Facilitating Change: Lessons from the TransforMED National Demonstration Project (Text Version)

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On September 14, 2009, Elizabeth Stewart made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (4.37 MB).

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Slide 1

Facilitating Change: Lessons from the TransforMED National Demonstration Project

AHRQ 2009 Annual Conference
Sept. 14, 2009
Elizabeth E. Stewart, PhD
Independent Evaluation Team from Center for Research in Primary Care & Family Medicine
 

 

Slide 2

Evaluation Team

• Carlos R. Jaen, MD, PhD
• Paul A. Nutting, MD, MSPH
• Benjamin F. Crabtree, PhD
• William L. Miller, MD, MA
• Kurt C. Stange, MD, PhD
• Elizabeth E. Stewart, PhD

 

Slide 3

National Demonstration Project

• Two-year project intended to 'test' the new model of family medicine as outlined in the FFM report.
• AAFP provided funding; TransforMED was created to design and implement the project.
• Independent evaluation team providing mixed-methods analysis for practice & patient outcomes.

 

Slide 4

NDP: Background & Timeline

• 500 practices applied
• 300 usable applications
• 36 practices selected
  • 18 randomized: FACILIATED
    • 17 (F) practices finished
  • 18 randomized: SELF-DIRECTED
    • 15 (SD) practices finished

NDP start: July 2006
NDP finish: June 2008
Touchstone Group Begins

 

Slide 5

TransforMED

An image of a map of the United States is shown. The map has Small, Solo, Medium, Large, and New Practice types labeled.

 

Slide 6

Real Practices. Real Stories

A number of images of groups of people are shown on the screen.

 

Slide 7

Implementation Assistance

Self-Directed

• List serve & website access
• 1 final NDP Learning Session
• Some $$ for self-organized retreat midway through NDP

Facilitated

• 6 practices/facilitator
• Access to facilitator (site visits, phone calls, emails)
• 4 NDP Learning Sessions
• Monthly conference calls
• Discounted technology
• Access to national consultants
• List serve & website access

 

Slide 8

Mixed Methods

QUANTITATIVE:
 

• Patient Health Outcomes (medical chart audits)
• Practice Finances (surveys - limited)
• Clinician/Staff Satisfaction (surveys)
• Patient Perception of Care (surveys)

QUALITATIVE:

• - Field notes, interviews, observations, email communication logs, conference calls, Learning Sessions, facilitator debriefs, list serve, documentation of model components.

 

Slide 9

Original TransforMED Model

An image of the Original TransforMED Model is shown.

 

Slide 10

The TransforMED Patient-Centered Model

 

Slide 11

A new way of thinking.

An image of an updated TransforMED Model is shown.

 

Slide 12

A new way of thinking.

• Transformation is more than a series of incremental changes; it requires requires epic whole practice re-imagination and redesign.
• Transformation to a PCMH requires substantial changes in the mental model of both physicians and practice staff.
• It is more than implementing sophisticated office systems. it is about adopting substantially different approaches to patient care

.

 

Slide 13

What helps a practice transform?

"Core Structure" - includes ability to manage basic finances, clinical & practice operations during times of stability & modest change.

"Adaptive Reserve" - ability of practice to be resilient, to bend & survive under force. Facilitates adaptation during times of dramatic change.

 

Slide 14

What is Adaptive Reserve?

Measured with the Clinician/Staff Questionnaire

• Anonymous questionnaire - 3x during project
• Based on validated PSQ and 'The Magnificent 7'
• Represents the perceptions of those living in the practice

89 questions total, pared down to 9 final categories through factor analysis:

• Respectful Interaction
• Learning Culture
• Reflection
• Work Environment
• Strong Leadership
• Sense making
• Diversity
• Mindfulness Communication

 

Slide 15

Change in Adaptive Reserve*

	Control	Facilitated
Baseline	71	70
28 months	70	78

*Adaptive reserve includes measures of leadership, sensemaking, diversity, mindfulness, communication, respectful interaction, learning culture, reflection and general work environment. Baseline vs. 28 months for facilitated group is statistically different. (p<0.01)
Measure of Adaptive Reserve
 

