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• Accelerating Clinical Transformation Using
  Community Collaboration Tools

Using online communities to accelerate innovation
adoption
Janet Guptill, PresidentKM At Work, Inc.
Neal Sofian, CEO The NewSof Group, Inc.
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Clinical Transformation and Communities of
Practice

• Why do we know that communities are a key
  component to accelerating adoption of innovative
  practices and technologies?
• The science behind individual behavior change
• The basis behind organizational change
• The role that communities and social networks
  play in creating change
• How do we systematically address accelerating
  adoption of innovative practices within hospital
  systems?
• Lessons learned from the practice of knowledge
  management
• Examples of hospital systems engaged in
  communities of practice to accelerate
  transformation
• How can Perot Systems, KM At Work, and NewSof
  bring a combined solution to its hospital system
  clients?

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The Problem

• Medical costs are too high
• Access to medical care is inconsistent
• Patient outcomes are not as good as they should
  be
• Practices are not optimal and significant
  variations persist, even with evidence-based
  medical guidelines
• Limited means to measure change and progress
• Knowledge remains in unusable silos

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Creating Systemic Change Within Across
Hospital Systems is Critical

• Hospitals need a simple way to learn from their
  peers in order to
• Share both formal and informal successful
  practices, success factors and lessons learned
• Access a searchable repository of content, both
  internally developed and externally contributed,
  to identify evidence-based practices, relevant
  research, and context-sensitive knowledge
• Identify and extend the reach of expert resources
  across member hospitals
• Connect with peers for just in time access to
  critical new knowledge at the point of care and
  the point of need
• Create and develop new knowledge regarding
  business and care practices
• Improve formal and informal communication
  regarding common projects, challenges, and
  environments.

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Guiding Principles Diffusion of Innovation

• Transferring knowledge is often not enough need
  to figure out how to transfer capabilities as
  well, through human and technology enabled
  support systems
• Getting an organization to adapt new ideas
  requires a process of re-inventionpeople need to
  own the result as their own idea--

• 10 Critical Dynamics of Innovation Diffusion
• Relative Advantage
• Trialability
• Observability
• Communications Channels
• Homophilous Groups
• Pace of Innovation/Reinvention
• Norms, Roles, and Social Networks
• Opinion Leaders
• Compatibility
• Infrastructure
• Source Diffusion of Innovations, Everett Rogers,
  1995

Diffusion is the process by which an innovation
is communicated through certain channels over
time among the members of a social system.
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Requirements of Effective System Change

• It Aint Dog Food if the Dog Dont Eat It!
• The program is only as good as the users
  willingness to use it
• Suction, Not Pressure!
• Develop internal motivations, align incentives
• Information is Not Enough
• If it was we wouldnt be talking today
• Watch What They Do, Not What They Say!
• People often tell you what they wish rather than
  how they actually behave. Design interventions
  and communication accordingly.
• Listen to Your MoM!
• (Microcultures of Meaning) Useful information is
  made relevant through people

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Creating Systemic Change

• Focus on the reach and richness of content
  (information alone is not enough)
• Creating change is both an individual and
  organizational process
• Think of behavior as a transaction by creating a
  health action, medical event, care process, or
  business exchange
• Create micro-cultures of meaning (to create
  context, tacit knowledge, and connectivity) at
  both the individual and organizational level
• Make contextual information available at the
  point of care or need
• Incent all parties toward the same outcomes
• Integrate multiple mediums and learning styles
• Focus on what people do, not what they say
• Start with the person, not the risk, issue, or
  technology
• Build relationships and process, not products and
  programs

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The Science

• Recent report human beings are Hardwired to
  Connect
• We are biologically primed for finding meaning
  through attachment to others
• Learning is social
• Acting on learning comes from context
• Context comes from the groups of like meaning or
  Micro-cultures of Meaning (MoM)
• Social Constructionism demonstrates that learning
  is always based on the context and language or
  stories of the group

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Change drivers in an online community

• Communication pervasive, ongoing, and
  multi-modal dont rely on email alone
• Context Information is not sufficient to create
  change it must be presented with the context to
  make it useful
• Coaching A suite of tools over time using
  multi-modalities and learning styles based on the
  degree of complexity or challenge in adopting the
  new behavior
• Connections Change processes and support
  resources need to be customized to the audience -
  Build relationships, not products Strive for
  continual improvement not a single event
• Coin Align incentives of all the stakeholders
  and participants
• Culture It is part of the core, not peripheral
  to a strategy - Personal stories/experience are a
  key driver in transmitting this strategy - Start
  with the person, not the technology or problem
• Create Microcultures of Meaning (MoM)

