Transcript Evidence Based Practice in Professional Roles

Quality Enhancement Research Initiative
Facilitation in Practice: Location, Level, Intensity
Anne Sales, PhD RN
Dichotomy informs our view of what
does and doesn’t work
• We know more about how to change
individual behavior than organizational
behavior
– Although we don’t know much about either
– Missing “layer” may be a clue to why interventions
work in one place and not in another
• The concepts of context and facilitation are
probably keys to what works and how
Describing facilitation
• Human vs. technological facilitation
• Human
– Characterized by hierarchy, roles, other
dimensions
• Technology
– Almost always requires human
intermediation
Quality Enhancement Research Initiative
Assessment of a Quality Improvement
Intervention to Promote VA National
Lipid Electronic Clinical Reminders
Anne Sales
Ashley Hedeen
Meg Plomondon
John Rumsfeld
VA HSR&D Service 01-040
Why electronic reminders?
• Hypothesis: Principal reason for gaps
in lipid management is lack of provider
attention
– Competing priorities
– Insufficient time for preventive care
– Lack of awareness that patient is at risk
– Data from qualitative study conducted in six VAMCs
Reminders raise awareness and are
actionable
• Electronic clinical reminders in CPRS deliver
patient-centered information to providers at
the point of care– clinic encounter or visit
– Meta-analyses describe studies showing that
reminders are effective in some cases in
increasing amount of preventive care
• Well-designed reminders allow providers to
take action to correct gaps in care through
the dialog boxes
– Interact with order entry, lab and pharmacy data,
and draft progress note
Sample of CPRS reminders:
Reminder due list on Notes tab
Reminders Due List on the Notes Tab.
Clicking on a reminder name opens the
reminder dialog.
Initial Dialog: IHD Lipid Profile
Summary of guidelines
Link to the Clinical Maintenance screen
Point-and-click options that resolve the reminder
Progress note generated
Evaluation Sites and Methods
• Two National IHD Lipid Reminders installed in
three sites in eastern half VISN 19 (Rocky
Mountains)
– Four sites in western half of VISN used as
comparison sites
• Conducted process evaluation of installation
and implementation of reminders in
intervention sites over 16 months– June 2002
through September 2003
Reminders Require a Two Stage
Process
• Installation
– National software patch to local clinical information
system
– VA’s information architecture involves local
systems with national input
– Installation was mandated; patches are sequential
• Implementation
– Required local IT support
• Mapping terms
• Training providers
• Learning reporting systems
Implementing Reminders
• One of three intervention sites implemented
reminders without effort within a month of
intervention starting
• Two original sites were merged mid-way
through intervention period
– Formed large health care system with tertiary
center and several large outpatient clinics
• Outpatient clinics had implemented reminders within first
two months; tertiary site was slower in implementing
reminders
• Third site implemented reminders
approximately two-thirds of the way into the
intervention period
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Use of reminders varied among
intervention sites
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Information from formative evaluation
• Sites where reminders were not fully
implemented were detectable before the
end of the project
– Stopped attending conference calls
– Poor response to requests for information
– Defensive reactions to questions about
progress
More description
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Internal vs. external
Limited vs. holistic
Formal vs. informal
Other continua…
View of health care delivery
Increasing distance from
patient and provider
Environment
High level policy
decisions
Industry
CONTEXT
System
Organization
Strategic decisions usually
get made here
or here
Unit/Clinic
WORKGROUP
Team/Microsystem
Individual provider
Patient
Penetration is hard
Internal facilitation:
providers/professionals as facilitators
• Roles include
– Opinion leader
– Change agent
– “Facilitator”/troubleshooter
– Convener
External facilitation
• Outside experts
– Consultants
– “Gurus”
– Researchers
– People from a higher level of the system or
organization
Limited vs. holistic facilitation
• May interact with concept of intensity
• Limited
– Focus on specific problem or behavior change
– May also reflect lower level of intensity
• Holistic
– Global
– Focus not on specific, but general behavior
change
Facilitation and leadership: Formality
vs. Informality
• Primacy of leadership
– Initiating change
– Managing change
– Judging change
• When is it complete… enough?
• How to measure successful change
Leadership occurs at all levels
– Senior management leadership
• Formal authority, power structure, hierarchy
– Mid-level
• Also authoritative, less power, moderate hierarchical
influence
– Front-line
• Peer respect and influence, networks
– Ancillary
• People connectors, networks, information chain
• Leadership is often emergent rather than
planned
Question of effectiveness
• How are people trained to be effective?
– What works?
– What do we know?
– Need for evidence base here
• Self-awareness and intentionality
– Counter to the “Nike/Just do it” mentality
– Goal-orientation and intentionality
contribute to ability to work through barriers
More keys to effectiveness
• Support
– Support groups
– Realism on the part of micro (local) and
macro (senior) leaders that change isn’t
free
• Resource commitment is essential
• Rewards are critical
The dark side
• Negative opinion leaders
• Questions of resistance
– Can arise from many sources:
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Conflicts over evidence
Fear of change
Loss of status
Lack of alignment of personal priorities with
organizational priorities
– Personal triumphs– ego gratification, inappropriate
pursuit of power
Living in a thunderstorm
Anatomy of a thunderstorm cell
• Leading edge
• Middle misery
• Trailing edge
– Resistance
• Terminal resisters
• “Drug-resistant” forms
– Resistance to change built through successive
abortive change efforts
– Recidivism
Tools for coping
• Adequate planning
– Anticipation
• Adequate provisions
• Sufficient support
Facilitators generally
• Need nurture and support
• Recognize and plan for barriers
– Adequate resources and support
• Recognize that values are important
component