Transformation is Hard Work: Ongoing Evaluation

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Transformation is Hard Work Ongoing Evaluation
Early Lessons from TransforMEDs National
Demonstration Project
Agenda Item IV
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National Demonstration ProjectEvaluation Team

• Center for Research in Family Medicine and
  Primary Care
• Carlos R. Jaén, MD, PhD (PI)
• Benjamin F. Crabtree, PhD
• Paul A. Nutting, MD, MSPH
• William L. Miller, MD, MA
• Kurt C. Stange, MD, PhD
• Elizabeth Stewart, PhD (Qual. Analyst)
• Ray Palmer, PhD (Biostatistician)
• Robert Wood, DrPH (Biostatistician)
• Marivel Davila, MPH (Quant. Analyst)

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NDP Evaluation Process

• The Center is conducting a rigorous, multi-method
  analysis of the NDP, using the combined knowledge
  from 15 years of studying medical practices and
  organizational change.

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National Demonstration Project
www.transformed.com
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NDP Evaluation Process

• Qualitative analysis has been ongoing with
  learnings presented in real time.
• A final report, using both qualitative and
  quantitative data, is expected in 2009.

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Goals of the NDP Evaluation

• To generate and disseminate new knowledge about
  the process of practice transformation.
• To evaluate and compare the effects of two
  transformation approaches (i.e., facilitated vs.
  self-directed) on practice and patient outcomes.

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Goals of the NDP Evaluation

• To determine the effect of the New Model
  implementation on the following
• Patient outcomes
• Patient-centered care
• Staff/physician working relationships
• Financials of the practice

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NDP Qualitative Data

• Continuous collection by facilitators and
  qualitative analyst
• Continuous analysis by Center evaluation team
• - Weekly phone analysis sessions
• - Quarterly analysis retreats
• - Board reports
• - Writing presentations

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NDP Qualitative Data

• Site Visits by facilitators analyst
• Formal Informal Interviews with key
  stakeholders staff
• Process observations
• Observations of patient paths
• Extensive field notes
• Documentation of Communication between
  facilitators practices
• Emails, phone calls, etc

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NDP Qualitative Data

• Shared Learning
• - Monthly multi-practice conference calls
• - Four on-site learning sessions over the
  course of the study
• - Email list serve website stories
• Data Management Analysis
• - Thousands of pages of data are stored
  in a protected qualitative database (Atlas.ti,
  Berlin)
• - Coded for both organizational and
  thematic purposes

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• 7 Early Lessons from the NDP

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1 Complexity Science helps understand
practices

• The understanding of complexity science is
  helpful in understanding practice change.
• Practices cannot be described in mechanistic
  terms, such as linear relationships among events.
  

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1 Complexity Science helps understand practices

• All the parts and people of a practice are
  interconnected and interdependent in terms of
  relationships and functions.
• Changes dont occur in a linear fashion. Small
  changes can have dramatic effects at times, large
  changes can produce small results at others.
• What works in one practice may not work in
  another multiple ways to achieve good outcomes

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2 Change is HARD

• Any change, even a change for the better, is
  always accompanied by drawbacks and discomforts.
  
• (Arnold Bennett)
• The world hates change, yet it is the only thing
  that has brought progress. (Charles Kettering)
• Change is hard really, really hard! (NDP
  Practice)

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2 Change is HARD

• Implementation of new model components,
  especially technology,
• is a monumental task.
• It requires a level of effort and intensity well
  beyond what most practices in studies or QI
  projects have done in the past.

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2 Change is HARD

• Many practices are familiar with making clinical
  changes. However, most practices are unfamiliar
  with changes at the systems level.
• Many do not function as a coordinated system and
  therefore lack insight into the complexity of
  their practice.

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2 Change is HARD
The facilitators have worked to help practices
understand the complexity of their organizations.
They have also worked to help each practice pace
their progress according to their start position
and the overall rigors of the NDP marathon.
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2 Change is HARD
Despite this, implementation of the model has
strained the practices because change is
demanding and rife with unexpected setbacks.
Many are precipitated by the change itself
others are simply the background context of
contemporary primary care practice.
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3 RELATIONSHIPS matter

• Transformation in the world happens when people
  are healed and start investing in other people.
• (Michael W. Smith)

Transformation in the world happens when people
are healed and start investing in other people.
(Michael W. Smith)
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3 RELATIONSHIPS matter

• Before the facilitators could begin making
  changes they had to shore up and fortify the
  practice relationship infrastructure.

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3 RELATIONSHIPS matter

• Several practices have been on the verge of
  either divorce or internal combustion.
• Half day staff retreats and
• team-building sessions planted
• seeds for better communication and mindfulness
  which helped build resiliency for future
  challenges.

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3 RELATIONSHIPS matter

• Often physicians and staff were reluctant to
  participate in such touchy-feely stuff.
• Later, some publicly admitted it was the only
  thing that finally worked.
• Sometimes the emphasis on relationships and
  teamwork led to increased (but needed) conflict
  and/or a natural (and needed) attrition.

