1. ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

2. CENTER FOR HEALTHCARE INNOVATION What is AHP? Application of Ron Heifetz’s Adaptive Leadership model to clinical practice Three key “simple rules” changes: – Patient must and can do their own adaptive health work; we can’t do it for them – But we can help them do it by upgrading our skills and using Adaptive Leadership principles. – Technology (drugs, procedures, etc.) has limited utility and significant potential for harm—use sparingly and judiciously

3. CENTER FOR HEALTHCARE INNOVATION Fundamentals of Adaptive Leadership Complex systems face adaptive and technical challenges. Adaptive challenges require learning and behavior change—adaptive work. Technical challenges can be addressed with technical solutions and expertise. Technical work will not solve adaptive challenges, and often make the problem worse. AL consists of knowing this, and how to help people and organizations do adaptive work.

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5. Example: GERD and PPIs Heartburn mostly related to lifestyle: diet, obesity, tobacco, alcohol. Treatment for GERD now: PPIs Feedback loops: hypergastrinemia and failure to address lifestyle factors Long-term use of PPIs (> 2 months) causes GERD sxs in normal people PPIs cause dependency and are addictive Prevalence of GERD has doubled in US since PPIs introduced

6. CENTER FOR HEALTHCARE INNOVATION Adaptive Work Avoidance Failure to adopt healthy lifestyles (patient) Failure to address unhealthy lifestyles (MD) Terminal chemotherapy instead of hospice Spinal fusion instead of active rehab for disc DJD Drugs in lieu of exercise, light, talk therapy, etc. for depression

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8. Implications We and our patients are both avoiding the challenge of doing the adaptive work required to be healthy and cope with suffering. We collaborate in this by inappropriately applying technical solutions in lieu of adaptive interventions, and by remaining unskilled in adaptive leadership. This causes a lot of harm and inefficiency (waste), and damages the doctor-patient relationship.

9. CENTER FOR HEALTHCARE INNOVATION Why is this happening? Adaptive work is hard and often avoided (by patients and providers). We aren’t incented to practice adaptively. We don’t know how to do it.

10. CENTER FOR HEALTHCARE INNOVATION What should we do? Support patient adaptive work by doing the adaptive work to change our Philosophy of practice – Explicitly identify adaptive challenges and interventions, to ourselves and our patients – Recognize the limitations of our technical expertise – Use technology sparingly and judiciously – Adopt a socio-ecological, whole-systems approach to health – Build our skills as adaptive leaders to help patients do adaptive health work System – Financial incentives – Blind faith in technology – Inputs (staffing, resources, culture)

11. CENTER FOR HEALTHCARE INNOVATION Facilitating adaptive work: Diagnose the system, and the problem Establish a “holding environment” Identify the “ripe” issues Think about your framing Regulate the “heat” See yourself as part of the system Hold steady Keep the work at the center of people’s attention

12. CENTER FOR HEALTHCARE INNOVATION The proper use of technology? Facilitate adaptive work (e.g., exer-gaming, mobile health apps, analgesics to facilitate PT, etc.) Relieve suffering that overwhelms patient coping Manage risk factors until adaptive work is effective Treat disease not amenable to adaptive work Avoid technology with long-term negative feedback loops on health

13. CENTER FOR HEALTHCARE INNOVATION Implementation Issues What does AHP look like behaviorally, for both patients and doctors? For which patients will this work? What to do for patients who respond negatively? How do we do the adaptive work to change our system and philosophy of care?

14. CENTER FOR HEALTHCARE INNOVATION Basic AHP Staff trained on adaptive leadership New patients are introduced to the practice’s philosophy of care SOAP approach modified to address both adaptive and technical components Measurement reflects both adaptive and technical components

15. CENTER FOR HEALTHCARE INNOVATION SOAP—New and Old TraditionalAHP S Standard historyAdd health beliefs, social support and network, family and work systems, patient complexity, detailed lifestyle inventory, etc. O Standard physical and diagnostic testing, (PHQ-9 in MN) Measures of resilience, adaptive capacity, learning orientation, etc. Social network survey? A Diagnosis, prognosisDistinguish adaptive and technical challenges explicitly. P Treatment, referrals, testing, etc.Distinguish adaptive and technical work. Develop plan for supporting adaptive work, including social and psychological interventions. Avoid technical interventions that reduce adaptive capacity/work.

16. CENTER FOR HEALTHCARE INNOVATION Paths to AHP Incremental: train staff on organizational Adaptive Leadership; then support them in generalizing to patient care. Transformational: train them directly on applying AL to patient care, and hope the culture accepts it. For full development, does this need to be managed as a separate company?

17. CENTER FOR HEALTHCARE INNOVATION Next Steps Design it Pilot and refine it Controlled trial? Or just spread it?

18. CENTER FOR HEALTHCARE INNOVATION Suggested References The Practice of Adaptive Leadership, by Heifetz, Grashow, and Linsky How Clients Make Therapy Work, by Bohart and Tallman “Adaptive Leadership and the Practice of Medicine” by Thygeson, Morrissey and Ulstad, JECP 2010