Accelerating Clinical Transformation Using Community Collaboration Tools

1. Accelerating Clinical Transformation Using Community Collaboration Tools Using online communities to accelerate innovation adoption Janet Guptill, PresidentKM At Work, Inc. Neal Sofian, CEO The NewSof Group, Inc.

2. Clinical Transformation and Communities of Practice • Why do we know that communities are a key component to accelerating adoption of innovative practices and technologies? • The science behind individual behavior change • The basis behind organizational change • The role that communities and social networks play in creating change • How do we systematically address accelerating adoption of innovative practices within hospital systems? • Lessons learned from the practice of knowledge management • Examples of hospital systems engaged in communities of practice to accelerate transformation • How can Perot Systems, KM At Work, and NewSof bring a combined solution to its hospital system clients?

3. The Problem • Medical costs are too high • Access to medical care is inconsistent • Patient outcomes are not as good as they should be • Practices are not optimal and significant variations persist, even with evidence-based medical guidelines • Limited means to measure change and progress • Knowledge remains in unusable silos

4. Creating Systemic Change Within & Across Hospital Systems is Critical Hospitals need a simple way to learn from their peers in order to: • Share both formal and informal successful practices, success factors and lessons learned • Access a searchable repository of content, both internally developed and externally contributed, to identify evidence-based practices, relevant research, and context-sensitive knowledge • Identify and extend the reach of expert resources across member hospitals • Connect with peers for just in time access to critical new knowledge at the point of care and the point of need • Create and develop new knowledge regarding business and care practices • Improve formal and informal communication regarding common projects, challenges, and environments.

5. Guiding Principles – Diffusion of Innovation • Transferring knowledge is often not enough; need to figure out how to transfer capabilities as well, through human and technology enabled support systems • Getting an organization to adapt new ideas requires a process of re-invention—people need to own the result as their own idea-- 10 Critical Dynamics of Innovation Diffusion: • Relative Advantage • Trialability • Observability • Communications Channels • Homophilous Groups • Pace of Innovation/Reinvention • Norms, Roles, and Social Networks • Opinion Leaders • Compatibility • Infrastructure Source: Diffusion of Innovations, Everett Rogers, 1995 “Diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system.”

6. Requirements of Effective System Change • It Ain’t Dog Food if the Dog Don’t Eat It! The program is only as good as the users willingness to use it • Suction, Not Pressure! Develop internal motivations, align incentives • Information is Not Enough If it was we wouldn’t be talking today • Watch What They Do, Not What They Say! People often tell you what they wish rather than how they actually behave. Design interventions and communication accordingly. • Listen to Your MoM! (Microcultures of Meaning)Useful information is made relevant through people

7. Creating Systemic Change • Focus on the reach and richness of content (information alone is not enough) • Creating change is both an individual and organizational process • Think of behavior as a transaction by creating a health action, medical event, care process, or business exchange • Create micro-cultures of meaning (to create context, tacit knowledge, and connectivity) at both the individual and organizational level • Make contextual information available at the point of care or need • Incent all parties toward the same outcomes • Integrate multiple mediums and learning styles • Focus on what people do, not what they say • Start with the person, not the risk, issue, or technology • Build relationships and process, not products and programs

8. The Science • Recent report: human beings are “Hardwired to Connect” • We are “biologically primed” for finding meaning through attachment to others • Learning is social • Acting on learning comes from context • Context comes from the groups of like meaning or Micro-cultures of Meaning (MoM) • Social Constructionism demonstrates that learning is always based on the context and language or stories of the group

9. Change drivers in an online community • Communication – pervasive, ongoing, and multi-modal – don’t rely on email alone • Context – Information is not sufficient to create change; it must be presented with the context to make it useful • Coaching – A suite of tools over time using multi-modalities and learning styles based on the degree of complexity or challenge in adopting the new behavior • Connections – Change processes and support resources need to be customized to the audience - Build relationships, not products – Strive for continual improvement not a single event • Coin – Align incentives of all the stakeholders and participants • Culture – It is part of the core, not peripheral to a strategy - Personal stories/experience are a key driver in transmitting this strategy - Start with the person, not the technology or problem • Create Microcultures of Meaning (MoM)

