1. Collaborative Medical Home-Building 101: Harry Potter Learns Practice Jazz
William L. Miller, MD, MA
Lehigh Valley Health Network
Allentown, PA
February 29, 2008
2008 STFM CONFERENCE ON FAMILIES AND HEALTH

2. Situation in FM Rising Demand Growing Competition
Urgent Care
Retail Clinics
EDs
CAM
NPs/PAs
Internet
Specialists
More Patient Needs Unmet
Shrinking Capacity
Less Hospital Care
Less ED Care
Less Procedures
Less Point of Care Services
Less Children
Less Income
Less Students/Graduates
Less Investment
More Demand
More Paperwork
More Documentation
More Referrals

3. The Miracle! PRIMARY CARE Patient-Centered Medical Home
Better Health Outcomes
Lower Costs
Greater Equity
Patient-Centered Medical Home

5. 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)

6. 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.

7. 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

8. 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

9. 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

11. Small (3 or less clinicians) 4
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

12. 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, )
Discounted goods and services
(e.g., website, disease registry)

13. 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
Site visits by qualitative analyst

14. Data Sources: Quantitative
Patient surveys
Clinician/staff surveys
Medical chart reviews
Practice finances

15. 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
strings between practices and facilitators
Online discussions between practices
Conference calls, learning sessions

16. NDP Early Results
Proof of concept of a new model(s) of care for family medicine:
Quality of care
No difference between FPs & SDPs on patient outcomes
No relationship between # components & patient outcomes
Practice finances
Practices are less facile than initially assumed
Other
Practice relationship-centeredness ~ Patient-centered care

17. NDP Early Results Determining the best process for transformation:
No difference between FPs & SDPs relative to # of components implemented
Tailoring appears helpful
Facilitation when relationships need work
Individual coaching for leadership, finances, etc.
With high motivation & high resources, consultative/instrumental approach helpful
The “New Model”  Patient-Centered Care

18. Emergent Hope Patient-centered medical homes may still be achievable
Multiple pathways
Full engagement of practice needed
Requires particular attention to:
The clinical process
Relationships among all members of practice
Relationships between practice & larger health care system & community
Motivation and capacity of key stakeholders
Confirmed earlier/current other studies

19. Personal Family Wisdom
Tree House Rule = “Whatever is said in the tree house, stays in the tree house.”
Earth is the tree house
Adoption Rule = “Nurture & discover the unknown child.”
“There is no perfection.”
“Mistakes are for learning.”

20. Background
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)

21. Observation Intervention
DOPC
STEP-UP
Direct
Observation
of Primary
Care ( )
Study To
Enhance
Prevention by
Understanding
Practice ( )
P&CD
Prevention & Competing Demands in Primary Care ( )
ULTRA
IMPACT
Using Learning Teams for Reflective Adaptation ( )
Insights from Multimethod Practice Assessment of Change over Time ( )

22. First insights into role of complexity in understanding practices
Practices could not be described in mechanistic terms – too many non-linear relationships among events
All the parts and people of a practice are interconnected and interdependent in terms of both relationships and functions.
Any change in one part of the practice will have ripple effects through the other parts of a practice. Those ripple effects will create tension and problems that can be barriers to change.
Changes don’t occur in a linear fashion. Small changes can have dramatic effects at times, large changes can produce small results at others.
What works in one practice may not work in another---many different ways of achieving good outcomes

23. Properties of Complex Adaptive Systems (CAS)
CAS consist of ‘agents’ with capacity to learn and freedom to act in unpredictable ways.
Agents are often individuals, they may be teams, organizational processes, technical components.
Agents are connected in non-linear ways--one agent’s actions changes the context for other agents.
The quality of the interactions among agents is more important than the quality of the agents.

24. Properties of Complex Adaptive Systems
Self-organization: systems generate new structures and patterns over time as a result of their own internal dynamics. Order emerges from patterns of relationships among agents.
Emergence: process by which non-linear interactions among agents results in new patterns of behavior. The system that evolves over time is more than the sum of its parts.
Co-evolution: process of mutual transformation of the agent and the environment in which it exists.