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Timeline of Behavior Models

• 1927 Pavlov
• 1930s Skinner
• 1935 Lewin Field Theory and Group Process
• 1950s Hockburn, Rosenstock, Health Belief Model
• Kasl, and Cobb
• 1957 Festinger Cognitive Consistency Model
• 1958 Heider Attribution Theory
• 1968 Slovic and Liechtenstein Prospect Theory
• 1972 Sayeki Multiattribute Utility Theory
• 1975 Rogers Protection Motivation Theory
• 1977 Bandura Social learning theory
• 1979 Bettman Consumer Information Processing
• 1980 Green PRECEDE
• 1982 Kotler Social Marketing
• 1982 Leventhal, Zimmerman, Self-regulation
  theory
• and Guttman
• 1982 Prochaska and Transtheoretical model
• Diclemente
• 1982 Ajzen Theory of Planned Behavior

Celeste Cafiero, Fern Carness, Changing Patient
Behavior
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What is a Microculture of Meaning?

• A community of people with common need or purpose
• Its about connecting people and their knowledge
  (explicit implicit) allowing them to
  communicate, share common experiences, interpret
  information, solve problems (personal, social,
  work), collaborate
• It assumes the consumer as well as the provider
  of information is a valuable source of actionable
  knowledge
• It can be a virtual support group, a form of
  intervention, training extension or a community
  of practice
• It is a way to build a comfortable place which
  facilitates action - intertwining interaction
  with contextual and professional information
• It is designed to turn information into usable
  knowledge
• It is far more than a collection of applications
• Interactions match normal community behavior with
  the added benefits of the reach and richness that
  technology can support

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What is Context?
The beliefs, values, institutions, customs,
labels, laws, divisions of labor, and the like
that make up our social realities are constructed
by members of a culture as they interact with one
another. That is, societies (communities)
construct the lenses through which their
members interpret the world (Freedman, 1996). We
see this as central for empowering effective
change at an individual or organizational level.
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Why is Context Important?
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Creating Community within a Hospital System and
Across Systems
Make networking explicit expected
Create room for reflection re-invention
Knowledge requires connecting people and content
Technology is essential but not sufficient
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Who is Like Me?

• Me can be based on
• Demographics age, sex, ethnicity, marital
  status, geography, work type
• Circumstances disease/risk state, club
  affiliation, employer, job role, a common problem
  and/or task, intra/inter mural work team, a
  common passion and/or need
• Common experience professional affiliation,
  alumni/veteran, an academic pursuit, attending
  particular events, caring for someone with a
  disability, hobby
• Me can be any or all of the above and more!
• In a hospital setting Me is often defined in
  terms of
• Physicians similar specialties, training,
  patient mix
• Nurses similar care setting, job
  responsibilities, roles in care process
  improvement
• Managers similar functional responsibility,
  strategic priority
• Patients and Families based on disease,
  condition, or medical experience
• Facilities demographics of patients, physical
  setting, affiliation

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Five Key Elements to Effective Collaboration

• Trust Participants must feel this is a trusted
  source of useful knowledge
• Relevance The knowledge that is shared applies
  directly to them
• Urgency The resources shared will help a member
  solve a problem quickly
• Incentive Collaborating helps advance career
  and/or job status or even personal health its
  worth it
• Reciprocity If I help someone with my knowledge
  or experience, someone will help me
• These are encouraged and reinforced within a MoM

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Guiding Principles Communities of Practice
Connecting people through online/offline
communities of practice involves building a set
of tools that simplify communication, link people
to content, and provide measurements of value and
impact--

• Key Technology Considerations
• for Supporting Communities of
• Practice
• Presence and visibility
• Rhythm
• Variety of interactions
• Efficiency of involvement
• Short-term value
• Long-term value
• Connection to the world
• Personal identity
• Communal identity
• Belonging and relationships
• Complex boundaries
• Evolution maturation and integration
• Active community-building
• Source Etienne Wenger, Supporting Communities of
  Practice, March 2001

Ideas and products and messages and behaviors
spread just like viruses do.-Malcolm Gladwell,
The Tipping Point
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How a MoM Works Online

