ALLINA HOSPITALS & ALLINA HOSPITALS & CLINICSCLINICS
Adaptive Health PracticeAdaptive Health Practice
N. Marcus Thygeson, MDN. Marcus Thygeson, [email protected]@allina.
comcom612-262-4945612-262-4945
CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
What is AHP?• Application of Ron Heifetz’s
Adaptive Leadership model to clinical practice
• Three key “simple rules” changes:– Patient must and can do their own
adaptive health work; we can’t do it for them
– But we can help them do it by upgrading our skills and using Adaptive Leadership principles.
– Technology (drugs, procedures, etc.) has limited utility and significant potential for harm—use sparingly and judiciously
CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
Fundamentals of Adaptive Leadership• Complex systems face adaptive
and technical challenges.• Adaptive challenges require
learning and behavior change—adaptive work.
• Technical challenges can be addressed with technical solutions and expertise.
• Technical work will not solve adaptive challenges, and often make the problem worse.
• AL consists of knowing this, and how to help people and organizations do adaptive work.
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CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
Example: GERD and PPIs• Heartburn mostly related to
lifestyle: diet, obesity, tobacco, alcohol.
• Treatment for GERD now: PPIs• Feedback loops: hypergastrinemia
and failure to address lifestyle factors
• Long-term use of PPIs (> 2 months) causes GERD sxs in normal people
• PPIs cause dependency and are addictive
• Prevalence of GERD has doubled in US since PPIs introduced
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CENTER FOR HEALTHCARE INNOVATION
Adaptive Work Avoidance• Failure to adopt healthy
lifestyles (patient)• Failure to address unhealthy
lifestyles (MD)• Terminal chemotherapy
instead of hospice• Spinal fusion instead of active
rehab for disc DJD• Drugs in lieu of exercise, light,
talk therapy, etc. for depression
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CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
Implications• We and our patients are both
avoiding the challenge of doing the adaptive work required to be healthy and cope with suffering.
• We collaborate in this by inappropriately applying technical solutions in lieu of adaptive interventions, and by remaining unskilled in adaptive leadership.
• This causes a lot of harm and inefficiency (waste), and damages the doctor-patient relationship.
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CENTER FOR HEALTHCARE INNOVATION
Why is this happening?• Adaptive work is hard and
often avoided (by patients and providers).
• We aren’t incented to practice adaptively.
• We don’t know how to do it.
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CENTER FOR HEALTHCARE INNOVATION
What should we do?Support patient adaptive work by doing the
adaptive work to change our• Philosophy of practice
– Explicitly identify adaptive challenges and interventions, to ourselves and our patients
– Recognize the limitations of our technical expertise
– Use technology sparingly and judiciously– Adopt a socio-ecological, whole-systems
approach to health– Build our skills as adaptive leaders to help
patients do adaptive health work• System
– Financial incentives– Blind faith in technology– Inputs (staffing, resources, culture)
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CENTER FOR HEALTHCARE INNOVATION
Facilitating adaptive work:• Diagnose the system, and the
problem• Establish a “holding
environment”• Identify the “ripe” issues• Think about your framing• Regulate the “heat”• See yourself as part of the
system• Hold steady• Keep the work at the center of
people’s attention
CENTER FOR HEALTHCARE INNOVATION
CENTER FOR HEALTHCARE INNOVATION
The proper use of technology?• Facilitate adaptive work (e.g.,
exer-gaming, mobile health apps, analgesics to facilitate PT, etc.)
• Relieve suffering that overwhelms patient coping
• Manage risk factors until adaptive work is effective
• Treat disease not amenable to adaptive work
• Avoid technology with long-term negative feedback loops on health
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CENTER FOR HEALTHCARE INNOVATION
Implementation Issues• What does AHP look like
behaviorally, for both patients and doctors?
• For which patients will this work? What to do for patients who respond negatively?
• How do we do the adaptive work to change our system and philosophy of care?
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CENTER FOR HEALTHCARE INNOVATION
Basic AHP• Staff trained on adaptive
leadership• New patients are introduced
to the practice’s philosophy of care
• SOAP approach modified to address both adaptive and technical components
• Measurement reflects both adaptive and technical components
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CENTER FOR HEALTHCARE INNOVATIONSOAP—New and Old
Traditional AHP
S
Standard history Add health beliefs, social support and network, family and work systems, patient complexity, detailed lifestyle inventory, etc.
OStandard physical and diagnostic testing, (PHQ-9 in MN)
Measures of resilience, adaptive capacity, learning orientation, etc. Social network survey?
ADiagnosis, prognosis Distinguish adaptive and technical
challenges explicitly.
P
Treatment, referrals, testing, etc. Distinguish adaptive and technical work. Develop plan for supporting adaptive work, including social and psychological interventions. Avoid technical interventions that reduce adaptive capacity/work.
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CENTER FOR HEALTHCARE INNOVATION
Paths to AHP• Incremental: train staff on
organizational Adaptive Leadership; then support them in generalizing to patient care.
• Transformational: train them directly on applying AL to patient care, and hope the culture accepts it.
• For full development, does this need to be managed as a separate company?
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CENTER FOR HEALTHCARE INNOVATION
Next Steps• Design it
• Pilot and refine it
• Controlled trial? Or just spread it?
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CENTER FOR HEALTHCARE INNOVATION
Suggested References• The Practice of Adaptive
Leadership, by Heifetz, Grashow, and Linsky
• How Clients Make Therapy Work, by Bohart and Tallman
• “Adaptive Leadership and the Practice of Medicine” by Thygeson, Morrissey and Ulstad, JECP 2010