MaineHealth

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MaineHealth Diabetes, Obesity, Cardiovascular
DOC Collaborative
Learning Session 3 Spreading Improvement
Overcoming Obstacles to Change Lisa Letourneau
MD, MPH

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Objectives

• Share concepts underlying spread and sustaining
  clinical improvements
• Understand how current work fits into broader
  environment of practice improvement
• Encourage thinking about ways to begin planning
  - or further develop your plans - to spread and
  sustain your work to date

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But Dont Good Ideas Just Spread Naturally??

• Most innovations in practice diffuse at a
  disappointingly slow rate
• Average time between appearance of good
  evidence in scientific literature and practice
  adoption gt 9yrs
• Sometimes longer Capn Cook, British navy,
  scurvy 264 years to change practice!!

D. Berwick, JAMA, April 2003
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The CONTEXT Current Healthcare Systems
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Why Is Spread So Slow?

• Science of diffusion of innovation (E. Rogers,
  Diffusion of Innovation, 1995 A. Van de Ven,
  others)
• 3 basic clusters of influence that correlate
  with rate of change of spread
• Perceptions of the proposed innovation
• Characteristics of those being asked to adopt it
• Contextual factors e.g. leadership,
  communication, incentives, management

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Perceptions of the Innovation

• Is proposed change a benefit??
• Is the change compatible with current values,
  beliefs, needs?
• How complex is proposed innovation?
• Simple innovations spread more quickly than
  complex ones
• Flexible innovations more acceptable than those
  needing rigid compliance

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Quality Care
Effective Change

• Right Patient
• Right Treatment
• Right Time
• Right Place
• Right Cost

• Right Idea
• Right People
• Right Time
• Right Place
• Right Cost

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Adopter Categorization Speed of Adoption
Late Majority
Early Majority
Early Adopters
Traditionalists
Innovators
2
13
35
35
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Contextual Factors

• Organizational culture, leadership
• Is innovation valued, supported, rewarded?
• Who are the opinion leaders, and what do they
  support?
• (NOTE opinion leaders are NOT necessarily
  innovators or early adopters!)

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Diffusion S-Curve the Tipping Point
Full adoption of change
100 50 20 0
Adoption of Change

• Tipping Point
• Occurs between 15-20 adoption
• Change acquires its own momentum
• Becomes difficult to stop!

Introduction of change
Time
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Disseminating Innovations in Health Care D.
Berwick

• Find sound innovations
• Find support innovators
• Invest in early adopters
• Make early adopter activity observable
• Trust and enable reinvention
• Create slack for change
• Lead by example

D. Berwick, JAMA, April 2003
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Key Components of a Spread Strategy

• Infrastructure
• Social system
• Communication
• Measurement and feedback
• Recognition and reward

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Adoption is a DOING thing!
BETTER IDEAS
COMMUNICATED
In a certain way
Happen over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2001, Sarah W. Fraser
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Recognize Reward

• Recognize sincere effort at every opportunity
• Give credit to all involved
• Celebrate early and often
• Recognize power rewards (even small ones!)

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Recognize Reward

• There is no limit to what we can accomplish if
  nobody cares who gets the credit

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The top ten (or so) list of sticking points to
change

• Physicians, RNs, MAs too busy
• Wheres the evidence
• Is so-and-so doing it?
• I dont know how, I dont remember
• The EMR is coming, the EMR is coming, the EMR is
  coming

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And then theres

• Its the patients fault, not our
  responsibility
• It wont work here, because (aka Its not
  how we do it here)
• Absence, or checking out
• Whos paying for this anyway?

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Potential Spread Strategies

• Optional
• Collective
• Authoritarian

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Most Well-Perceived Optional

• (Secret Ingredient add liberal amounts of
  increasing pressure)

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Sources of Pressure

• Organizational leadership
• Sense of organizational fit
• Peers
• Believable, transparent data (especially
  comparative data!)
• Capitalize on other external drivers, views from
  the future

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ConsiderSelf Management Support for the
Practice Team

• Visible senior leader support for change
• Practice-based process redesign (e.g.
  point-of-care prompts, registry maintenance,
  recall system, standing orders, etc)
• Allow for reasonable reinvention at each site
• Consider improvement champion, data coordinator
  at each site
• Use data across practice to drive change

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Other Improvement Efforts

• Regional PHO efforts
• MaineCare
• Diabetes registry, upcoming chronic disease
  improvement pilot
• Maine Center for Disease Control (BOH)
• Healthy Maine Partnerships
• Asthma, CVD practice grants
• Employer Initiatives (e.g. BIW!)
• P4P Programs
• Public data sharing MHMC Pathways to Excellence
  program

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MMC PHO 2006Quality Care Rewards Program

• PCPs caring for Adults
• Process measures rates for annual OV, HbA1c,
  LDL testing
• Outcome measures
• HbA1c lt 7
• HbA1c gt 9
• LDL lt100
• BP lt130/80

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Overlap of Local Incentive Programs
MMC PHO PTE Anthem Process of
Care - Diabetes X X X - Asthma
X X X - CVD X X
X - Well care X X Diab, CVD
Outcomes X X X EMR X
X E-rx X X X Registries X
X X Generic prescribing X
X
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MaineHealth Experience
Recognize different motivators need both the
heart and the head!

• Professionalism
• Self-respect
• Peer respect

• Efficiency
• Financial incentives

Motivators for adoption spread of change
Helpful to sustain change
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Patience and Persistence