• Personal Behavior The Online Functionality
• Greeting/Welcome Registration, Personal Web Page
  Profile, Welcome email Prepackaged links
  (based on profile) of applications, people,
  content, resources for new users
• Gathering Member Directory, Search, Friends
  List Chat
• Giving/Referring Discussion and Chat, Resource
  Contributions and opinion giving Ratings,
  volunteering, and Expression Gallery
• Finding Help, Sharing Resources, Ask the
  Community Manager, Search
• Helping/Instructing Multimedia Stories, Talk
  shows, Web logs, Moderated Chats and
  Discussion Boards, Web casts
• Family/Patient/Peer Web logs. Secure internal
  email, External email Updates/notification
• Connecting Email, Chat, Discussion Boards,
  Group Web logs
• Relationship forming Tailored newsletters,
  personalization filters and email
  notification of relevant knowledge, people,
  status within the community, and resources
• All functionality must be tied together
  matching human behavior. The whole is always
  greater than the sums of the functional parts

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How a MoM Works Online

• Professional Behavior The Online Functionality
• Greeting/Capabilities Registration, Personal Web
  Page Profile, Welcome assessment, team
  building, email Prepackaged links (based on
  profile) of applications, people, content,
  resources for new users
• Team Development Member Directory, Search,
  Friends List, Chat, Web connection
  interface
• Collaborating, Co-development Discussion with
  Presentation and Chat, Resource Contributions
  and Ratings and Expression Gallery
• Proven Practices Resources, Ask the Community
  Manager, Search
• Training, Online seminars Multimedia Stories,
  Talk shows, Web logs, Moderated
• Professional Development Chats and Discussion
  Boards, Web casts
• New Research, Innovations Web logs. Secure
  internal email, External email
  Collaborating notification
• Networking, Shop Talk Email, Chat, Discussion
  Boards with Presentations, Group Web logs
  with controls over access
• Grand Rounds, In-service Tailored newsletters,
  personalization filters and email

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Sample Collaboration Tools

• Community building and connectivity tools
• Personal repository for all user saved content,
  presentations/education sessions attended and the
  members who attended, people of personal
  interest, resources, lessons learned, web logs,
  identified discussion boards, external weblinks,
  etc.
• System-generated messages, surveys,
  announcements, service offerings, education
  schedules, etc.
• Community Member web pages, sharing contact
  information and member interests and needs, to
  support expertise locator function
• Ad-hoc communities for attendees of events to
  support ongoing discussions
• Discussion boards (asynchronous)
• Chats (real-time)
• Email tied to existing email systems, as desired
• Individual and/or group web logs
• Special events capabilities Web casting,
  moderated chats, etc.

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Sample Collaboration Tools

• A searchable content repository
• Audio, video, presentation, and support materials
  of in-person, teleconference or other educational
  programs
• Email notification of all new content, resources
  and connections as desired
• Searchable and rate-able research, resources,
  people
• Accessible intuitive web pages and directories
  for individual users
• Easily searchable successful practices, case
  studies and lessons learned (can be submitted
  and/or retrieved) and attached documents
• Resource/document sharing in multiple formats
• Online surveys with ability to deliver tailored
  responses and information
• Benchmarking capabilities regarding successful
  practices, resources and lessons learned

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Knowledge ManagementThree typical uses in
hospitals

• Clinical Decision Support - Incorporating
  evidence-based medical knowledge
• Performance Improvement - Using scorecards,
  analysis methodologies, etc.
• Multi-Site Collaboration - Collaborative
  knowledge-sharing forums
• Build trust
• Facilitate peer-to-peer knowledge transfer

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Collaboration Tools Connecting Resources and
People in Real Time and When There is Time
Who has expertise in this area?
Who else faces similar challenges to mine?
Is anyone else working on problems like mine?
What ideas have been tried and tested?
How can I share what I have learned?
Is there a recommended way to do this?
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Collaboration Tools Lessons Learned from Other
Industries
Saved tens of millions of dollars by creating a
worldwide repository of best practices
1.5 million in savings from two of its
communities of practice
More than 1 billion in documented bottom-line
savings since 1995
Gained 1.5B in annual wafer manufacturing
capacity by sharing best practices
50 million a year in travel cost avoidance and
6 million annually by finding information more
quickly through its KM initiative
Virtual collaboration has become the way
business is conducted - APQC.org
Saved more than 150M in the first year of an
initiative to identify and share marketing best
practices
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Health System Collaboration Examples
Our goal is for CHI to become known as an
innovative organization. That will be our legacy
for the future health care system that CHI
learns to leverage the wisdom of the whole,
efficiently, effectively and humanely. -
Kevin E. Lofton, FACHE, CEO, Catholic Health
Initiatives
Each year, CHRISTUS Health presents Touchstone
Awards to those practices and programs that stand
out as touchstones in exemplifying the Mission
and Values of one of our Directions of Excellence
The Ascension Health Exchange is a collection of
online Communities designed to facilitate sharing
and foster innovation and quality improvement
across Ascension Health to achieve our Calls to
Action
Implementing a One VA information technology framework that supports the integration of information across business lines and provides a source of consistent, reliable, accurate and secure information to veterans and their families, employees and stakeholders.
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Health System KM Examples