10. Timeline of Behavior Models 1927 Pavlov 1930s Skinner 1935 Lewin Field Theory and Group Process 1950s Hockburn, Rosenstock, Health Belief Model Kasl, and Cobb 1957 Festinger Cognitive Consistency Model 1958 Heider Attribution Theory 1968 Slovic and Liechtenstein Prospect Theory 1972 Sayeki Multiattribute Utility Theory 1975 Rogers Protection Motivation Theory 1977 Bandura Social learning theory 1979 Bettman Consumer Information Processing 1980 Green PRECEDE 1982 Kotler Social Marketing 1982 Leventhal, Zimmerman, Self-regulation theory and Guttman 1982 Prochaska and Transtheoretical model Diclemente 1982 Ajzen Theory of Planned Behavior 1985 Marlatt and Gordon Relapse Prevention Model 1986 Bandara Social Cognitive Theory 1991 Green and Kreuter PRECEDE-PROCEED 1992 Langer and Warheit Pre-adult Health Decision-Making Model 2000 Newton and Sofian Microcultures of Meaning Celeste Cafiero, Fern Carness, Changing Patient Behavior

11. What is a Microculture of Meaning? • A community of people with common need or purpose • It’s about connecting people and their knowledge (explicit & implicit): allowing them to communicate, share common experiences, interpret information, solve problems (personal, social, work), collaborate • It assumes the consumer as well as the provider of information is a valuable source of actionable knowledge • It can be a virtual support group, a form of intervention, training extension or a community of practice • It is a way to build a comfortable ‘place’ which facilitates action - intertwining interaction with contextual and professional information • It is designed to turn information into usable knowledge • It is far more than a collection of applications • Interactions match normal community behavior with the added benefits of the reach and richness that technology can support

12. What is Context? The beliefs, values, institutions, customs, labels, laws, divisions of labor, and the like that make up our social realities are constructed by members of a culture as they interact with one another. That is, societies (communities) construct the ‘lenses’ through which their members interpret the world” (Freedman, 1996). We see this as central for empowering effective change at an individual or organizational level.

13. Why is Context Important?

14. Creating Community within a Hospital System and Across Systems Make networking explicit & expected Create room for reflection & re-invention Knowledge requires connecting people and content Technology is essential but not sufficient

15. Who is Like Me? Me can be based on: • Demographics: age, sex, ethnicity, marital status, geography, work type • Circumstances: disease/risk state, club affiliation, employer, job role, a common problem and/or task, intra/inter mural work team, a common passion and/or need • Common experience: professional affiliation, alumni/veteran, an academic pursuit, attending particular events, caring for someone with a disability, hobby Mecan be any or all of the above and more! In a hospital setting Me is often defined in terms of: • Physicians: similar specialties, training, patient mix • Nurses: similar care setting, job responsibilities, roles in care process improvement • Managers: similar functional responsibility, strategic priority • Patients and Families: based on disease, condition, or medical experience • Facilities: demographics of patients, physical setting, affiliation

16. Five Key Elements to Effective Collaboration • Trust: Participants must feel this is a trusted source of useful knowledge • Relevance: The knowledge that is shared applies directly to them • Urgency: The resources shared will help a member solve a problem quickly • Incentive: Collaborating helps advance career and/or job status or even personal health – it’s worth it • Reciprocity: “If I help someone with my knowledge or experience, someone will help me” These are encouraged and reinforced within a MoM

17. Guiding Principles – Communities of Practice Connecting people through online/offline communities of practice involves building a set of tools that simplify communication, link people to content, and provide measurements of value and impact-- Key Technology Considerations for Supporting Communities of Practice • Presence and visibility • Rhythm • Variety of interactions • Efficiency of involvement • Short-term value • Long-term value • Connection to the world • Personal identity • Communal identity • Belonging and relationships • Complex boundaries • Evolution: maturation and integration • Active community-building Source: Etienne Wenger, Supporting Communities of Practice, March 2001 “Ideas and products and messages and behaviors spread just like viruses do.”-Malcolm Gladwell, ‘The Tipping Point’