25. Implications for Practice Change
Patterns of relationships among staff (‘agents’) are critical determinants of practice change. (The quality of the interactions is more important than the quality of the staff.)
From high quality interactions, process will emerge to create high quality change
Emerging processes will not be the same in every practice.

26. According to CAS principles, successful practices will:
Move from an ‘organization as machine’ paradigm and begin to understand their practices as complex adaptive systems.
Pay more attention to the quality of the interactions among staff than on the quality of the staff.
Focus on staff learning rather than on what they know today.
Encourage cognitive diversity among staff (and teams) and leverage diversity to foster learning and emergence
Recognize that the practice is a social entity, and foster sense-making, learning, and improvisation
Expect and celebrate surprise as opportunities to learn and grow
Begin to understand the interdependence between the formal and informal organizations rather than making everyone conform to the formal organization

27. According to Complexity Science …
There are ghosts in the system because of Sensitivity to Initial Conditions.
Persistence of self-organization when there is much loose coupling and multiple feedback loops.
Power laws are operating because of Non-linearity (think 80/20)
No normal distributions so averages are meaningless
Examples:
Length of stay – can’t use averages since the distribution isn’t a “normal” one – 80% of LOS # is based on 20% of the outlier patients
Referred admissions from family docs – 80% of admissions come from 20% of the docs
80% of a practice’s attention is devoted to 20% of their patients
80% of employee challenges in a practice are related to only 20% of the employees

28. IMPACT CHANGE MODEL

29. Relationship-Centered Practice Capacity Model
Reflection
Action
Trust
Mindful
Respect
Heedful
Diversity
Social/
Task
Rich/Lean
STORIES
Learning CULTURE
Teamwork
Sensemaking
Improvisation
Build Memory
Dynamic Local Ecology
Facilitative LEADERSHIP
Knowledge
Skills
Finances
Operations

30. 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.

31. NDP Early Lessons: Motivation & Capacity
Leadership & key stakeholders need to be motivated and engaged in the change process.
A practice's resources & capacity for change at baseline is a huge determinant for that practice's progress, and equally important is the ability to increase that capacity.

32. NDP Early Lessons: Leadership & Reflection
The most successful practices seem to have shared leadership systems rather than an individual physician leader.
So little leadership
So much power
A critically important role of leadership is to assure adequate time for personal and practice-level reflection.

33. NDP Early Lessons: Relationships & Conversations
Despite being highly motivated some practices had serious dysfunctional problems within the relationship infrastructure that required significant time and energy on the part of the facilitator.
A critical factor in improving relationships is for leadership to assure adequate and appropriate conversations.

34. Early Lessons: Technology & Fatigue
The technology in the New Model, while shining with possibilities, is not by any means an easy "plug and play" interface for the practices.
Due in part to the ongoing challenges of technology, even the most successful practices are experiencing change fatigue.

35. NDP Early Lessons: Help & Support
Depending on initial practice capacity assessment, may need one or more:
Targeted consultation – e.g. Advanced Access, EMR, finances, specific operations, etc.
Coaching – e.g. leadership, finances, etc.
Facilitation – e.g. relationships, reflection, leadership, etc (different intensity of joining practice and/or system, ranging from just being there to active facilitation).
Group Learning & Knowledge Access

36. More Lessons from NDP Essential New Skills/Curriculum Identity Issues
Paradigm Problems
Dual Organization
Importance of IMPACT Model
Breathe & Celebrate
No Transformation Yet

37. NDP Early Lessons: It’s Personal
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 patient & relationship (team) centered.
Each practice not only has a different way of implementing the new model, but each 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.

