Team Up for Health Project

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Team Up for Health Project

• Practice Coach Training Workshop
• Perry Dickinson, MD
• Larry Fisher, PhD

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Practice Change and Improvement Process
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Targeting Physicians for Change Not Very
Effective

• Clinician behavior resistant to change
• Traditional CME relatively ineffective
• Takes an average of 17 years for innovations to
  find their way into clinician behavior
• Attempts to enhance clinician adherence to
  evidence-based guidelines usually result in
  modest or no improvement

4
Practice-level Change

• More effective to focus on changing practice
  systems
• IOM Quality Chasm report and others - new focus
  on practice change needed
• Limited success of QI efforts may stem from a
  simplistic view of organizations
• Understanding practices as complex systems very
  helpful

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How Do Practices Change?

• Most practices do a poor job of implementing
  change end up being stuck in a rut
• Usually change when practice leaders see the need
  for change, with little input from staff missed
  opportunities, unanticipated problems
• Usually implement a big change all at once with
  no way of assessing the results take too big a
  bite

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Change in Practice Systems

• Every practice is unique - what works in one
  practice may not work in another
• Interrelationships of the parts of the system are
  key
• Outside forces can facilitate change but the
  details of the change itself must be guided by
  the people within the practice
• Ripple effect of changes
• Tension and conflict are natural part of change
• Change should be sequenced in small bites PDSA
  cycles

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The PDSA Cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Hunches Theories Ideas
Follow-up Tests
Very Small Scale Test
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Facilitators
Facilitators
Facilitators
Change culture and capacity
Care process content
Quality Improvement
Motivators



Barriers
Barriers
Barriers
Modified from Solberg L. Improving Medical
Practice A Conceptual Framework. Annals of
Family Medicine. 20075252-255.
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Practice Change Culture

• History, stories of successful change
• Mindful of opportunities for change
• Value the diversity of experiences and ideas
  within the practice
• Respectful interactions with each other
• Make time and space for reflection, improvement

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Importance of Leadership

• Traditional models of leadership not as relevant
  in practices especially small ones
• Key aspects relevant to improvement process
• Make time and space for reflection
• Vision
• Mindful of opportunities for improvement
• Responsive to data
• Encourage open exchange of ideas
• Sense-making

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Support for Practice Change

• Quality Improvement Coach
• Practice assessment and feedback
• Performance measurement
• Practice improvement teams
• Implementation of change management/ improvement
  process

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QI Coaches

• Increasing use of coaches in practice improvement
• Generally external to the practice, but can be
  internal
• Used to help practices get started and overcome
  barriers
• Often facilitate formation, initial activities of
  practice Improvement Teams

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Role of Coaches

• Assessment of current status in practice
• Feedback assessment and data to practice
• Encourage improvement team formation
• Initially facilitate team meetings
• Serve as connection to resources
• Transition to practice taking process over
• Facilitation vs direction of change

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Performance Measurement

• Data on how practice or individual clinicians are
  doing with performance measures often key for
  motivating and guiding change
• Practices may be in different places regarding
  quality and trust of data
• Part of the initial process may involve helping
  practice to institute better system for
  collecting and reporting data
• Help practices learn how to use data in the
  change process

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Improvement Teams

• Have to make time and space for reflection on
  areas needing change, planning
• Best way of doing this is forming practice
  Improvement Team with regular meetings to
  consider and plan improvement efforts
• Should include multiple perspectives, input from
  all major parts of the practice
• Takes time and persistence for team to become
  optimally functional
• Teams often need help in getting started

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Improvement Team Formation Facilitation

• Improvement team formation a key part of the
  feedback session
• Selection of team members, define roles
• Set up regular meetings, ground rules
• Discuss communication between team and rest of
  practice
• Coach serves initially as team facilitator,
  gradually pulls back

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Respectful Interactions

• Based on three related building blocks
• Trust - willing to base actions on reports of
  others
• Honesty willing to say what I really think
• Self-respect trusting that my perspective and
  ideas have value
• Openness to being changed by others.

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Improvement Culture

• Reflection
• Mindfulness
• Value diversity
• Heedfulness in how people work together

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Lessons Learned from Practice Redesign Projects

• Practice change is difficult, takes time, and is
  best done through improvement teams
• The Chronic Care Model has to be implemented in
  pieces, over time
• Practices need help in order to change
• Practices can really help each other in this
  process
• Teamwork important on multiple levels