Practice in a networked health care system
-
Upload
sawyer-jefferson -
Category
Documents
-
view
32 -
download
4
description
Transcript of Practice in a networked health care system
Practice in a networked health care system
David Patrick Ryan, Ph.D. C.Psych. Director of Education, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto
Objectives
Situate practice as a networked phenomenon
Consider the continuum of tight and loosely coupled networks
Provide an overview of concepts from network and systems theory
Review network analytic tools
Reflect on the implications of networked practice for the knowledge to practice process
The ubiquitous ‘network’ concept
National health networks (see Mur-Veeman et al 2003)
Multisite hospital networks
Research networks
Disease/population focused networks
Primary Care Networks
Family Health Networks
Local Health Integration Networks
Some of Disease/Population Networks in Ontario Network Name Focus Clinical
ServicesFunding Role
The Child Health Network
population no no Plan, collaborationstandard setting
Cancer Care Ontario
disease yes base Service, research, leadership
Ontario Family Health Networks
population yes base A managed care network
The Cardiac Care Network
disease Wait list mgmt project Monitor analyze and advise MOH
Northern Diabetes Health Network
disease yes base Assess needs, contract services, evaluate, educate
GTA Rehab. Network
population no no Plan, research, educate, advise
ABI Network
population data base mgmt
mixed Lead, advocate educate collaborate
RGP Network
population yes and no mixed Advocate educateleadership, service
Dementia networks disease no startup Advocate educate collaborate
Network studies and related themes
Intraspeciality medical networks (Coleman et al. 1966)
Networks within practices (Scott et al. 2005) (Miller et al 2001)
Comparisons of discipline specific networks ( West et al 1999)
Primary care research networks (Mold & Peterson, 2005)
Shared care (Hickman et al. 1994)
Coordination versus continuity (Pinkerton et al 2004)
Inter-teamwork (Ryan, 1996)
Communities of practice (Parboosingh, 2002 )
Practice collaboratives (Mittman, 2004)
What a difference a decade makes or maybe not
“Despite the ubiquity of the network concept in planning programs, the issue of how networks of health care facilities affect the delivery of services has not been intensively studies. Although there are references in the organizational literature . . . very few studies have documented the effects of these programs. . . . Further, the value of network programs in actually improving the dissemination of new treatment technologies or disease management has not been adequately explored on either a theoretical or an applied level” (Fennell & Warenecke, 1988 p.12)
“Ever since the seminal work of Coleman et al (1966), networks have been seen as important in the process by which clinicans adopt (or fail to adopt) new innovations in clinical practice. Yet very little is actually known about the social networks of clinicians in modern health care settings” (West et al., 1999 p. 633)
Do we need the network concept?
Convergent validity – is it different from other organizational forms e.g. are networks different from teams?
Heuristic validity - is the network concept rooted in a body of knowledge that has led to useful theory?
Operational validity – are there standardized and validated measures?
Predictive validity – does the theory and measures predict behavior?
On teams and networks Dimension Team Network
Level of analysis fixed agnostic
Goals prescribed organic
Development intentional emergent
Relationships narrow ties multiple ties
Sample sizes Small n Medium to large
Theoretical origins Social Psychology Sociology
Output Process gains social capital
Strength of ties Strong Weak
Participation mandated self-selected
Causal models linear non-linear and recursive
Boundaries Fixed Flexible
Authority Formal Informal
The collaboration prerequisite
When environments require complex interdependency the quality of collaborative alliances may predict outcomes better than the internal processes of individual teams (Pfeiffer, 86)
Just as simply putting health professionals together to work in teams seldom leads to effective teamwork so simply putting teams to together to work seldom leads to effective inter-team collaboration (Ryan, et al. 1996)
Words of advice for young people
Minimizing variation to reduce error and increase the quality of health care through the use of standardized guidelines “has not been as successful as traditional logic might suggest” (Miller et al 2001)
There seems to be little relation between the quality of the evidence and its diffusion into practice (Fitzgerald et al 2002)
The ways people actually work usually differ fundamentally from the ways organizations describe that work (Mintzberg & Vander Heyden,, 1999)
Our beliefs to the contrary, a great deal of human behavior is illogical (Kruger & Dunning, 1999) (Tversky & Kahneman, 1967)
Beneath each espoused culture lies another that is implicit, informal and unacknowledged (Argyris,
Social Network Theories
Structural holes (Burt)
Resource mobilization and connectedness (Lin)
Peripheral participation (Wenger)
Strength of weak ties (Granovetter)
Trust and strong ties (Uzzi)
Networked individualism (Wellman)
What does this mean for practice networks
Practice networks should be construed as a local complex adaptive systems with the high levels of uncertainty, contextual uniqueness and surprise.
Like other complex adaptive systems, practice networks self-organize, reveal emergent behavior, and co-evolve.
Successful practicse networks minimize errors, make good sense of what is happening, and effectively improvise
In this context variation rather than standardization is to be expected and a good coach is essential
from Miller et al (2002)
Network character, type of change and prescriptive interventions (McGrath & Krackhardt, 2003)
Change Model
Type of change
Network character
Mechanism Where to intervene
External ties
Network wide
Strong dense ties exist with many external ties across subgroups
Trust and social identity
The people with strong external ties (structual holes)
Viscosity
Adoption of controversial innovations
Strong, dense internal ties but few external ties across subgroups
Individual commitment within a subgroup
Introduce change in one group at periphery (strength of weak ties)
Structural leverage
Innovation clearly superior
When the networks formal structure is low
Creating buzz (contagion)
Introduce change to a friend of a network member (opinion leaders)
Network stages of development
Adapted from Brown et al (2001) Strategic Planning in Rural Health Networks available online at www.academyhealth.org/ruralhealth/ strategicplanning.pdf
Forming
Evolving
Maturing
Growth
Joint planning Program evaluation
Joint marketingExpanding service line
New servicesProgram integration
Efficiency
Benchmarking Standard setting
Administrative consolidation
Shared services Service relocation
Value
Resource manualsPeer networks Member directory
Grant writingShared investments
Common budgetingResource planning