Facilitation in Practice: Location, Level, Intensity

1. Quality Enhancement Research Initiative Facilitation in Practice: Location, Level, Intensity Anne Sales, PhD RN

2. 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

3. Describing facilitation • Human vs. technological facilitation • Human • Characterized by hierarchy, roles, other dimensions • Technology • Almost always requires human intermediation

4. Quality Enhancement Research Initiative Assessment of a Quality Improvement Intervention to Promote VA NationalLipid Electronic Clinical Reminders Anne Sales Ashley Hedeen Meg Plomondon John Rumsfeld VA HSR&D Service 01-040

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. Use of reminders varied among intervention sites

13. 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

14. More description • Internal vs. external • Limited vs. holistic • Formal vs. informal • Other continua…

16. Internal facilitation: providers/professionals as facilitators • Roles include • Opinion leader • Change agent • “Facilitator”/troubleshooter • Convener

17. External facilitation • Outside experts • Consultants • “Gurus” • Researchers • People from a higher level of the system or organization

18. 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

19. 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

20. 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

21. 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

22. 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

23. The dark side • Negative opinion leaders • Questions of resistance • Can arise from many sources: • 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

24. Living in a thunderstorm

25. 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

26. Tools for coping • Adequate planning • Anticipation • Adequate provisions • Sufficient support

27. Facilitators generally • Need nurture and support • Recognize and plan for barriers • Adequate resources and support • Recognize that values are important component