Benjamin Crabtree Regenstreif Conference Slides

Transformation is Hard Work: Lessons from TransforMED’s

National Demonstration Project

Presented by Benjamin F. Crabtree, PhD

October 3, 2007

B. F. Crabtree2Center for Research in Family Medicine and Primary Care

Disclosure

• Dr. Crabtree is the co-PI of the TransforMED NDP Evaluation– Supported by grants from the American

Academy of Family Physicians and 2 grants from the Commonwealth Fund


Agenda• Background on collaborative research

and organizational change perspectives of team

• Review the components of an ideal primary care practice

• Describe the TransforMED National Demonstration Project (NDP)

• Highlight the evaluation of the NDP– Early findings from qualitative analyses

• Questions and answers

Center for Research in Center for Research in Family Medicine and Family Medicine and

Primary CarePrimary CareKurt C. Stange, MD, PhDKurt C. Stange, MD, PhD

Carlos R. Jaén, MD, PhDCarlos R. Jaén, MD, PhD

Benjamin F. Crabtree, PhDBenjamin F. Crabtree, PhD

Paul A. Nutting, MD, MSPH Paul A. Nutting, MD, MSPH

William L. Miller, MD, MAWilliam L. Miller, MD, MA


Background

• Collaborative team has conducted a series of descriptive and intervention projects over a 15 year period.

• Funded by NCI, NHLBI, NIDDK, NIMH and American Academy of Family Physicians (AAFP)

• Results from these projects have informed an evaluation of the AAFP’s National Demonstration Project (TransforMED)


Observation Intervention

DOPC STEP-UP

IMPACT

DirectObservation of PrimaryCare (1994-97)

Study ToEnhance Prevention by Understanding

Practice (1996-2000)

Insights from Multimethod Practice Assessment of Change over Time (2001-2004)

P&CDPrevention & Competing Demands in Primary Care (1996-99)

ULTRAUsing Learning Teams for Reflective Adaptation (2002-07)


First insights into role of complexity in understanding

practicesPractices could not be described in mechanistic

terms, such as non-linear relationships among events– All the parts and people of a practice are interconnected and

interdependent in terms of both relationships and functions.– Any change in one part of the practice will have ripple effects

through the other parts of a practice. Those ripple effects will create tension and problems that can be barriers to change.

– Changes don’t 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---many different ways of achieving good outcomes


Properties of Complex Adaptive Systems (CAS)

• CAS consist of ‘agents’ with capacity to learn and freedom to act in unpredictable ways.

• Agents are often individuals, they may be teams, organizational processes, technical components

• Agents are connected in non-linear ways--one agent’s actions changes the context for other agents.

• The quality of the interactions among agents is more important than the quality of the agents


Properties of Complex Adaptive Systems(Cont.)

Self-organization: systems generate new structures and patterns over time as a result of their own internal dynamics. Order emerges from patterns of relationships among agents.

Emergence: process by which non-linear interactions among agents results in new patterns of behavior. The system that evolves over time is more than the sum of its parts.

Co-evolution: process of mutual transformation of the agent and the environment in which it exists.



DOPC STEP-UP

IMPACT









DOPC STEP-UP

IMPACT







“All models are wrong. Some are useful.”

-George Box, 1979

Box, G.E.P., Robustness in the strategy of scientific model building, in Robustness in Statistics, R.L. Launer and G.N. Wilkinson, Editors. 1979, Academic Press: New York.


Mo

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External influences on change option landscape

Motivation, Innovation & Independence

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Evaluating & exercising choices for change

Extern

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Motivation of key stakeholders

Capacity for change

OutsideMotivators

Choices for Change

Baseline

Follow-up

Co-ev

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IMPACT IMPACT CHANGE MODELCHANGE MODEL


Change Is Challenging

Mo

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3 & 4 interrelationships

1 & 2 interrelationships

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1 & 4 interrelationships 2 & 3

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Motivation of key stakeholders

Capacity to Change

OutsideMotivators

Choices for Change

Baseline

Follow-up

Co-ev

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KABOOM!!!BlockingFactors


Implications for Practice Change

• Patterns of relationships among staff (‘agents’) are critical determinants of practice change. (The quality of the interactions is more important than the quality of the staff.)

• From high quality interactions, process will emerge to create high quality change

• Emerging processes will not be the same in every practice.



DOPC STEP-UP

IMPACT








Capacity to Change Model

Reflection

Action

Trust

Miindful

Respect

Heedful Diversity

Social/Task

Rich/Lean

STORIES

Learning CULTURE

TeamworkSensemakingImprovisation

Build Memory

Dynamic Local

Ecology

Inquiry-Centered LEADERSHIP


According to CAS principles, successful practices will:

• Move from an ‘organization as machine’ paradigm and begin to understand their practices as complex adaptive systems.

• Pay more attention to the quality of the interactions among staff than on the quality of the staff.

