T2 SYSTEMS INTERVENTIONS TO YOUR AREA OF EXPERTISE
• DEVELOP ONE LOI/BRIEF PROPOSAL
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Introduction: PART 2Introduction: PART 2
WHAT IS TRANSLATIONAL
RESEARCH?
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T1 and T2 TRANSLATIONT1 and T2 TRANSLATION
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Translation as Institutional Initiative
NIH Roadmap for Medical Research
Re-engineering the clinical research enterprise
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DEFINING THE PROBLEM• “Silos:” Institutional and programmatic boundaries had
created fragmented research efforts, training programs and resources that would be effective if integrated.
• “Fragmentation:” The lack of centralized infrastructure has been a huge barrier to conducting clinical and translational research.
• “Balance:” Declining interest in patient-oriented research
• “Lack of collaboration:” Need for a team approach—breaking down barriers between basic and clinical scientists
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Two Spheres of Translational Research
T1 “Roadblock”
-to harness knowledge from basic sciences to produce new drugs, devises and treatment options
-to transfer new understanding on diseases mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy and prevention
• T2 “Roadblock”-ensuring that new treatments
and research knowledge actually reach the patients or populations for whom they are intended and are implemented correctly
-helping clinicians and patients make more informed choices, providing reminders and point-of-care decision support tools, and strengthening the patient-clinician relationship
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Two Spheres of Translational Research
T1Research methods
- molecular biology- genetics- basic sciences- clinical sciences
Settings- strong laboratories- cutting edge technology
Challenges-biological & technological complexities- trial recruitment- regulatory concerns
T2Research Methods
-”implementation science” & org theory-evaluation studies- clinical epidemiology-communication theory- public policy-health services research
Settings- community and practice-based settings- population-based interventions
Challenges-organizational inertia-resource constraints-inability to control “noise”-power relations/vested interests
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Translational Research InfrastructureNIH Clinical and Translational Science Awards
• 24 CTSIs (“academic homes”) already formed• Goal of 60 CTSIs by 2012• Budget of $500 million per year
Multi-Stakeholder Translational Research Programs
European Commission – program centerpiece
Two new journals: Translational MedicineJournal of Translational Medicine
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THE PROMISE OF T2 TRANSLATION
• It could ultimately save more lives than T1
• T2 could make the health care system perform better in delivering what we have
• Greater fidelity in delivering aspirin to eligible patients could prevent more strikes that developing more potent antiplatelet agents
• Increasing patient safety, access and equity could do more to improve health than a new imaging device or class of drugs.
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Introduction PART 2Introduction PART 2
HOW DO WE UNDERSTAND T2 IMPLEMENTATION
AT THE SYSTEMS LEVEL?
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Organizational Environments
Intra- VERSUS Inter- Organizational Theory
Environment supplies resources to organizations (money, people, power, legitimacy)
Organizations are focused on survival not efficiency
Resource Dependency: Power flows to places within the organization that attract resources
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Organizational Fields:One Way to Think about Environments
To ensure mutual survival, organizations form a social order or “organizational field”
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Characteristics of Organizational Fields
• A power structure
• Shared goals, rules and assumptions
• Meaningful roles
• Government organizations are part of the field
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The HEALTH CARE SYSTEM
AS AN
ORGANIZATIONAL FIELD
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The Health Care System
Large Employers
Government Insurance Plans
(e.g., Medicare, Medicaid)
Managed Health Plans(e.g., HMOs, PPOs)
Hospital Corporations“Providers” and
“Consumers”
SUPPLIERS
BUYERS
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Who has power?
LARGE BUYERS:
EMPLOYERS AND GOVERNMENT PURCHASERS
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Government Organizations Play Different Roles
• Government as “venture capitalist”
• Rule maker and enforcer (e.g., FTC, courts)
• Largest Buyer in the market (e.g., Medicare, Medicaid)
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Other Players in the Field
• Health Plans (providers + insurers)• Organized Provider Groups (AMA, ANA)• Quasi-governmental agencies (NCQA)• Supplier corporations (Pharma)• Consumer groups (AARP, Unions)• Educational institutions (UCSF)• Science institutions (NIH, RWJF)
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What is a Health Plan?
provider + insurance = MANAGEDgroup plan HEALTH
PLAN
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CASE STUDY: CASE STUDY:
The U.S. Health Care The U.S. Health Care Transformation (1965-1995)Transformation (1965-1995)
The reorganization of a The reorganization of a fieldfield
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Dr. Marcus Welby: WHAT HAPPENED?
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The Health Care Transformation
Before 1965
• Doctor-controlled order
• Protect doctor-patient
relationship
• Independent, nonprofit organizations
• Non-interference in medical affairs
After 1980
• Buyer-dominated market
• Increase efficiency and cost accountability
• For-profit medical corporations
• Stimulates competition and steers the market
System ofPower
Shared Goals
Roles forOrganizations
Government’sRole
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Summary
• T2 has at least two parts: intra- and inter-organizational change strategies
• Sociology of Organizational Environments provides a frame for understanding systems
• Key aspects of systems: power structure, shared goals, roles for organizations and government