Sustaining and Spreading Medical Home Transformation

Transcription

1 Sustaining and Spreading Medical Home Transformation Moderator: Nicole Van Borkulo, MEd, Qualis Health Speakers: Mindy Stadtlander, MPH, CareOregon Robert Reid, MD, PhD, Assoc. Investigator, Group Health Research Institute

2 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

3 Spread and Sustainability in Medical Home Transformation Mindy Stadtlander, MPH Clinical Systems Innovation Program Manager, CareOregon

4 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

5 SPREAD To distribute widely To expand the impact of an intervention/workflow SUSTAINABILITY Ability to maintain/ hold the gains Ensure continuity in improvement

6 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,

7 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,

8 Add communication and change management training Have teams that have gone before provide training Add Sustainability Team Provide Providers- Only session Add postimplementation collaborative meetings Shift to interactive trainings

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10 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

11 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

12 Identify key strategic measures Identify positive outliers Use them to understand best practice

13 Source: Multnomah County Health Department, Portland OR Pilot Clinic

14 Source: Multnomah County Health Department, Portland OR

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16 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

17 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

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21 Process Benefits (beyond patient care) Credibility Adaptability Ability to monitor progress Helpful resource: NHS Sustainability Guide Staff Involvement in training Attitudes towards sustaining the change Senior and Clinical leadership engagement Organization Alignment with strategic aims Infrastructure

22 Standard Work Visual Management Orientation and Training

23 Implementation Monitoring Training Can also be applied to leadership Rounding Checking

24 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

25 Do 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 Don t Create it in an administrative conference room Put it in a binder! Make it difficult to change/ improve

26 Allows you to detect quickly what is normal and what is abnormal

27 Teams develop and maintain visual boards Leaders go and see and ask questions Visual Management

28 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

29 Visual Improvement Board Clinic Vision/ Aim Outcome Measures Current Improvement Projects / Process Measures Staff Engagement Customer Service Visitor Comments

30 Source: Multnomah County Health Department, Portland OR, Telephone Improvement Kaizen Source: Old Town Clinic, Portland OR, Leadership Improvement Board

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32 How will you communicate with new staff the process? What training materials and needed? Should core competencies be updated? Who will train new staff?

33 Ongoing training and development Role group meetings Updates at staff meetings Collaborative meetings Job descriptions Competencies Employee evaluations

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35 Goal 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 Summary There are a few papers out there that are really helpful to spur your thinking IHI and NHS Take what is useful and resonates with your clinic culture You are not alone!

36 Mindy Stadtlander:

37 Perspectives on Sustaining & Spreading PCMH Transformation Rob Reid MD PhD Group Health Research Institute December 19, 2012

38 Sustainability & Spread It s not the innovation that matters most; it s what happens after the innovation.

39 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

40 Deciding what to sustain? Improvement P A D S Identify the features to institutionalize Ideas National PCMH Curriculum

41 Holding the gains through standard processes and routine work Improvement Ideas P A D S Wedges signify making the work routine, no backsliding! National PCMH Curriculum

42 Improvement is continuous Continually build upon the institutionalized improvement National PCMH Curriculum

43 Spread exports the essential components 43 Site 1 Site 2 National PCMH Curriculum: Module 6 DRAFT

44 but leaves room for customization 44 Site-specific features Site 1 Site 2 National PCMH Curriculum

45 Spread can happen in different ways Adapted from Greenhalgh T et al Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 82(4):

46 Spread mode implications for coaching Technique Natural, passive Social Technical Managerial Watch for: Slow pace of change and lack of fidelity Dependence on existing channels of communication and on the popularity and energies of the champion for the work CMEs and how-to manuals don t change behavior. Buyin by all staff and leadership support need to be attended to. Reinforce the need for flexibility in implementation while adhering to core concepts

47 47 Roger s Theory of Diffusion

48 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 Sources: Damschroder L, e al. Implementation Science. 2009;4(1):50. Greenhaugh T et al. Milbank Q 2004;82(4) National PCMH Curriculum

49 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? Sources: Damschroder L, e al. Implementation Science. 2009;4(1):50. Greenhaugh T et al. Milbank Q 2004;82(4) National PCMH Curriculum:

50 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

51 Spreading the PCMH at Group Health 51 National PCMH Curriculum

52 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:

53 Spread Properties the Group Health Experience 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

54 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

55 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