• Catholic Health Initiatives 67 hospitals in 19
  states, 67,000 employees, 6 billion annual
  operating revenues focus on Knowledge
  Communities
• Ascension Health 67 hospitals in 20 states,
  100,000 employees, 9 billion annual operating
  revenues focus on Content Management
• Bon Secours Health System Inc. 24 hospitals in
  8 states, 27,000 employees, 2.3 billion annual
  operating revenues focus on Capability Transfer
• CHRISTUS Health 34 hospitals in 5 states and
  Mexico, 25,000 employees, 2 billion annual
  operating revenues focus on Best Practices
  Knowledge Transfer
• Veterans Health Administration 23 integrated
  service networks, 24 billion in annual operating
  expenses focus on Tracking and Metrics
• Air Force Medical Service 74 hospitals and
  clinics distributed all over the globe, 6.2B
  expenses, 39,000 employees focus on technology
  and support infrastructure

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What does it take to make change happen in
hospital systems?
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The Process for Effective KM
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The Elements of Comprehensive KM
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Key Components of System-wide KM
System Internal Communities
System External Communities
Directory Knowledge Communities Link to national
strategy SMEs
Health information resources Health risk
assessments Community service mission
System ProfessionalDevelopment
System Knowledge Warehouse
ELearning Leadership Development Mentoring Career
Opportunities Performance Appraisals
Research Proven Practices Facility
Profiles Performance Improvement
System Value Measurement
System Knowledge Cultivation
Knowledge Creation Knowledge Transfer Knowledge
Stewardship Knowledge Coaching
Satisfaction surveys Success stories Activity
metrics
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Knowledge Transfer for Performance Improvement
A Framework
Leadership/ Management
People/Culture
Process
Technology
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Knowledge Management How do we do it?

• 1. Create the infrastructure
• Access Make it easy for people to find the
  knowledge they need
• Apply Provide the context for making the
  knowledge relevant
• Accelerate Inoculate the organization with
  successes
• Build knowledge transfer into organizational
  goals
• Strategy clearly articulate the expected
  outcomes
• Design Understand the processes and supporting
  technology needed
• Operations Integrate into existing staff roles
  and responsibilities
• 3. Measure the results
• Value connect knowledge sharing to
  organizational impact
• Metrics Collect satisfaction, process, and
  outcome measures
• Communicate Share success stories, continually
  educate

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Create the Infrastructure to Share Knowledge

• Access Simplify electronic access to critical
  knowledge and the people who created it and
  become more transparent in sharing hospital
  performance indicators
• Web-based repositories
• Best practice libraries
• Experiential knowledge sharing
• Search and submit capabilities
• Data and benchmarks
• Guidelines
• Embedded clinical rules alerts
• Community creation toolkits

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Create the Infrastructure to Share Knowledge

• Apply Facilitate peer connections to
• Share explicit (documents) and tacit (experience)
  knowledge
• Apply general knowledge to specific issues
• Talk about performance improvement
• Build trust to support change
• Innovate
• Blended Learning Email, telephone, face-to-face
• Codified community roles Moderator, recorder,
  coordinator
• Formalized ways to legitimize participation
• Communication tools
• Connect people with experience and need
• Success stories

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Create the Infrastructure to Share Knowledge

• Accelerate Consider dedicated resources to
  accelerate adoption of new knowledge Documents,
  educational forums, personalized support
• Peer exchange bank
• Project management
• Consulting
• Train-the-trainer
• Pilots
• Packaged documentation
• Awards and incentives
• Ongoing community facilitation

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Build knowledge acceleration into strategic goals
an example
CHIs Desired Future State gives focus to its
preferred future, and describes the key
attributes and imperatives of that future. Five
Core Strategies People, Information, Quality,
Performance, and Growth will focus the
investments in time, money and human energy that
CHI believes will be imperative for staying the
course and sustaining momentum toward its Desired
Future State. CHIs strategic focus will also be
infused with a spirit of Innovation that
fosters and rewards creative thinking and
accelerates learning Knowledge exchange to
ensure CHIs success in a dynamic health care
environment and Partnership with employees,
physicians, local communities, and other
organizations that will advance CHIs efforts in
advocacy, research and development, deployment of
medical/information technologies and the creation
of new models of care.
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Measure the results examples
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Building Communities within/across Hospital
Systems Key Phases

