Post on 12-Nov-2014
description
transcript
ADVANCING TRANSFORMATION SCIENCE
Bridges to Sustainable Healthcare Transformation Through Evidence, Partnerships & Technology:
19th International ConferenceSan Francisco, CA, January 19-22, 2011
Brad Doebbeling, MD, MScProfessor 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
Crucial for Evaluation, Analysis, Funding & Publishing
Frameworks
Social Subsystem• Key stakeholder views • Patient barriers/facilitators• Organizational buy-in• Leadership support• Training• Unintended social
consequences
Technical Subsystem• Usability• Functionality/scope• Computer/IT support• Flexibility in IT tools• Iterative design• Unintended technical
consequences
Joint Optimization• Integration of CDS -
for CRC screening - into clinical workflow
External Subsystem (Context)• PERFORMANCE MEASUREMENT• Workload• Financial factors• Unintended external
consequences
Socio-technical Systems Framework
Westbrook et al., JAMIA, 2007; Harrison et al., JAMIA 2007
Birth
Maturity
Creative Destruction
Renewal
For more information on the ecocyle go to http://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html
Panarchy or Ecocycle Model of Change
Network or group level
A change in conversation A change in routine A change in resource commitment or influence
Institutional level
A change in culture A change in laws A change in resource distribution/availability
Organizational level
A change in strategiesA change in procedures A change in resource distribution/availability
Individual level
A change of heart A change of habits A change of ambition
“Getting To Maybe: How the World is Changed”Frances Westley, Brenda Zimmerman, Michael Patton, 1996, Random House Canada
Novel Transformation Strategies
Implementation & Spread
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
Core not dense enough
Obvious clusters, not well integrated
Core not diverse – too small
Example – Before – Montana Hospital
Core is much more dense
Core is more diverse – more departments and roles present
Still room for improvement…
Example – After – Montana Hospital
Identifying Effective Transformation Strategies
Strategy
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
Strategies from Regenstrief Conference
Complex Adaptive Systems Framework
-Conceptual framework of complexity dynamics and complex adaptive systems.-Ground quality improvement strategies in a theoretical perspective that views primary care practices as dynamic complex adaptive systems
Fostering Organizational Redesign
-Conceptualize organizations as a series of conversations.-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 Measures and Incentives
-Develop new approaches to evaluation of the performance measurement system.-Develop new measures to identify and address gaps in the current system.
Continuous Learning Organizations
-End-users need to make the research “right” for their context—customize guidelines for local use.-Continuous learning organizations set measurable targets for change, assess progress and provide feedback to stakeholders.
Integrating Health Information and Communication Technologies
-The implementation of evidence-based tools, resources and information systems at the point of care.-The use of telemedicine/Personal Health Records to improve access to care and improve health outcomes.
Doebbeling & Flanagan, Medical Care (in revision, 2011)
Related Research QuestionsComplex 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 Technologies
-What type of health information promotes collaboration between patient and provider?-What health information innovation development implementation strategies influence uptake?
Doebbeling & Flanagan, Medical Care (in revision, 2011)
Collaborating Across Programs
“Collaboratories”
Needed R&D
Negotiation
ConflictManagement
Facilitation
Collaboration
Difficult Conversations
Strategy
Innovation
My Conclusions
DATA POOLDATA POOL
From Argyris & Schon
My Analysis
Relevant Data
The Publication
SHARE
ASK
SHARE
ASK
SHARE
ASK
My Conclusions
Their Analysis
Relevant Data
DATA POOL
Their Conclusions
DATA POOLFrom Argyris & Schon
My Analysis
Relevant Data
Collaboration
Collaboration = Communication+ Skill + Context (Leadership x Culture)
Wikis: our work
Blog: my thinking
Twitter: peripheral awareness
Email: specific question
1. (Communication) Tools
Harvard Negotiation Project
If “Yes”
Commitment
If “No”
Alternatives
Interests
Options
Legitimacy
CommunicationRelationship
Delivery Systems
Needed R&D
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.
Delivery System Evaluation FOA10-012. 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
ARRA Delivery System FOA Grantees: Impacted Sites of Care(1-2 sites per study)
7
3
13
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Hospital Other Specialty Primary Care
ARRA Delivery System FOA Grantees: Primary Health Conditions
Cardiological conditions +
hypertension, 2
Pediatric Health, 1
Orthopedics, 1
Multiple Chronic Conditions, 6
Asthma, 1
Mental Health + substance abuse,
4
Chronic Kidney Disease, 1
ARRA Delivery System FOA Grantees: Geographic Spread
1
National =2
5
1
1
1
1
1
32
22
1
2
1
2
1
1
2
1 1
1
1
2
Information System & Cognitive Support Research
Needed R&D
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
SHARP program
Fill technology gaps for nation-wide, meaningful use of electronic health records (EHR)
Awardee Research Focus Area
University of Illinois at Urbana-Champaign (#10510624)
Security of Health Information Technology
The University of Texas Health Science Center at Houston (#10510592)
Patient-Centered Cognitive Support
Harvard University (#10510924)
Healthcare Application and Network Platform Architectures
Mayo Clinic College of Medicine (#10510949)
Secondary Use of EHR Data
Data capture and information sharing
Advanced clinical processes
Improved outcomes
Long-term Approach to Meaningful Use
o Stage 1 – 2011
Stage 2 – 2013
Stage 3 – 2015
Rtn
http://www.cms.gov/ehrincentiveprograms/
“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
As-is care process model
Information architectures
Improved processmodels Sensitivity
analysis
S/W implement
ation models
Trade-off analysis
Better care process
Cost-effectiveHIT system
Information usageRisk & cost
Value to care
Care-centered design
Technology-centered design
Keith Butler, U Wash, SHARP-C
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
“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
Thank You!
Questions?
Contact Brad Doebbeling bdoebbeling@gmail.com