 

Slide 16

The Role of Facilitation

1. Consulting
2. Coaching
3. Facilitating Adaptive Reserve

 

Slide 17

Facilitation: Consultant

• Huddles & Meetings
• Workflow analysis
• Metrics, PDSA cycles
• Specific projects

HIT assistance – vendor liaison, implementation

 

Slide 18

Facilitation: Coach

Staff: Empowerment, task delegation
Practice Managers
 

• Project Mgt
• Personnel/HR
• Finances
• Communication
• Empowerment
• Support

Physicians

• Leadership
• Finances
• Delegation
• Time Mgt
• Communication
• Support

 

Slide 19

Facilitation: Adaptive Reserve

• Staff Retreats with Pre-Work & Follow-up
• Intense Coaching
• Conflict Resolution
• Rich & Lean Communication

Facilitated Learning Sessions w/other practices

 

Slide 20

Patient Outcomes Surveys

• Mailed to cross-section of 120 pts/practice, 3x
• Based on multiple validated surveys and intended to measure 7 attributes of patient-centered primary care.*

1. Superb Access
2. Patient Engagement
3. Clinical Information Systems to Support Care
4. Care Coordination
5. Integrated & Comprehensive Team Care
6. Routine Patient Feedback to Doctors
7. Publicly available information

Also assess patient enablement & patient satisfaction.

* Commonwealth Fund

 

Slide 21

 POS Core Elements to Measure
 

1. Patient Enablement (PEI)
2. Empathetic Care (CARE)
3. Comprehensive Care (CPCI)
4. Accumulated Knowledge (CPCI)
5. Inter Personal Com (CPCI)
6. Coordinated Care (CPCI)
7. Advocacy (CPCI)
8. Health Promotion (ACES)
9. Cultural Responsiveness
10. Family Context (CPCI)
11. Organizational Access
12. Community Context (CPCI)
13. Usual Provider Continuity (CPCI)
14. Interpersonal treatment
15. Recommend Doctor
16. Rating of Doctor (1-10)
17. Med Home (PCPE)
18. Same Day Access Available
19. Overall health status (1-5)

 

Slide 22

Self-Directed Practices: Some Decreases

	Baseline		9 months		28 months
	Mean	SD	Mean	SD	Mean	SD
Empathetic Care	.87	.20	.84**	0.20	.84**	.20
Comprehensive Care	.84	.16	0.82	0.16	.81**	.15
Interpersonal Com.	.81	.18	.78**	0.18	.80	.18
Advocacy	.82	.16	.80*	0.16	.80	.16
Health Promotion	.14	.34	.24***	0.34	.16	.31

Only showing core elements with significant changes from baseline:
*= p <05; ** = p <.01; *** = p <.001

 

Slide 23

Self-Directed Practices: Some Decreases

	Baseline		9 months		28 months
	Mean	SD	Mean	SD	Mean	SD
Community Context	.71	.22	.67**	0.22	.66***	.22
Interpersonal treatment	.91	.17	.89*	.17	.91	.16
Recommend Doctor	.94	.15	.91*	.15	.92	.14
Rating of Doctor	.91	.15	.88*	.15	.88	.15
Same Day Access	.41	.48	.34*	.48	.40	.49
Overall health status	3.38	.94	3.44*	.94	3.50*	.92

Only showing core elements with significant changes from baseline:
* = p<.05; ** = p <.01; *** = p <.001

 

 

Slide 24

No Significant Change in Facilitated Practices

• Facilitated practices showed relatively small, if any, changes in any of the 19 categories over time.
• Despite tremendous changes going on at the practice, the core elements of the patient experience appeared unchanged.
• This may suggest that facilitation had a buffering effect. Patients in the SD practices may have felt the chaos of change but pts in the facilitated practices did not.

 

Slide 25

Thank you.