Outline of ideas to advance the science of transforming health care organizations. 81. “Advancing Transformational Science”, Bridges to Sustainable Healthcare Transformation Through Evidence, Partnerships & Technology: 19th International Conference San Francisco, CA, January 19-22, 2011.

1. Bridges to Sustainable Healthcare Transformation
Through Evidence, Partnerships & Technology:
19th International Conference
San Francisco, CA, January 19-22, 2011
Brad Doebbeling, MD, MSc
Professor of Medicine, Epidemiology, & Biomedical
Engineering, Indiana University School of Medicine
Senior Scientist, IU Center for Health Services Research,
Indianapolis VA COE, Regenstrief Institute,
Indianapolis
Award Number: HHSA290200600013I, Task Order No. 4

2. Frameworks

4. Socio-technical Systems Framework
Social Subsystem Technical Subsystem
• Key stakeholder views • Usability
• Patient barriers/facilitators • Functionality/scope
• Organizational buy-in • Computer/IT support
• Leadership support Joint Optimization •Flexibility in IT tools
• Training • Integration of CDS - •Iterative design
• Unintended social for CRC screening - • Unintended technical
consequences into clinical workflow consequences
External Subsystem (Context)
• PERFORMANCE MEASUREMENT
• Workload
• Financial factors
• Unintended external consequences
Westbrook et al., JAMIA, 2007; Harrison et al., JAMIA 2007

5. Panarchy or Ecocycle Model of Change
Renewal Maturity
Creative
Birth
Destruction
For more information on the ecocyle go to
http://www.plexusinstitute.org/edgeware/archive/think/main_aides9.html

6. Institutional level
A change in culture
A change in laws
A change in resource
distribution/availability
Organizational level
A change in strategies
A change in procedures
A change in resource
distribution/availability
Network or group level
A change in conversation
A change in routine
A change in resource
commitment or influence
Individual level
―Getting To Maybe: How the World is Changed‖
A change of heart Frances Westley, Brenda Zimmerman, Michael
A change of habits Patton, 1996, Random House Canada
A change of ambition

7. Implementation & Spread

8. Social Network Analysis
 Reveals communicative patterns
of complex groups and teams
 Identifies the strength and frequency
of connections
(e.g., with whom and how often do you
communicate about reducing MRSA)
 Describes current network in
general & MRSA Bundle
implementation in particular
 Tool for Implementation & Spread

9. Example – Before – Montana Hospital
Obvious
clusters, not well
integrated
Core not dense
enough Core not diverse
– too small

10. Example – After – Montana Hospital
Core is much
more dense
Core is more Still room for
diverse – more improvement…
departments and
roles present

11. Strategy

12. Transformative Change:
7 Effective Strategies
 Fostering Change
 Communication & Collaboratives
 Local, Focused Implementation
 Frontline Staff Engagement
 Organizational Learning
 Support, Resources & Accountability
 Feedback & Reinforcement
Qualitative Thematic Analysis, Healthcare Associated Infections (HAI) Initiative
Assessment Program , AHRQ ACTION, HHSA290200600013I , 2010

13. Strategies from Regenstrief Conference
Complex Adaptive Systems -Conceptual framework of complexity dynamics and complex
Framework adaptive systems.
-Ground quality improvement strategies in a theoretical perspective
that views primary care practices as dynamic complex adaptive
systems
Fostering Organizational -Conceptualize organizations as a series of conversations.
Redesign -The creation of healthy work cultures depends upon
communication, teamwork, trust and partnerships.
-Enhance the quality of listening, to foster openness and trust
Appropriate Performance -Develop new approaches to evaluation of the performance
Measures and Incentives measurement system.
-Develop new measures to identify and address gaps in the current
system.
Continuous Learning -End-users need to make the research ―right‖ for their context—
Organizations customize guidelines for local use.
-Continuous learning organizations set measurable targets for
change, assess progress and provide feedback to stakeholders.
Integrating Health Information -The implementation of evidence-based tools, resources and
and Communication information systems at the point of care.
Technologies -The use of telemedicine/Personal Health Records to improve
access to care and improve health outcomes.
Doebbeling & Flanagan, Medical Care (in revision, 2011)

14. Related Research Questions
Complex Adaptive Systems Framework -What organizational change strategies are based
on complexity science principles?
-How do they create and sustain change?
-What characteristics foster using a complexity
science perspective in transformation efforts?
Fostering Organizational redesign -What organization redesign strategies facilitate
the creation of healthy work cultures?
-How can implementations be tailored to suit
different organizations and patient populations?
Appropriate Performance Measures and Incentives -What performance measures/incentives
encourage collaboration and coordinated care
among providers?
-How can performance measurement be more
dynamic to continually adapt to healthcare
changes?
Continuous Learning Organizations -What barriers and facilitators exist for end-users
to customize guidelines for use?
-What strategies and investments work best for
continuous learning organizations?
Integrating Health Information and Communication -What type of health information promotes
Technologies collaboration between patient and provider?
-What health information innovation development
implementation strategies influence uptake?
Doebbeling & Flanagan, Medical Care (in revision, 2011)

15. Needed R&D

16. Collaboration Negotiation
Strategy
Difficult
Conversations
Innovation
Conflict
Management
Facilitation

17. My Conclusions
My Analysis
Relevant Data
DATA POOL
DATA POOL
From Argyris & Schon

18. The Publication

19. SHARE
My Conclusions Their Conclusions
ASK
SHARE
My Analysis Their Analysis
ASK
SHARE
Relevant Data Relevant Data
ASK
DATA POOL
DATA POOL
From Argyris & Schon