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3 RELATIONSHIPS matter

• We knew we had a great potential but didnt know
  what to do with it. Barbara facilitator came
  out for a week and did the Meyers Briggs
  assessment so we could learn about communication.
  Over the week, we learned a little more about
  each other and the intrinsic qualities that make
  us human. By the last day, we realized what we
  had within our midst, the POWER to become a high
  functioning practice. Each of our skill sets
  allows us to contribute to highest quality care
  to our patients. What Barb gave us at that
  retreat was the knowledge that we can be a team,
  and even if we fall back, we can get there
  again.

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3 RELATIONSHIPS matter

• The quality of a practices relationships help
  to determine its capacity to change.
• A practice's capacity for change at baseline is
  a huge determinant for that practice's progress.
• Equally important is the facilitator's ability
  to increase that capacity.

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3 RELATIONSHIPS matter
Capacity to change is dependent upon some of the
key elements facilitators worked to foster in the
beginning
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3 RELATIONSHIPS matter

• Web of healthy relationships
• Mutual trust, respect, and mindfulness
• Strong leadership and decision making
• Culture of learning
• sense-making
• Teamwork

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4 LEADERSHIP is key

• If your actions inspire others to dream more,
  learn more, do more and become more, you are a
  leader.
• (John Quincy Adams)
• Effective leadership is putting first things
  first. (Steven Covey)
• We wanted to be doctors, not leaders. Then we
  learned we had to be both. (NDP physician)

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4 LEADERSHIP is key

• The most successful practices seem to have shared
  leadership systems rather than an individual
  physician leader.
• Leadership systems have complementary pieces
• Practice vision
• 2. Practice operations
• 3. Practice finances

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4 LEADERSHIP is key
When the leadership system is in place, a
practices ability to adopt changes accelerates
significantly.
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5 PERSONAL Transformation is Needed
For some physicians, the new model requires
transformation at the personal level, as
practices must move from a physician-centric
approach to one that is more team-centered and
relationship-centered.
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5 PERSONAL Transformation is needed
Each practice not only has a different way of
implementing the new model, but each change
leader physician has a different vision of what
transformation really is.
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6 Theres no such thing as Plug n Play.
Technology has great potential, but Nothing
talks to anything else. (NDP Physician)
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6 Theres no such thing as Plug n Play.
The technology landscape for medical practices
resembles a pile of different jigsaw puzzles
thrown together. Sorting through and making it
work requires tremendous energy.
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6 Theres no such thing as Plug n Play.

• Different types of practices face different
  technology challenges
• Large systems
• Private solo physicians
• Established vs. new practices
• Workflow changes requires mindfulness and
  planning ahead
• Relationships with vendors

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7 The Elusive Patient-Centered Medical Home


Creating a PCMH is much more than a sum of
implementing discrete model components.
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7 The Elusive Patient-Centered Medical Home

Such transformation is exceedingly difficult, and
those who attempt it are heroic. To achieve
transformation, full engagement of critical
members of the practice is needed. At the same
time, the practice needs to remain in charge of
its own destiny.

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7 The Elusive Patient-Centered Medical Home


Early data from patient surveys suggests that
some facilitated and self-directed practices are
seen as PCMHs by their patients.
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7 The Elusive Patient-Centered Medical Home
This is encouraging and suggests that a PCMH can
be achieved, although it should be acknowledged
that there are multiple pathways to get there.
However, the data also suggest that this
characteristic was largely in place in these
practices at baseline.


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7 The Elusive Patient-Centered Medical Home


No one knows what makes a patient-centered
medical home, but TransforMED has the resources
at hand to become knowledge leaders in this
expanding yet elusive topic.
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7 Early Lessons from the NDP

• Complexity science helps
• Change is HARD
• RELATIONSHIPS matter
• LEADERSHIP is key
• PERSONAL transformation is needed
• There is no such thing as Plug n Play
• The elusive patient-centered medical home not
  a sum of parts

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Patient-defined Medical Home

• Research Question How do patients who have a
  medical home rate key characteristics thought to
  be important for a PCMH?
• 1997 consecutive patients who were seen in NDP
  practices at two points in time completed patient
  outcome mailed surveys

Supported by Commonwealth Fund
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Patient-defined Medical Home

• Patient-defined medical home
• Strongly agree on 2 questions
• I receive exactly the care I want and need when
  and how I want and need it.  
• I am delighted with this practice

Supported by Commonwealth Fund
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Patient-defined Medical Home

• Summary scales of measures
• CPCI advocacy/trust, coordination of care,
  community context, communication, family context,
  integrated comprehensive care, personal physician
  preference, shared knowledge.
• CARE empathy care
• AAMC Tool cultural responsiveness
• PEI patient enablement index
• Supported by Commonwealth Fund

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Supported by Commonwealth Fund