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Facilitating Change:Lessons from the TransforMED National Demonstration ProjectAHRQ 2009 Annual Conference Sept. 14, 2009Elizabeth E. Stewart, PhD Independent Evaluation Team from Center for Research in Primary Care & Family Medicine

Evaluation team
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

National demonstration project
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.

Ndp background timeline

  • 300 usable applications

36 practices selected

18 randomized:


18 randomized:


15 (SD) practices finished

NDP: Background & Timeline

NDP start: July 2006

NDP finish: June 2008

17 (F) practices finished

Touchstone Group Begins

Implementation assistance
Implementation Assistance


  • 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

Self- Directed

  • List serve & website access

  • 1 final NDP Learning Session

  • Some $$ for self-organized retreat midway through NDP

Mixed methods
Mixed Methods


  • Patient Health Outcomes (medical chart audits)

  • Practice Finances (surveys – limited)

  • Clinician/Staff Satisfaction (surveys)

  • Patient Perception of Care (surveys)


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

  • Access to Care &Information

  • Health care for all

  • Same-day appointments

  • After-hours access coverage

  • Lab results highly accessible

  • Online patient services

  • e-Visits

  • Group visits

  • Practice Management

  • Disciplined financial management

  • Cost-Benefit decision-making

  • Revenue enhancement

  • Optimized coding & billing

  • Personnel/HR management

  • Facilities management

  • Optimized office design/redesign

  • Change management

  • Practice Services

  • Comprehensive care for both acute and chronic conditions

  • Prevention screening and services

  • Surgical procedures

  • Ancillary therapeutic & support services

  • Ancillary diagnostic services

  • Health Information Technology

  • Electronic medical record

  • Electronic orders and reporting

  • Electronic prescribing

  • Evidence-based decision support

  • Population management registry

  • Practice Web site

  • Patient portal

  • Care Management

  • Population management

  • Wellness promotion

  • Disease prevention

  • Chronic disease management

  • Care coordination

  • Patient engagement and education

  • Leverages automated technologies

  • Quality and Safety

  • Evidence-based best practices

  • Medication management

  • Patient satisfaction feedback

  • Clinical outcomes analysis

  • Quality improvement

  • Risk management

  • Regulatory compliance

  • Continuity of Care Services

  • Community-based services

  • Collaborative relationships

  • Hospital care

  • Behavioral health care

  • Maternity care

  • Specialist care

  • Pharmacy

  • Physical Therapy

  • Case Management

  • Practice-Based Care Team

  • Provider leadership

  • Shared mission and vision

  • Effective communication

  • Task designation by skill set

  • Nurse Practitioner / Physician Assistant

  • Patient participation

  • Family involvement options

A new way of thinking
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.

A new way of thinking1
A new way of thinking…

  • Physicians will need to move towards facilitated leadership skills and away from authoritative ones.

  • Physician-patient relationship will need more emphasis on partnership to achieve patients’ goals.

  • Practice will need to change from a machine that processes patients for the doctors to a team that proactively manages a population of individual’s health.

What helps a practice transform
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.

What is adaptive reserve
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 Strong Leadership

    Learning Culture Sense making

    Reflection Diversity

    Work Environment Mindfulness


Change in adaptive reserve
Change in Adaptive Reserve*

*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

The role of facilitation
The Role of Facilitation

1. Consulting

2. Coaching

3. Facilitating Adaptive Reserve

Facilitation consultant
Facilitation: Consultant

Huddles & Meetings

Metrics, PDSA cycles

Workflow analysis

Specific projects

HIT assistance – vendor liaison, implementation

Facilitation coach
Facilitation: Coach

Staff: Empowerment, task delegation

Practice Managers

* Project Mgt

* Personnel/HR

* Finances

* Communication

* Empowerment

* Support


* Leadership

* Finances

* Delegation

* Time Mgt

* Communication

* Support

Facilitation adaptive reserve
Facilitation: Adaptive Reserve

Facilitated Learning Sessions w/other practices



Staff Retreats

With Pre-Work

& Follow-up

Rich & Lean




Patient outcomes surveys
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.*

  • Superb Access

  • Patient Engagement

  • Clinical Information Systems to Support Care

  • Care Coordination

  • Integrated & Comprehensive Team Care

  • Routine Patient Feedback to Doctors

  • Publicly available information

  • Also assess patient enablement & patient satisfaction.

    *Commonwealth Fund

Pos core elements to measure
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)

Self directed practices some decreases
Self-Directed Practices: Some Decreases

Only showing core elements with significant changes from baseline:

* = p <.05; ** = p <.01; *** = p <.001

Self directed practices some decreases1
Self-Directed Practices: Some Decreases

Only showing core elements with significant changes from baseline:

* = p <.05; ** = p <.01; *** = p <.001

No significant change in facilitated practices
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.