1. Strategy clarify objectives, envision the
   future
2. Assessment understand current state, identify
   needed changes
3. Design delineate the components to be built,
   create a working prototype, develop
   implementation plan, specifications document, and
   cost
4. Build create knowledge creation transfer
   processes, develop the tools and templates,
   integrate with IT strategy
5. Operationalize support, customization,
   training, documentation, maintenance updates

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Phase 1 - Strategy

• Clarify Objectives WIIFM? For relevant
  participants (physicians, nurses, managers,
  patients)
• Increase customer satisfaction, improve service
  quality, reduce response time
• Improve outcomes
• Reduce unnecessary variation
• Recruit and retain qualified staff
• Reduce costs, streamline operations, avoid
  duplication
• Picture Future Success - Describe the future from
  all stakeholder perspectives
• Identify Oversight team and key contact points to
  synchronize on KM aims

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Phase 2 - Assessment

• Current state how well do current tools and
  processes work? What needs to be kept,
  eliminated, enhanced, created? How do people
  currently communicate/share with each other?
• Culture what barriers exist regarding sharing
  and reuse of knowledge? What are the most
  effective means of communication between
  individuals and teams?
• Processes how do we bake it in to create,
  capture, share, and reuse knowledge?
• Vitality what are key roles needed to keep the
  knowledge current, relevant, and critical?
• IT Infrastructure what currently exists and
  what are the gaps? How will the databases
  integrate? What are internal vs. external access
  points? Where do current IT plans fit in?

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Phase 3 - Design

• Feedback identify pilots to model the new
  vision and try out the new approaches
• Prototype create a working example for
  clinicians, managers, patients if appropriate -
  to generate detailed user feedback and develop
  roll-out plans
• Context create links to existing data sets,
  tools, and people incorporate external resource
  links and resources
• Learning refine and create new knowledge
  creation transfer processes
• Assessment determine how to measure and track
  the value
• Innovation and New Directions incorporate
  planning for the future, including new care
  delivery, staffing, and payment models

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Phase 4 - Build

• Create core processes
• Communities of practice roles, rules,
  requirements
• Knowledge creation transfer techniques
• Integrated clinical information systems
• Data Warehouse and Reporting
• Education and Development
• Develop technology plan
• Develop collaborative spaces internal and
  external
• Integrate the underlying database model into the
  overall IT strategy
• Develop and conduct training programs
• Integrate user feedback tracking and value
  metrics reporting
• Modify processes, tools, and reporting based on
  how people actually use them
• Develop operations plan
• Knowledge community roles, rules, support
• Content management roles, rules, support
• Professional development program
• Knowledge cultivation program
• Customer relationship management programs
• Communications plan

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Phase 5 - Operationalize

• Identify recruit key opinion leaders/magnets to
  participation and leadership
• Ongoing coaching of knowledge community leaders,
  content librarians, and technology stewards
• Ongoing execution of knowledge creation
  transfer processes
• Ongoing training and adoption support
• Ongoing tool development, software maintenance,
  capability upgrades
• Ongoing communication strategy support
• Ongoing integration with overall IT strategy

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Catholic Health Initiatives (CHI)
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Ascension Health
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CHRISTUS
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Bon Secours Health System
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Air Force Medical Service
Knowledge Junction TM Concept
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Lessons Learned

• People to People Connection is critical!
• Executive Support is required to gain acceptance.
• Link directly to the core strategies of the
  organization.
• Tools Templates simplify the process for
  participation.
• Dont over-engineer the process of sharing!
• Maintain flexibility stay focused on needs!

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Lessons Learned

• Prototyping pilot new tools with small groups.
• Patience it takes time and behavioral change
  for this to become the way we work.
• Self Service make it easy and rewarding for
  people to utilize the tools themselves.
• Success Stories build momentum and recognize
  the
• heroes.
• Partner with IT technology can greatly enhance
  the
• collaboration and sharing process.

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Final Thoughts

• Specific responsibility for connecting the dots
  increases the speed of connection define who
  will be responsible for the knowledge sharing
  strategy.
• Performance improvement can be multiplied by
  spreading ideas from one department or facility
  to others integrate performance improvement
  resources into the design.
• Recognition for sharing increases participation
  both formal and informal communication is key.
• A focus on connection increases the speed of
  adoption of proven practices proactively manage
  the social networks.