38. Harry Potter Wisdom
Make choices
Seek good friends
Do what matters

39. Change Thinking Unfreeze & Initiate
Set initial conditions & start conversations
Requires HEAT
Everyone must be unfrozen
Transition & Trouble
Prepare for & deal with difficult emotions & conversations
Requires good & flexible project management
COMMUNICATE
Chill & Accelerate
Continue culture change & seek disruptions
Expect “change fatigue”
Unfreeze = Sunny vision; fiery passion; burning platform = This is the Harry Potter part
- Assure everyone is regularly connected and has skills to converse
Transition = this is the jazz part
Chill & Accelerate = this means you built adaptive capacity (relationships/leadership/reflective space/skills)

40. Being “Tempered Radicals”
Resisting quietly & staying true to one’s self
Turning personal threats into opportunities
Broadening the impact through negotiation
Leveraging small wins
Organizing collective action
- Debra E. Meyerson (2001)

41. Jazz Secrets Turn-taking Building Empathetic listening
Soloing
Supporting
Passing-off
Building
Empathetic listening
Continual negotiation
Facilitative leadership
Hanging out
Here & Now
In the Groove

42. Leadership Types Leadership as Leader – Engineer
Strategic Engineer (design for fit with environ.)
Economic Engineer (design for perfor. outcomes)
Social Engineer (design for behav. outcomes)
Leadership for Emergence
Administrative Leadership
Enabling Leadership
Adaptive Leadership
- See Complexity Systems Leadership Theory by Hazy, et al (2007)

43. Emergent Leadership Properties
Distributing Intelligence
Fostering Conversations
& Enriching Connections
Sustaining Tensions
Looking for Patterns
- See Complexity Systems Leadership Theory by Hazy, et al (2007)

44. The Magnificent 7 Mindfulness Respectful interaction
Heedful inter-relating
Mix of rich and lean communication
Diversity
Mix of social and task relatedness
Trust

45. Types of Teams CONTROL (Think Football) AUTONOMY COLLABORATION
(Think Baseball)
COLLABORATION
(Think Basketball)
From R. Keidel, Corporate Players

46. Characteristics of Good Team
Relational Coordination
Frequent, timely communication
Shared goals
Shared knowledge
Mutual respect
Problem-solving
Team Culture (supportive)
Other Key Features
Clinical & administrative systems
Training & cross-training

47. Roles of Future FP Manager of Care Staff
Manger of Informational System
Doer of the Tough Clinical
“It’s OUR patient” and not “It’s MY patient.”

48. 3 Conversational Intents
Doing the Project
Stakeholder/Structure/Matrix Development Work
Adaptive Capacity Building

49. Some New Models The BIG Home The LITTLE Home
TransforMED
Ambulatory Practice of the Future
Optimal Healing Environments
Cooperative Clinics
The LITTLE Home
Micropractices
Concierge practices
Access Healthcare
Real Estate Agents with Perks
“Retail” clinics
Urgent care/ED express care

50. References Organizational Change & Complexity Science
Cohen D, McDaniel RR Jr, Crabtree BF, et. al. A practice change model for quality improvement in primary care practice. J Healthc Manag May-Jun;49(3):
Miller, W.L., Crabtree, B.F., McDaniel, R.A., and Stange, K.C. Understanding Primary Care Practice: A Complexity Model of Change. J Fam Pract, (5):
Miller WL, McDaniel RR, Jr., Crabtree BF, Stange, K. Practice Jazz: Understanding variation in family practice using complexity science. J Fam Pract 2001; 50(10):

51. References
Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective practice improvement process. Joint Comm J Qual and Patient Safety. 2005; 31(8):
Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. J Gen Intern Med 2006; 21: S9-15.

52. References
Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR. Delivery of Clinical Preventive Services in Family Medicine Offices. Ann Fam Med. 2005; 3(5):
Miller WL, Crabtree BF. Healing landscapes: Patients, relationships and optimal healing places. J Complementary and Alternative Med. 2005, 11 Suppl 1:S41-9.
Crabtree B. Primary Care Practices are Full of Surprises! Health Care Manage Rev, 2003, 28(3):

53. References
Tallia AF, Lanham H, McDaniel R, Crabtree BF. Seven Characteristics of Successful Work Relationships Family Practice Management Jan; 13(1):47-50.
Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: Case study of an exemplar small medical group. Ann Fam Med Mar-Apr;4(2):