• Focus on staff learning rather than on what they know today.• Encourage cognitive diversity among staff (and teams) and leverage

diversity to foster learning and emergence• Recognize that the practice is a social entity, and foster sense-

making, learning, and improvisation • Expect and celebrate surprise as opportunities to learn and grow• Begin to understand the interdependence between the formal and

informal organizations rather than making everyone conform to the formal organization


National Demonstration Project

• Proof of concept of a new model of care for family medicine– Quality of care– Practice finances

• Determining the best process for transformation– Facilitated– Self-directed


Components needed

• Access to care• Access to

information• Team approach• Point of care

services• Information

services• Redesigned offices• Management• Quality and safety

• Whole-person orientation

• Medical home• Patient-centered

care• Continuous

relationship







National Demonstration National Demonstration ProjectProject

Evaluation TeamEvaluation TeamCenter for Research in Family Center for Research in Family

Medicine and Primary CareMedicine and Primary CareCarlos R. Jaén, MD, PhD (PI)Carlos R. Jaén, MD, PhD (PI) Benjamin F. Crabtree, PhDBenjamin F. Crabtree, PhDPaul A. Nutting, MD, MSPH Paul A. Nutting, MD, MSPH William L. Miller, MD, MAWilliam L. Miller, MD, MAKurt C. Stange, MD, PhDKurt C. Stange, MD, PhD

&&Elizabeth Stewart, PhD (analyst)Elizabeth Stewart, PhD (analyst)

Reuben R. McDaniel, EdD (consultant)Reuben R. McDaniel, EdD (consultant)


Domains of Evaluation• Discovering what the transformed model

looks like in the real world

• Effect of the transformed model on the practice

• Effect of the transformed model on patients

• Understanding the process of practice change

• Understanding transformation


Sample Hypotheses• Practices that have motivated leaders that

promote patterns of frequent opportunities for reflection with internal and external partners and are patient-focused will be more likely to integrate the components of the TransforMED.

• Practices that have a more participatory decision making style and frequent opportunities for conversations about practice improvement will have higher levels of quality of patient care as measured by the chart audit and patient questionnaires.


Design• Volunteer practices selected by technical

advisory committee from over 300 applicants

• Randomly assigned to two change approaches:– Facilitated– Self-directed

• 2 year follow-up (Possible extension)

• Mixed method assessment– RCT with pre/post and inter-group comparisons– Comparative case study


NDP PracticesPractice Description Number of Sites

Facilitated

Self-directed

Solo and Solo +1 3 3Small (3 or less clinicians) 4 4

New 2 2

Medium (4-6 clinicians) 5 5

Large (7 or more clinicians) 4 4

Total 18 18


Facilitated Practices

• Each practice assigned one of 3 facilitators with each facilitator having a panel of 6 practices

• Intervention included site visits, learning sessions, opportunities for sharing via conference calls and webinar, and connecting to consultants

• Overtly focused on TransforMED “bubbles”


Self-Directed Practices

• The self-directed group has a very minimal intervention that will still allow this group to be a valid comparison group

• Have resources from TransforMED web page, but not facilitated

• Practices self-organized and created their own retreat

• Being in the national spotlight was a motivator

• Site visit by evaluation team


Data Sources

• Key informant & informal interviews

• Contact logs

• Email strings

• Ethnographic observation

• Clinician/staff surveys

• Online discussions

• Medical record review

• Patient surveys

Qualitative Learning

Emerging themes one year into the NDP


How are we learning?

• Facilitators field notes• E-mails logs, webpage postings• Logs of phone conversations• Notes of facilitators huddles, other

meetings• Weekly conference calls between

members of the evaluation team.


NDP Early lessons

1. The most successful practices seem to have shared leadership systems rather than an individual physician leader

2. Despite being highly motivated some practices had serious dysfunctional problems within the relationship infrastructure that required significant time and energy on the part of the facilitator


NDP Early lessons

3. A practice's capacity for change at baseline is a huge determinant for that practice's progress, and equally important is the facilitator's ability to increase that capacity

4. Technology in the New Model, while shining with possibilities, is not by any means an easy "plug and play" interface for the practices


NDP Early lessons

5. Due in part to the ongoing challenges of technology, even the most successful practices are experiencing change fatigue


NDP Early lessons

6. Depending on initial practice capacity assessment, may need one or more:a. Targeted consultation – e.g. Advanced

Access, EMR, finances, specific operations, etc.

b. Coaching – e.g. leadership, finances, etc.

c. Facilitation – e.g. relationships, reflection, leadership, etc (different intensity of joining practice and/or system, ranging from just being there to active facilitation).

More information

www.transformed.com



Questions?


References• Organizational Change & Complexity

Science1. Cohen D, McDaniel RR Jr, Crabtree BF, et.

al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004 May-Jun;49(3):155-68.

2. Miller, W.L., Crabtree, B.F., McDaniel, R.A., and Stange, K.C. Understanding Primary Care Practice: A Complexity Model of Change. J Fam Pract, 1998 46(5):369-376.

3. Miller WL, McDaniel RR, Jr., Crabtree BF, Stange, K. Practice Jazz: Understanding variation in family practice using complexity science. J Fam Pract 2001; 50(10):872-878.


References

4. Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective practice improvement process. Joint Comm J Qual and Patient Safety. 2005; 31(8):438-446.

5. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. J Gen Intern Med 2006; 21: S9-15.


References

6. Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR. Delivery of Clinical Preventive Services in Family Medicine Offices. Ann Fam Med. 2005; 3(5): 430-435.

7. Miller WL, Crabtree BF. Healing landscapes: Patients, relationships and optimal healing places. J Complementary and Alternative Med. 2005, 11 Suppl 1:S41-9.

8. Crabtree B. Primary Care Practices are Full of Surprises! Health Care Manage Rev, 2003, 28(3):279-283.


References

9. Tallia AF, Lanham H, McDaniel R, Crabtree BF. Seven Characteristics of Successful Work Relationships Family Practice Management 2006 Jan; 13(1):47-50.

10.Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: Case study of an exemplar small medical group. Ann Fam Med. 2006 Mar-Apr;4(2):109-16.

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Benjamin Crabtree Regenstreif Conference Slides