Transcript Slide 1

Team Up for Health Project
Practice Coach Training Workshop
Perry Dickinson, MD
Larry Fisher, PhD
Practice Change and
Improvement Process
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”
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
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
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
The PDSA Cycle
Act
• What changes
are to be made?
• Next cycle?
Study
• Complete the
analysis of the data
• Compare data to
predictions
• Summarize what
was learned
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
Repeated Use of the PDSA
Cycle
Changes That
Result in
Improvement
A P
S D
Implementation of
Change
Hunches
Theories
Ideas
A P
S D
Very Small
Scale Test
Follow-up
Tests
Wide-Scale
Tests of
Change
Facilitators
Facilitators
Facilitators
Motivators + Change culture + Care process = Quality
and capacity
content
Improvement
Barriers
Barriers
Barriers
Modified from: Solberg L. Improving Medical Practice: A Conceptual Framework.
Annals of Family Medicine. 2007;5:252-255.
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
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
Support for Practice Change
• Quality Improvement Coach
• Practice assessment and feedback
• Performance measurement
• Practice improvement teams
• Implementation of change management/
improvement process
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
Role of Coaches
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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
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
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
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
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.
Improvement Culture
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Reflection
Mindfulness
Value diversity
Heedfulness in how people work together
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