18. How a MoM Works Online Personal BehaviorThe Online Functionality* Greeting/Welcome Registration, Personal Web Page & Profile, Welcome email Prepackaged links (based on profile) of applications, people, content, resources for new users Gathering Member Directory, Search, ‘Friends List” Chat Giving/Referring Discussion and Chat, Resource Contributions and opinion giving Ratings, volunteering, and Expression Gallery Finding Help, Sharing Resources, Ask the Community Manager, Search Helping/Instructing Multimedia Stories, Talk shows, Web logs, Moderated Chats and Discussion Boards, Web casts Family/Patient/Peer Web logs. Secure internal email, External email Updates/notification Connecting Email, Chat, Discussion Boards, Group Web logs Relationship forming Tailored newsletters, personalization filters and email notification of relevant knowledge, people, status within the community, and resources *All functionality must be tied together matching human behavior. The whole is always greater than the sums of the functional parts

19. How a MoM Works Online Professional BehaviorThe Online Functionality* Greeting/Capabilities Registration, Personal Web Page & Profile, Welcome assessment, team building, email Prepackaged links (based on profile) of applications, people, content, resources for new users Team Development Member Directory, Search, ‘Friends List”, Chat, Web connection interface Collaborating, Co-development Discussion with Presentation and Chat, Resource Contributions and Ratings and Expression Gallery Proven Practices Resources, Ask the Community Manager, Search Training, Online seminars Multimedia Stories, Talk shows, Web logs, Moderated Professional Development Chats and Discussion Boards, Web casts New Research, Innovations Web logs. Secure internal email, External email Collaborating notification Networking, Shop Talk Email, Chat, Discussion Boards with Presentations, Group Web logs with controls over access Grand Rounds, In-service Tailored newsletters, personalization filters and email Project Status notification of relevant knowledge, people, and resources *All functionality must be tied together matching human behavior. The whole is always greater than the sums of the functional parts

20. Sample Collaboration Tools • Community building and connectivity tools: • Personal repository for all user saved content, presentations/education sessions attended and the members who attended, people of personal interest, resources, lessons learned, web logs, identified discussion boards, external weblinks, etc. • System-generated messages, surveys, announcements, service offerings, education schedules, etc. • Community Member web pages, sharing contact information and member interests and needs, to support expertise locator function • Ad-hoc communities for attendees of events to support ongoing discussions • Discussion boards (asynchronous) • Chats (real-time) • Email tied to existing email systems, as desired • Individual and/or group web logs • Special events capabilities: Web casting, moderated chats, etc.

21. Sample Collaboration Tools • A searchable content repository: • Audio, video, presentation, and support materials of in-person, teleconference or other educational programs • Email notification of all new content, resources and connections as desired • Searchable and rate-able research, resources, people • Accessible intuitive web pages and directories for individual users • Easily searchable successful practices, case studies and lessons learned (can be submitted and/or retrieved) and attached documents • Resource/document sharing in multiple formats • Online surveys with ability to deliver tailored responses and information • Benchmarking capabilities regarding successful practices, resources and lessons learned

22. Knowledge ManagementThree typical uses in hospitals Clinical Decision Support - Incorporating evidence-based medical knowledge Performance Improvement - Using scorecards, analysis methodologies, etc. Multi-Site Collaboration - Collaborative knowledge-sharing forums Build trust Facilitate peer-to-peer knowledge transfer

23. Collaboration Tools – Connecting Resources and People in Real Time and When There is Time Who has expertise in this area? Who else faces similar challenges to mine? Is anyone else working on problems like mine? What ideas have been tried and tested? How can I share what I have learned? Is there a recommended way to do this?

24. Collaboration ToolsLessons Learned from Other Industries Saved “tens of millions of dollars” by creating a worldwide repository of “best practices” $1.5 million in savings from two of its communities of practice More than $1 billion in documented bottom-line savings since 1995 Gained $1.5B in annual wafer manufacturing capacity by sharing “best practices” $50 million a year in travel cost avoidance and $6 million annually by finding information more quickly through its KM initiative Virtual collaboration has become the way business is conducted - APQC.org Saved more than $150M in the first year of an initiative to identify and share marketing best practices

25. Health System Collaboration Examples “Our goal is for CHI to become known as an innovative organization. That will be our legacy for the future health care system – that CHI learns to leverage the wisdom of the whole, efficiently, effectively and humanely.” - Kevin E. Lofton, FACHE, CEO, Catholic Health Initiatives Each year, CHRISTUS Health presents Touchstone Awards to those practices and programs that stand out as “touchstones” in exemplifying the Mission and Values of one of our Directions of Excellence The Ascension Health Exchange is a collection of online Communities designed to facilitate sharing and foster innovation and quality improvement across Ascension Health to achieve our Calls to Action

