1. The BC Clinical Care Management Initiative as a Case Study in Large Scale Change CARES International Conference on Realist Approaches, October 29, 23014 Allan Best, PhD InSource Research Group allan.best@in-source.ca

2. Objectives for this Roundtable Introduce InSource Overview project Summarize methods and findings Position work in larger context of health system transformation

4. Old London Bridge, circa 1600s

5. Why Do We Need Health System Transformation Research? The healthcare system is complex Increasing chronic disease and ageing population Rising costs Fragmentation and increased complexity Complex problems require complex solutions Need to understand enablers and constraints to achieve systems transformation Need to know “what works, for whom, under what circumstances”

6. What is Systems Thinking? “a discipline for seeing wholes, … a framework for seeing interrelationships rather than things, for seeing patterns of change rather than static snapshots” (Senge, 1990) Sees systems as organic, dynamic, non-linear The whole is greater than the sum, reductionist thinking and command and control practice won’t work Demands continuous learning and adaptation

7. 1.Apply complex adaptive systems lens iteratively to develop understanding of enabling, constraining, and contextual factors to CCM as a case study for Large Scale Change 2.Make recommendations to: –Improve implementation of guidelines –Apply implementation strategies to other health system issues The Client’s Objectives

8. Not Included in Our Study An evaluation of CCM outcomes/impact Data did not allow comparison of specifics across initiatives or Health Authorities A prescriptive road map for the future

9. Context matters Organizational culture has a substantial effect on implementation of change Anticipate variation across regions and programs with respect to enablers and constraints but similarities are expected to outweigh the variation Each stage of the project will build upon the earlier findings iteratively Project Assumptions and Approach

10. BCMA MoHPoliticians CCM BCPSQC LSC Implementation Lead M&E Clinical leads CEO/ Exec CCM SC Patients and Community LSC Green = clinical function Blue = research function Pink = Supportive function HA Board Quality Delivery team Stakeholder Map of CCM Initiative MSFHR LSC POLITICAL EXECUTIVE CLINICAL

11. A Brisk Project Timeline

12. Top Leverage Points for Change – Survey data

13. Themes were our initial step to building a set of lessons learned We found high levels of consistency across interviews, focus groups, forum and survey Themes address various levels - provincial, HA, hospital site, clinical and patient Emerging Themes

14. What Does It Take to Build Local Ownership? Enabling committed and distributed leadership Promoting two way communication Aligning incentives Encouraging local ownership Enabling access to data and information systems Affecting culture change Promoting integrated guideline implementation Promoting and coaching collaborative clinical teams

15. Prepare for change initiatives such as CCM to evolve Clear a path through the complexity Promote shared clinical leadership Strengthen knowledge management Implement an on-going (long-term) communication strategy to promote shared understanding, engagement and broad-based ownership of change initiatives Recognize the effectiveness of networks Emerging Themes

16. 16 Causal Loop Diagram – CULTURE revised

17. Enduring, embedded collaboration Tools for developing systems conversations, within and across levels, and with the public Structural change – siloes, professional autonomy and compensation, time to learn, university and funding priorities Comprehensive measures, feedback loops, learning platforms Future Priorities for Large Scale Change

18. 18 Integrating Learning, Continuous Change and Accountability Developmental Evaluation Realist Approaches Outcomes and Accountability

19. Thank you! allan.best@in-source.ca http://bcpsqc.ca/blog/knowledge/a-case-study-of- bcs-clinical-care-management-initiative/ Additional Reading: Best et al. Large system transformation in health care: A realist review and evaluation of its usefulness in a policy context. Milbank Quarterly 2012, 90(3), 421–456. Willis et al. Systems thinking for transformational change in health. Evidence and Policy 2014, 10(1), 113-126. Willis et al. Sustaining organizational culture change in health systems. Journal of Health Organization and Management, in press.