Presentation Information Transformation is Hard Work: Lessons from TransforMED’s National Demonstration Project Presented by Elizabeth E. Stewart, PhD October 21, 2007 CONFIDENTIAL

National Demonstration Project Evaluation Team Presentation Information National Demonstration Project Evaluation Team Center for Research in Family Medicine and Primary Care Carlos R. Jaén, MD, PhD (PI) Benjamin F. Crabtree, PhD Paul A. Nutting, MD, MSPH William L. Miller, MD, MA Kurt C. Stange, MD, PhD & Elizabeth Stewart, PhD (analyst) Reuben R. McDaniel, EdD (consultant) Collaborative team has conducted a series of descriptive and intervention projects over a 15 year period. Funded by NCI, NHLBI, NIDDK, NIMH and American Academy of Family Physicians (AAFP) Results from these projects have informed an evaluation of the AAFP’s National Demonstration Project (TransforMED) CONFIDENTIAL

National Demonstration Project: Background Presentation Information National Demonstration Project: Background The Future of Family Medicine report (2004) gave recommendations on “developing a strategy to transform and renew the specialty of family medicine.” 1 The American Academy of Family Physicians allocated funding for a demonstration project to “test” the implementation of the new model(s) of family medicine as proposed by FFM. 1 The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2:S3-S32. CONFIDENTIAL

National Demonstration Project: Background Proof of concept of a new model(s) of care for family medicine: Quality of care Practice finances Determining the best process for transformation: Facilitated Self-directed

Components of TransforMED Model of Care Presentation Information Components of TransforMED Model of Care Access to care Access to information Team approach Point of care services Information services Redesigned offices Practice management Quality and safety Whole-person orientation Personal medical home Patient-centered care Continuous relationship Access to Care – same day scheduling Access to Information – practice website Team Approach – staff working to highest potential Point of Care – Acute, chronic, procedures, wellness Information services – EHR, disease registry Redesigned offices – optimal patient flows Quality & safety – “best practices,” patient feedback/satisfaction CONFIDENTIAL

Presentation Information CONFIDENTIAL

Domains of NDP Evaluation Discovering what the transformed model looks like in the real world Effect of the transformed model on the practice Effect of the transformed model on patients Understanding the process of practice change Understanding transformation

NDP Design Volunteer practices (36) selected by technical advisory committee from over 300 applicants Randomly assigned to two change approaches: Facilitated (18) Self-directed (18) July 2006 to June 2008 (2 yrs) Mixed method assessment: RCT with pre/post and inter-group comparisons Comparative case study

Presentation Information www.transformed.com CONFIDENTIAL

Presentation Information Practice Description Number of Sites Facilitated Self-directed Solo and Solo +1 3 Small (3 or less clinicians) 4 New 2 Medium (4-6 clinicians) 5 Large (7 or more clinicians) Total 18 CONFIDENTIAL

Facilitated Practices Three TransforMED facilitators – each one assigned 6 practices. Intervention includes: Site visits Learning sessions/collaboratives Facilitated conference calls and webinars Connecting to nationally known consultants Constant contact w/facilitators (phone, email) Discounted goods and services (e.g., website, disease registry)

Self-Directed Practices Presentation Information Self-Directed Practices Very minimal intervention that will still allow this group to be a valid comparison group Access to resources and information from TransforMED website Practices self-organized and created their own retreat At present, site visits by qualitative analyst Their data are not the basis in this report – however, ongoing learning provides confirmatory data SD data are not the basis of this report but will play a critical role in future learnings CONFIDENTIAL

Data Sources: Quantitative Presentation Information Data Sources: Quantitative Patient surveys Clinician/staff surveys Medical chart reviews Practice finances CONFIDENTIAL

1st year Data Sources: Qualitative Presentation Information 1st year Data Sources: Qualitative Field notes/observations from facilitators (site visits, phone call logs, etc) Field notes/observations from Qual. Analyst (facilitator huddles, meetings, etc) Key informant & informal interviews Email strings between practices and facilitators Online discussions between practices Conference calls, learning sessions Comparative case analyses of the 18 facilitated practices to present today’s learnings Weekly analysis calls and face to face analysis sessions CONFIDENTIAL

Presentation Information NDP Early Lessons Without further ado CONFIDENTIAL

Presentation Information NDP Early Lessons Implementation of new model components, especially technology, is a monumental undertaking… requiring a level of effort and intensity well beyond what most practices have done in the past. Practices are unfamiliar with changes at the systems level, and many do not function as a coordinated system and therefore lack insight into the complexity of their practice. Change requires buy-in from all levels. Before change could occur, practices had to learn techniques to overcome their daily treadmill. Such techniques include how to hold meetings, how to review finances, and how to communicate and work as a team CONFIDENTIAL