26. Health System KM Examples… • Catholic Health Initiatives — 67 hospitals in 19 states, 67,000 employees, $6 billion annual operating revenues – focus on Knowledge Communities • Ascension Health —67 hospitals in 20 states, 100,000 employees, $9 billion annual operating revenues – focus on Content Management • Bon Secours Health System Inc. – 24 hospitals in 8 states, 27,000 employees, $2.3 billion annual operating revenues – focus on Capability Transfer • CHRISTUS Health–34 hospitals in 5 states and Mexico, 25,000 employees, $2+ billion annual operating revenues – focus on Best Practices Knowledge Transfer • Veterans Health Administration — 23 integrated service networks, $24 billion in annual operating expenses – focus on Tracking and Metrics • Air Force Medical Service–74 hospitals and clinics distributed all over the globe, $6.2B expenses, 39,000 employees – focus on technology and support infrastructure

27. What does it take to make change happen in hospital systems?

28. The Process for Effective KM

29. The Elements of Comprehensive KM

30. Key Components of System-wide KM System Internal Communities System External Communities Directory Knowledge Communities Link to national strategy SMEs Health information resources Health risk assessments Community service & mission System ProfessionalDevelopment System Knowledge Warehouse ELearning Leadership Development Mentoring Career Opportunities Performance Appraisals Research Proven Practices Facility Profiles Performance Improvement System Value Measurement System Knowledge Cultivation Knowledge Creation Knowledge Transfer Knowledge Stewardship Knowledge Coaching Satisfaction surveys Success stories Activity metrics

31. Knowledge Transfer for Performance Improvement – A Framework Leadership/ Management People/Culture Process Technology

32. Knowledge Management –How do we do it? 1. Create the infrastructure • Access – Make it easy for people to find the knowledge they need • Apply – Provide the context for making the knowledge relevant • Accelerate – Inoculate the organization with successes • Build knowledge transfer into organizational goals • Strategy – clearly articulate the expected outcomes • Design – Understand the processes and supporting technology needed • Operations – Integrate into existing staff roles and responsibilities 3. Measure the results • Value – connect knowledge sharing to organizational impact • Metrics – Collect satisfaction, process, and outcome measures • Communicate – Share success stories, continually educate

33. Create the Infrastructure to Share Knowledge Access:Simplify electronic access to criticalknowledge and the people who created it and become more transparent in sharing hospital performance indicators • Web-based repositories • Best practice libraries • Experiential knowledge sharing • Search and submit capabilities • Data and benchmarks • Guidelines • Embedded clinical rules & alerts • Community creation toolkits

34. Create the Infrastructure to Share Knowledge Apply: Facilitate peer connections to: • Share explicit (documents) and tacit (experience) knowledge • Apply general knowledge to specific issues • Talk about performance improvement • Build trust to support change • Innovate • Blended Learning: Email, telephone, face-to-face • Codified community roles: Moderator, recorder, coordinator • Formalized ways to legitimize participation • Communication tools • Connect people with experience and need • Success stories

35. Accelerate:Consider dedicated resources to accelerate adoption of new knowledge: Documents, educational forums, personalized support Peer exchange “bank” Project management Consulting Train-the-trainer Pilots Packaged documentation Awards and incentives Ongoing community facilitation Create the Infrastructure to Share Knowledge

36. Build knowledge acceleration into strategic goals – an example CHI’s “Desired Future State” gives focus to its preferred future, and describes the key attributes and imperatives of that future. Five Core Strategies – People, Information, Quality, Performance, and Growth – will focus the investments in time, money and human energy that CHI believes will be imperative for staying the course and sustaining momentum toward its Desired Future State. CHI’s strategic focus will also be infused with a spirit of: Innovation that fosters and rewards creative thinking and accelerates learning; Knowledge exchange to ensure CHI’s success in a dynamic health care environment; and Partnership with employees, physicians, local communities, and other organizations that will advance CHI’s efforts in advocacy, research and development, deployment of medical/information technologies and the creation of new models of care.

