Practice in a networked health care system

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Practice in a networked health care system
David Patrick Ryan, Ph.D.
C.Psych. Director of
Education, Regional Geriatric Program of Toronto
Assistant Professor, Faculty of Medicine,
University of Toronto
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Objectives
Situate practice as a networked
phenomenon Consider the continuum of tight and
loosely coupled networks Provide an overview
of concepts from network and systems
theory Review network analytic tools Reflect on
the implications of networked practice for the
knowledge to practice process
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The ubiquitous network concept
National health networks (see Mur-Veeman et al
2003) Multisite hospital networks Research
networks Disease/population focused networks
Primary Care Networks Family Health Networks
Local Health Integration Networks
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Some of Disease/Population Networks in Ontario
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Network studies and related themes
Intraspeciality medical networks (Coleman et al.
1966) Networks within practices (Scott et al.
2005) (Miller et al 2001) Comparisons of
discipline specific networks ( West et al
1999) Primary care research networks (Mold
Peterson, 2005) Shared care (Hickman et al.
1994) Coordination versus continuity (Pinkerton
et al 2004) Inter-teamwork (Ryan, 1996)
Communities of practice (Parboosingh, 2002
) Practice collaboratives (Mittman, 2004)
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What a difference a decade makes or maybe not
Despite the ubiquity of the network concept in
planning programs, the issue of how networks of
health care facilities affect the delivery of
services has not been intensively studies.
Although there are references in the
organizational literature . . . very few studies
have documented the effects of these programs. .
. . Further, the value of network programs in
actually improving the dissemination of new
treatment technologies or disease management has
not been adequately explored on either a
theoretical or an applied level (Fennell
Warenecke, 1988 p.12) Ever since the seminal
work of Coleman et al (1966), networks have been
seen as important in the process by which
clinicans adopt (or fail to adopt) new
innovations in clinical practice. Yet very little
is actually known about the social networks of
clinicians in modern health care settings (West
et al., 1999 p. 633)
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Do we need the network concept?
Convergent validity is it different from other
organizational forms e.g. are networks different
from teams? Heuristic validity - is the network
concept rooted in a body of knowledge that has
led to useful theory? Operational validity
are there standardized and validated measures?
Predictive validity does the theory and
measures predict behavior?
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On teams and networks
Dimension Team Network
Level of analysis fixed agnostic
Goals prescribed organic
Development intentional emergent
Relationships narrow ties multiple ties
Sample sizes Small n Medium to large
Theoretical origins Social Psychology Sociology
Output Process gains social capital
Strength of ties Strong Weak
Participation mandated self-selected
Causal models linear non-linear and recursive
Boundaries Fixed Flexible
Authority Formal Informal
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The collaboration prerequisite
When environments require complex interdependency
the quality of collaborative alliances may
predict outcomes better than the internal
processes of individual teams (Pfeiffer, 86)
Just as simply putting health professionals
together to work in teams seldom leads to
effective teamwork so simply putting teams to
together to work seldom leads to effective
inter-team collaboration (Ryan, et al. 1996)
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Words of advice for young people
Minimizing variation to reduce error and increase
the quality of health care through the use of
standardized guidelines has not been as
successful as traditional logic might suggest
(Miller et al 2001) There seems to be little
relation between the quality of the evidence and
its diffusion into practice (Fitzgerald et al
2002) The ways people actually work usually
differ fundamentally from the ways organizations
describe that work (Mintzberg Vander Heyden,,
1999) Our beliefs to the contrary, a great deal
of human behavior is illogical (Kruger
Dunning, 1999) (Tversky Kahneman, 1967)
Beneath each espoused culture lies another that
is implicit, informal and unacknowledged
(Argyris,
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Social Network Theories
Structural holes (Burt) Resource mobilization
and connectedness (Lin) Peripheral participation
(Wenger) Strength of weak ties (Granovetter) Trust
and strong ties (Uzzi) Networked individualism
(Wellman)
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A network analysis diagram (Burt, 1999)
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Social Network Diagram of a Family Practice (from
Scott et al 2005)
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Social Network diagram of another family practice
(from Scott et al 2005)
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What does this mean for practice networks
Practice networks should be construed as a local
complex adaptive systems with the high levels of
uncertainty, contextual uniqueness and
surprise. Like other complex adaptive systems,
practice networks self-organize, reveal emergent
behavior, and co-evolve. Successful practicse
networks minimize errors, make good sense of what
is happening, and effectively improvise In this
context variation rather than standardization is
to be expected and a good coach is essential from
Miller et al (2002)
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Health Professional Advice Network ( from Coleman
et al 1966 p. 75)
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Health professional discussion network (from
Coleman et al 1966 p.76)
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Health professionals friendship network ( from
Coleman et al 1966 p. 78)
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Network character, type of change and
prescriptive interventions (McGrath Krackhardt,
2003)
Change Model Type of change Network character Mechanism Where to intervene
External ties Network wide Strong dense ties exist with many external ties across subgroups Trust and social identity The people with strong external ties (structual holes)
Viscosity Adoption of controversial innovations Strong, dense internal ties but few external ties across subgroups Individual commitment within a subgroup Introduce change in one group at periphery (strength of weak ties)
Structural leverage Innovation clearly superior When the networks formal structure is low Creating buzz (contagion) Introduce change to a friend of a network member (opinion leaders)
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Network stages of development
 
Adapted from Brown et al (2001) Strategic
Planning in Rural Health Networks available
online at www.academyhealth.org/ruralhealth/
strategicplanning.pdf
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Please find a copy of the reference list for this
talk online at the url below
http//rgp.toronto.on.ca/article.p
l?sid05/08/30/1936247