Presentation Information NDP Early Lessons The most successful practices seem to have shared leadership systems rather than an individual physician leader. Leadership systems have complementary pieces for practice vision, practice operations, and practice finances. When the leadership system is in place, a practice’s ability to adopt changes accelerates significantly. The NDP practices with such a system in place at baseline were not only farther along at baseline, but able to adopt change more rapidly. Practices without strength in all three system components often hit stumbling. CONFIDENTIAL

Presentation Information NDP Early Lessons Despite high levels of motivation, some practices had serious dysfunctional problems at baseline. These required significant time and energy on the part of the facilitator. Before the facilitators could begin making changes… they had to shore up and fortify the practice relationship infrastructure. Sometimes this required leadership coaching with a physician or an all-staff retreat. In some practices, natural attrition helped CONFIDENTIAL

Presentation Information NDP Early Lessons A practice's capacity for change at baseline is a huge determinant for that practice's progress. Equally important is the facilitator's ability to increase that capacity. Such capacity is dependent upon some of the key elements facilitators worked to foster in the beginning. Not surprisingly, such capacity is dependent upon some of the key elements that the facilitators worked to foster in the beginning: a web of healthy relationships, including mutual trust, respect, and mindfulness; strong leadership and decision making; and teamwork. Capacity for change also includes a culture of learning, sensemaking, work environment, and attention to fitness landscape. CONFIDENTIAL

Presentation Information NDP Early Lessons Proposed new model technology is not by any means an easy "plug and play" interface for the practices. The technology landscape for medical practices resembles a pile of different jigsaw puzzles thrown together. Sorting through and making it work requires tremendous energy. Implementation forces rigorous examination to guard against “automated inefficiencies.” Currently the technology landscape for medical practices resembles a pile of different jigsaw puzzles all thrown together. It takes time, energy, and relentless problem-solving to try to find the right pieces to finally fit together. Most practices, especially the small ones, do not have this kind of time or technological expertise. Large practices connected to health systems may have technology assistance, but sometimes not a mutual understanding of what the physicians need. The TransforMED facilitators play a critical role in putting the pieces of the puzzle together. They make the phone calls to the necessary companies, they bird-dog the details of interface, they push the issues when needed, and generally provide support and follow-through. Despite the hard work on all ends, the challenges continue into the second year of the NDP. CONFIDENTIAL

Presentation Information NDP Early Lessons Due in part to the ongoing challenges of technology, even the most successful facilitated practices are experiencing change fatigue. Learning sessions have been critical for renewal and regeneration. Preliminary data from SD practices also indicate a strong desire for an outside force to “ride herd” and sustain energy. CONFIDENTIAL

Presentation Information NDP Early Lessons For some physicians, the new model requires transformation at the personal level, as practices must move from a physician-centric approach to one that is more team-centered. Each practice not only has a different way of implementing the new model, but each change leader physician has a different vision of what transformation really is. Some physicians believe it is moving from a patient-approach to population-approach… others think it is when their practice is a joyful place or efficient place to work… still others believe transformation can only occur when the national system of compensation changes. CONFIDENTIAL

Presentation Information NDP Early Lessons Focusing the Role of Facilitator: Depending on initial practice capacity assessment, a practice may need one or more: Targeted consultation Practice finances (reduce overhead, etc) EHR implementation/work flow Specific operations (same day scheduling, group visits, etc) Part of analyses includes dissecting the role of the facilitator as change agents within the practice. It appears they can play three different roles, sometimes all three for the same practice. CONFIDENTIAL

Presentation Information NDP Early Lessons Focusing the Role of Facilitator: 2. Coaching Leadership Finances (understanding/managing) Specific roles (office manager) CONFIDENTIAL

Presentation Information NDP Early Lessons Focusing the Role of Facilitator: 3. Facilitation * Relationships * Reflection * Leadership Facilitation seems to vary in its intensity, ranging from “joining” a practice or system to being a supportive background presence. CONFIDENTIAL

Presentation Information Family Medicine Practice Trying to Change… Final early lesson/metaphor: the need to upgrade an airplane, with the upgrade needing to be done while the plane is still flying. In this case, most practices are more like a 1950’s era twin prop DC-3 and they need to upgrade into a New Model Star Ship Enterprise. Part of the change process the facilitators are doing is teaching them how to glide; how to get breathing space to allow them to gain altitude. Those now at treetop need a little more altitude before they can do changes, since each is guaranteed to lose 10K feet when making the required changes. The upgrade needs to be done while the plane is still flying! CONFIDENTIAL

Presentation Information The question is – if and when they do manage to transform in midair, is the transformation complete? Stay tuned. Transformation Complete? CONFIDENTIAL