37. Measure the results – examples

38. Building Communities within/across Hospital Systems – Key Phases • Strategy– clarify objectives, envision the future • Assessment – understand current state, identify needed changes • Design – delineate the components to be built, create a working prototype, develop implementation plan, specifications document, and cost • Build – create knowledge creation & transfer processes, develop the tools and templates, integrate with IT strategy • Operationalize – support, customization, training, documentation, maintenance & updates

39. Phase 1 - Strategy • Clarify Objectives – WIIFM? For relevant participants (physicians, nurses, managers, patients) • Increase customer satisfaction, improve service quality, reduce response time • Improve outcomes • Reduce unnecessary variation • Recruit and retain qualified staff • Reduce costs, streamline operations, avoid duplication Picture Future Success - Describe the future from all stakeholder perspectives Identify Oversight team and key contact points to synchronize on KM aims

40. Phase 2 - Assessment • Current state – how well do current tools and processes work? What needs to be kept, eliminated, enhanced, created? How do people currently communicate/share with each other? • Culture – what barriers exist regarding sharing and reuse of knowledge? What are the most effective means of communication between individuals and teams? • Processes – how do we “bake it in” to create, capture, share, and reuse knowledge? • Vitality – what are key roles needed to keep the knowledge current, relevant, and critical? • IT Infrastructure – what currently exists and what are the gaps? How will the databases integrate? What are internal vs. external access points? Where do current IT plans fit in?

41. Phase 3 - Design • Feedback – identify pilots to model the new vision and try out the new approaches • Prototype – create a working example – for clinicians, managers, patients if appropriate - to generate detailed user feedback and develop roll-out plans • Context – create links to existing data sets, tools, and people; incorporate external resource links and resources • Learning – refine and create new knowledge creation & transfer processes • Assessment – determine how to measure and track the value • Innovation and New Directions – incorporate planning for the future, including new care delivery, staffing, and payment models

42. Phase 4 - Build • Create core processes • Communities of practice – roles, rules, requirements • Knowledge creation & transfer techniques • Integrated clinical information systems • Data Warehouse and Reporting • Education and Development • Develop technology plan • Develop collaborative spaces – internal and external • Integrate the underlying database model into the overall IT strategy • Develop and conduct training programs • Integrate user feedback tracking and value metrics reporting • Modify processes, tools, and reporting based on how people actually use them • Develop operations plan • Knowledge community roles, rules, support • Content management roles, rules, support • Professional development program • Knowledge cultivation program • Customer relationship management programs • Communications plan

43. Phase 5 - Operationalize • Identify & recruit key opinion leaders/magnets to participation and leadership • Ongoing coaching of knowledge community leaders, content librarians, and technology stewards • Ongoing execution of knowledge creation & transfer processes • Ongoing training and adoption support • Ongoing tool development, software maintenance, capability upgrades • Ongoing communication strategy support • Ongoing integration with overall IT strategy

44. Catholic Health Initiatives (CHI)

45. Ascension Health

46. CHRISTUS

47. Bon Secours Health System

48. Expertise Locator Document Repository People with Known Expertise & Know-how Collaboration Areas Keywords, Concepts & Phrases Learning Mgmt System Threaded discussions, email, etc. SCORM (Learning Objects) Hierarchical Site Map All Documents Related to the Node (Explicit) External Links related to the Node (Explicit) Education & Training Topics Relevant to the Node (Explicit) Communities and Affinity Groups within the Node (Tacit) People with Experience & Know-how Concerning the Node (Tacit) Collaboration Concerning the Node’s Business (Tacit) Enterprise Taxonomy Knowledge Junction Air Force Medical Service Knowledge Junction TM Concept

49. Lessons Learned • People to People Connection is critical! • Executive Support is required to gain acceptance. • Link directly to the core strategies of the organization. • Tools & Templates simplify the process for participation. • Don’t over-engineer the process of sharing! • Maintain flexibility – stay focused on needs!

50. Lessons Learned • Prototyping – pilot new tools with small groups. • Patience – it takes time and behavioral change for this to become the “way we work”. • Self Service – make it easy and rewarding for people to utilize the tools themselves. • Success Stories – build momentum and recognize the heroes. • Partner with IT – technology can greatly enhance the collaboration and sharing process.