20. Collaboration

21. Collaboration = Communication+ Skill +
Context (Leadership x Culture)

22. 1. (Communication) Tools
 Wikis: our work
 Blog: my thinking
 Twitter: peripheral awareness
 Email: specific question

23. Relationship Communication
Interests
Options
Legitimacy
If “No” If “Yes”
Alternatives Commitment
Harvard Negotiation Project

24. Needed R&D

25. DELIVERY SYSTEM FOAs
1. RFA 10-012 -- Comparative Effectiveness Delivery System Evaluation Grants –
R01 (Michael Harrison)
Research on existing designs or redesigns (interventions) in payment,
reporting, and organization of care delivery
CER= compare alternative designs or redesigns; compare one redesign to
status quo accepted as current policy
2. RFA 10-013 Comparative Effectiveness Delivery System Demonstration Grants –
R18 (Michael Harrison)
(A) Demonstration of redesigns in
 primary care
 care continuum
 payment and reporting
(B) Research on implementation and effectiveness of these redesigns
3. RFA 10-014 -- Accelerating Implementation of Comparative Effectiveness
Findings on Clinical and Delivery System Interventions by Leveraging AHRQ
Networks – R18 (Dina Moss)
 PURPOSE: Spread of CER findings by leveraging the capacities of multi-
stakeholder or multi-site networks: Goal is implementation of existing
evidence, not creation of new evidence
 Reporting of progress in achieving project goals is required –
evaluation is not; Evaluation to be conducted by external contractor.

26. Delivery System Evaluation FOA
10-012. Delivery System Evaluation Grants – R01 (a.k.a.
―Evaluation grants‖) (Harrison)
 Evaluate ability of alternative system designs, change
strategies, and interventions to enhance system
performance (quality, efficiency, etc.); evaluate
applicability of change strategies across diverse
settings.
 3-year projects with no extensions
 $7 million allocated for 6-10 awards
 Support Contractor -- Econometrica with sub to Booz
Allen for portal
 6 funded

27. ARRA Delivery System FOA Grantees: Impacted Sites of Care
(1-2 sites per study)
14
13
12
11
13
10
9
8
7
6
5
4 7
3
2
3
1
0
Hospital Other Specialty Primary Care

28. ARRA Delivery System FOA Grantees:
Primary Health Conditions
Chronic Kidney
Disease, 1 Cardiological
Pediatric Health, Asthma, 1 conditions +
1 hypertension, 2
Orthopedics, 1
Mental Health +
substance abuse,
Multiple Chronic 4
Conditions, 6

29. ARRA Delivery System FOA Grantees: Geographic Spread
1 1
11
1
2 3
2
2
1
1 1
1
1 1
5 2
2
1
2
1
2
1
National =2

30. Needed R&D

31. Nation-wide Adoption of EHR
 There is critical nation-wide need to improve health care
services while reducing cost
 Federal goal is 50% EPR adoption by private clinics and
hospitals by 2016
 Current adoption is ~ 14% for private hospitals and
clinics
 Private providers have serious concerns about:
 steep start-up cost
 rejection by physicians
 unknown, sustained overhead for training, tech support, etc.
 disruption of health care workflows

32. SHARP program
Fill technology gaps for nation-wide, meaningful use of
electronic health records (EHR)
Awardee Research Focus Area
University of Illinois at
Security of Health
Urbana-Champaign
Information Technology
(#10510624)
The University of Texas
Patient-Centered Cognitive
Health Science Center at
Support
Houston (#10510592)
Healthcare Application and
Harvard University
Network Platform
(#10510924)
Architectures
Mayo Clinic College of Secondary Use of EHR
Medicine (#10510949) Data

33. Long-term Approach to Meaningful Use
Stage 3 – 2015
Stage 2 – 2013
Improved
outcomes
Advanced
oStage 1 – 2011
clinical
processes
Data
capture and
information
sharing http://www.cms.gov/ehrincentiveprograms/
Rtn

34. ―Process Improvement Through Participatory
Design of Health Information Systems‖
 Tools and methods to make health care improvements
integral to the way HIT systems are created
Keith Butler, U Wash, SHARP-C

35. Care-centered design
As-is care
process
model
Improved
process
models Sensitivity
analysis Value to care
Better care
Trade-off process
analysis
Information usage
Cost-effective
S/W HIT system
Risk & cost
implement
ation
models
Information
architectures
Technology-centered design
Keith Butler, U Wash, SHARP-C

36. Acknowledgements
 Funding from AHRQ
 Testing Techniques to Radically Reduce Antibiotic Resistant
Bacteria HHSA2902006000131 (Completed)
 Healthcare Associated Infections (HAI) Initiative Assessment
Program HHSA290200600013I (Current)
 Implementing and Improving the Integration of Decision
Support into Outpatient Clinical
WorkflowHSA2902006000131(Current)
 Funding from AHRQ and CDC
 Testing Spread and Implementation of Novel MRSA-Reducing
Practices HHSA290200600013 (Current)
 Thanks to our collaborators, partners, providers, patients!
 Thanks to Michael Harrison, PhD, AHRQ and Keith Butler, PhD, U
Washington/SHARP-C

37. ―Collaboration‖ – What does it
mean?
 ―Alone we can do so little; together we can do so
much.‖ – Helen Keller
 ―Strength is derived from unity. The range of our
collective vision is far greater when individual
insights become one.‖ – Andrew Carnegie

38. Thank You!
 Questions?
 Contact
 Brad Doebbeling
 bdoebbeling@gmail.com