1. Summer Institute 2010 Deep Dive into Community F. Daniel Duffy, MD, MACP July 31, 2010

2. Why are we here? Present

3. Why are we here? PresentFuture School of Community Medicine Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in care

4. How do we do it? Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in care Plan & design PresentFuture School of Community Medicine

5. YES, BUT…Community Medicine Moves from isolated and self-interested silos to connectedness and care for the whole Shifts from problems to be solved to our community’s positive potential Encourages collaboration in creating the future that cares for the whole

6. Theory U The way in which we attend to a situation determines how a situation unfolds: I attend this way, therefore it emerges that way. Principles and practices for collectively creating the future that wants to emerge. Otto Sharmer, 2009

7. How does the “U” Journey Work? LISTEN to others and to what life calls us to do SENSE Go to the places of most potential, observe and listen with our minds, hearts and wills wide open CREATE Prototype a microcosm of the new to explore the future by doing EVOLVE ecosystems by acting from the emerging whole PRESENCE Retreat and reflect to allow inner knowing to emerge PresentFuture

8. Social activities Anchoring lectures Stakeholder dialogues World-Café: discover the whole Professional meaning groups Prototyping the future Evolving Community Medicine

9. Co-Sensing: Listen, Discover, Connect Dialogue Groups Appreciative Inquiry Shadowing Patients Poverty Simulation PhotoVoice Observe, observe, observe; suspend voice of judgment, cynicism, fear Dialogue, listen deeply, connect with mind, heart, and will wide open Allow the system to see itself Learning journeys into community World Café Anchoring Lectures Learning from the past

10. Appreciative Inquiry Interviews Dialogue focuses on the individual’s or group's most positive potential – not on problems! We inquire to learn with an open mind, open heart and open will. Our conversations appreciate rather than criticize and judge

11. World Café practice Hospitable Café-like setting  Hosts  Travelers Meaningful questions Everyone contributes  Cross pollination  Diverse perspectives Listen together for deeper insights Harvest discoveries

12. Co-Presencing: Professional Meaning Professional Meaning “Presencing” Conversations The call to service, to give ourselves to something larger than ourselves, and to become what we were meant to become. Our public self is shaped by life experiences and masks the authentic self beneath rationalizations, excuses, and resentments that stem from fear, blame, and sorrow in our relationships with each other. Our authentic self is in touch with truth, generosity, and love and is the source of inspiration, compassion, and creativity

13. Co-Creating: Prototype 0.8 Create prototype 0.8 microcosms Explore the future by doing rather than by analyzing Quickly build an experiential microcosm of the future that needs you to come into being Present ideas or work in progress before they are fully developed Get feedback to improve it and make it useful

14. Co-Evolving: Act as Ecosystem Part Grow innovation ecosystems by seeing and acting from the emerging whole Systems governed by:  Markets  Hierarchy (regulation)  Networking New governing system:  Seeing from “presencing” the emerging whole  Acting from our crystallized vision of the future

15. What Have We Learned from Summer Institutes?

16. Summer Institutes 2008 Rationale & Vision for School of Community Medicine Plight of Uninsured Vulnerable people need us Developing knowledge Moral imperative 2009 Dr. Clancy’s story Health & community structure Determinants of health Behavior change Ethics & social justice Crystallize a better future Tulsa’s history full of violence and community separation Social agencies are eager to help – but are uncoordinated Low density, separated, low social capital, auto, poor air, accidents Poverty is not a choice, can happen suddenly, is a hard lifestyle Health care institutions somewhat isolated from community needs Uninsured patients appreciate access to low cost care

17. Prototypes 0.8 2008 Take it to the streets Electronic portal Center for behavioral health Connecting care – Tulsa HIE Fewer patient more professionals Go forth and multiply No senior left aside Community research infrastructure Science of cultural competency 2009 Yo-Yo 96 Frequent flyer – ER clinic CANDLe3 HUB Spanish Immersion Healthy Hornets CHAMP Service-Share Foundation AH-AH i-Volunteer app Life Skills – you can do it Shock Aah, Hugs

18. Healthcare Ecosystem Complex adaptive system integrating human biology economics, socio-political organization, psychological factors, and health care delivery to produce health.

19. The Patient is at the Center of the Health Care Ecosystem

20. The structure and function of community government and services affects the health of everyone SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

21. An individual’s genetics, family, culture, education and society affect health Spiritual School Friends Family Money Home Food SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

22. Personal Lifestyle choices and access to healthy options affects everyone’s health Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

23. Health care begins with a Medical Home Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support Medical Home SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

24. …and a network of services Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support Medical Home Pharmacy Specialist Lab Tests X-Ray SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

25. …and more services Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support Medical Home Pharmacy Specialist Lab Tests X-Ray HospitalNursing Home Surgery SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

26. Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support Medical Home Pharmacy Specialist Lab Tests X-Ray HospitalNursing Home Surgery Emergency Rehab SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

27. Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support Medical Home Pharmacy Specialist Lab Tests X-Ray HospitalNursing Home Surgery Emergency Rehab SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

28. Spiritual School Friends Family Money Home Food Child Care Leisure Yoga Fitnes s Fat Habits Support Medical Home Pharmacy Specialist Lab Tests X-Ray HospitalNursing Home Surgery Emergency Rehab Research SafetyLaw & OrderTransportationAgenciesCitizenshipUtilitiesPublic Health

29. Innovations that Improve the Health Care Ecosystem SupplierProcess Customer

30. Disruptive Technology (LEAN) Disruption – makes simpler and more affordable Technology – a way of combining inputs of materials, components, information, labor and energy into outputs of greater value. Business Model – work that creates value someone will buy

31. Value Stream Map Value to patient

32. Value Stream Map Value to Patient Check-In 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Scheduler 1.------- 2,------- Scheduler 1.------- 2,------- Report 1.------- 2,------- Report 1.------- 2,------- Triage 1.------- 2,------- Triage 1.------- 2,-------

33. Check-In 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Triage 1.------- 2,------- Triage 1.------- 2,------- Scheduler 1.------- 2,------- Scheduler 1.------- 2,------- Report 1.------- 2,------- Report 1.------- 2,-------

34. Check-In 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Triage 1.------- 2,------- Triage 1.------- 2,------- Scheduler 1.------- 2,------- Scheduler 1.------- 2,------- Report 1.------- 2,------- Report 1.------- 2,-------

35. Check-In 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Triage 1.------- 2,------- Triage 1.------- 2,------- Scheduler 1.------- 2,------- Scheduler 1.------- 2,------- Report 1.------- 2,------- Report 1.------- 2,------- Bright Idea For Improvement or Innovation in a Process Step In the Work

36. Prototype 0.8 Solution Poster Issue: Patient repeats history multiple times Background/Measures Patient survey 50% poor history Nurse/doctor delays, patient waits Root Cause Analysis Why? – Tradition Why? – Training students Why? – Habit of practice Why? – Forms in EMR Why? – No time to develop Repeated questions Current Condition Future Condition Patient generated form Title: Patient INFO to EMR Quickly Team: JB.CD. RK. SW. FG HO Countermeasures: Patient Questionnaire Implementation Plan: TaskWhoWhenOutcome Forms J.B. 8/1 New form EMRC.D.8/15Template TrainingRK8/30“can do” Cost $600 Benefit Save time Rapid Cycle Test of Change IM Clinic Team 1, SW, 9/1-10 Follow-up – Expected Measure Patient wait time drops 50%

37. A small group of committed people can change the world. In fact nothing else ever has! Margaret Mead

38. Enjoy your deep dive into shaping the future of community medicine