Understanding Health System Transformation Through BC's Clinical Care Management Initiative: An Interactive Discussion QUALITY FORUM

Carol Herbert, MD Senior Associate, InSource Research Group

February 27, 2014

Workshop Objectives

• Overview of CCM project • Discuss your personal experience with

large scale change/CCM • Provide input on emerging analytic

frameworks

Health System Transformation Research

The healthcare system is complex •Increasing chronic disease and ageing population •Rising costs •Fragmentation and increased complexity

Complex problems require complex solutions •Need to understand enablers and constraints to systems transformation •Need to know “what works, for whom, under what circumstances”

What is In-Source?

• Independent health research group focused on

system transformation

• Leaders and experienced specialists in project

management, knowledge to action, system

thinking tools, communications, etc.

• Extensive background in major system

transformation initiatives

1. Apply complex adaptive systems lens iteratively to develop

understanding of enabling, constraining, and contextual

factors to CCM as a case study for Large Scale Change

(LSC)

2. Make recommendations to:

– Improve implementation of guidelines

– Apply implementation strategies to other health system

issues

5

Objectives of CCM Project

Clinical Care Management

• One of the Key Result Areas of the Ministry of Health’s Innovation and Change agenda

• Objectives of CCM: – To improve quality, safety and consistency – To improve patient experiences of care – To integrate continuous clinical quality

improvement • 11 CCM areas – based on input during the

preliminary data collection, we elected to focus on Sepsis, Surgery and VTE across all HAs

• Context matters • Organizational culture has a substantial effect

on implementation of change • Anticipate regional variation with respect to

enablers and constraints but similarities are expected to outweigh the variation

• Each stage of the project will build upon the previous work iteratively

Project Assumptions and Approach

Project Timeline

High Level Emerging Themes from KIIs

• CCM initiative is viewed positively overall

• CCM guideline implementation is seen as an effective method for system transformation

• Leadership is both an enabler and constraint (distinct senior, front line and physician champion roles)

• Open, transparent communication, that takes into account local context, is essential

High Level Emerging Themes from KIIs cont.

• Engaging physicians is critical

• Resourcing is a particular issue for smaller, rural areas

• EHR capacity is varied, but considered important enabler

• Metrics and measurement are powerful enablers at the local level

• Culture is key!

Quotes from the Interviews

"I think culture has a huge role in trying to start new programs and get things going that are different....So we have a lot of really awesome, new, young OR nurses. They have pretty strong personalities like they're right up there, I really like them, they speak up and they don't hesitate to voice their concerns and I think it's fantastic. So I think that the culture is changing partly because we've been working on culture change as those people were going through their training, and so they're starting to really sort of say no I'm not going to stand up for this you know, and I'm going to speak up.”

Quotes from the Interviews

"It's really the culture around places and it's the different people, so... if you have champions of something in one facility, and if those champions are people that other people respect and look up to, [they] say,"Well, you know, so and so says it's a good thing and they're really promoting this and so, maybe we should give this a try. I think that really helps."

• Principles are an initial step to building a set of recommendations

• Currently based on the preliminary data collection in December and initial review of the key informant interview data

Emerging Guiding Principles

• Addressing Provincial, HA, hospital management, clinical and patient levels

• Principles common to many levels include – Enabling committed and distributed leadership – Promoting two way communication – Aligning incentives – Encouraging local ownership – Enabling access to data and information systems – Affecting culture change – Promoting integration of guideline implementation – Promoting and coaching collaborative clinical teams

Emerging Guiding Principles

• CLDs are commonly used to show the feedback loops in a system, indicating direction of influence through the use of arrow heads pointing in one or both directions

• Applied so far to Culture, Leadership and Organizational Capacity

Emerging System Maps (Causal Loop Diagrams)

16

Causal Loop Diagram - CULTURE

17

Causal Loop Diagram – CULTURE (draft)

18

Causal Loop Diagram – CULTURE (draft)

19

Causal Loop Diagram – CULTURE (draft)

20

Causal Loop Diagram – CULTURE (draft)

21

Causal Loop Diagram – CULTURE (draft)

Causal Loop Diagram – LEADERSHIP (draft)

Causal Loop Diagram – ORGANIZATIONAL CAPACITY (draft)

1. Choose one facilitator and one recorder at your table

2. Review the questions on the report out sheets at your table

3. Look to your handouts, take 5 minutes to: Jot down ideas on your individual question sheets (white) Chose one causal loop diagram (CLD) at your table, place

red dots on the top 5 hindrances to large scale change, and green dots on the top 5 facilitators

4. Discuss and work through each question as a group, recorder to

write down main points on the group question sheet (blue). This

sheet and your CLDs with dots, will be handed in and included in

our project as data

5. We will ask for 4-5 tables to volunteer to report to the full group at

the end

Small Group Discussions

For more information contact

Jennifer Bitz, MA, PMP Project Manager and Director

InSource Research Group

jen.bitz@in-source.ca