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