Transformation is Hard Work: Lessons from TransforMED’s
National Demonstration Project
Presented by Benjamin F. Crabtree, PhD
October 3, 2007
B. F. Crabtree2Center for Research in Family Medicine and Primary Care
Disclosure
• Dr. Crabtree is the co-PI of the TransforMED NDP Evaluation– Supported by grants from the American
Academy of Family Physicians and 2 grants from the Commonwealth Fund
B. F. Crabtree3Center for Research in Family Medicine and Primary Care
Agenda• Background on collaborative research
and organizational change perspectives of team
• Review the components of an ideal primary care practice
• Describe the TransforMED National Demonstration Project (NDP)
• Highlight the evaluation of the NDP– Early findings from qualitative analyses
• Questions and answers
Center for Research in Center for Research in Family Medicine and Family Medicine and
Primary CarePrimary CareKurt C. Stange, MD, PhDKurt C. Stange, MD, PhD
Carlos R. Jaén, MD, PhDCarlos R. Jaén, MD, PhD
Benjamin F. Crabtree, PhDBenjamin F. Crabtree, PhD
Paul A. Nutting, MD, MSPH Paul A. Nutting, MD, MSPH
William L. Miller, MD, MAWilliam L. Miller, MD, MA
B. F. Crabtree5Center for Research in Family Medicine and Primary Care
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)
B. F. Crabtree6Center for Research in Family Medicine and Primary Care
Observation Intervention
DOPC STEP-UP
IMPACT
DirectObservation of PrimaryCare (1994-97)
Study ToEnhance Prevention by Understanding
Practice (1996-2000)
Insights from Multimethod Practice Assessment of Change over Time (2001-2004)
P&CDPrevention & Competing Demands in Primary Care (1996-99)
ULTRAUsing Learning Teams for Reflective Adaptation (2002-07)
B. F. Crabtree7Center for Research in Family Medicine and Primary Care
First insights into role of complexity in understanding
practicesPractices could not be described in mechanistic
terms, such as 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
B. F. Crabtree8Center for Research in Family Medicine and Primary Care
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
B. F. Crabtree9Center for Research in Family Medicine and Primary Care
Properties of Complex Adaptive Systems(Cont.)
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.
B. F. Crabtree10Center for Research in Family Medicine and Primary Care
Observation Intervention
DOPC STEP-UP
IMPACT
DirectObservation of PrimaryCare (1994-97)
Study ToEnhance Prevention by Understanding
Practice (1996-2000)
Insights from Multimethod Practice Assessment of Change over Time (2001-2004)
P&CDPrevention & Competing Demands in Primary Care (1996-99)
ULTRAUsing Learning Teams for Reflective Adaptation (2002-07)
B. F. Crabtree11Center for Research in Family Medicine and Primary Care
Observation Intervention
DOPC STEP-UP
IMPACT
DirectObservation of PrimaryCare (1994-97)
Study ToEnhance Prevention by Understanding
Practice (1996-2000)
Insights from Multimethod Practice Assessment of Change over Time (2001-2004)
P&CDPrevention & Competing Demands in Primary Care (1996-99)
ULTRAUsing Learning Teams for Reflective Adaptation (2002-07)
“All models are wrong. Some are useful.”
-George Box, 1979
Box, G.E.P., Robustness in the strategy of scientific model building, in Robustness in Statistics, R.L. Launer and G.N. Wilkinson, Editors. 1979, Academic Press: New York.
B. F. Crabtree13Center for Research in Family Medicine and Primary Care
Mo
tivat
iona
l re
cip
roci
ty
External influences on change option landscape
Motivation, Innovation & Independence
De
velo
pin
g c
ha
nge
tr
aje
cto
ries
1 2
3 4
5
6
7
8
910
Evaluating & exercising choices for change
Extern
al co
nting
encie
s
&
capa
city t
o ch
ange
Motivation of key stakeholders
Capacity for change
OutsideMotivators
Choices for Change
Baseline
Follow-up
Co-ev
olutio
n & re
spon
se to
inte
rven
tions
IMPACT IMPACT CHANGE MODELCHANGE MODEL
B. F. Crabtree14Center for Research in Family Medicine and Primary Care
Change Is Challenging
Mo
tiva
tion
al r
eci
pro
city
3 & 4 interrelationships
1 & 2 interrelationships
De
velo
pin
g c
ha
ng
e
tra
ject
ori
es
1 2
3 4
5
6
7
8
1011
1 & 4 interrelationships 2 & 3
inte
rrelat
ionsh
ips
Motivation of key stakeholders
Capacity to Change
OutsideMotivators
Choices for Change
Baseline
Follow-up
Co-ev
olutio
n & re
spon
se to
inte
rven
tions
KABOOM!!!BlockingFactors
B. F. Crabtree15Center for Research in Family Medicine and Primary Care
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.
B. F. Crabtree16Center for Research in Family Medicine and Primary Care
Observation Intervention
DOPC STEP-UP
IMPACT
DirectObservation of PrimaryCare (1994-97)
Study ToEnhance Prevention by Understanding
Practice (1996-2000)
Insights from Multimethod Practice Assessment of Change over Time (2001-2004)
P&CDPrevention & Competing Demands in Primary Care (1996-99)
ULTRAUsing Learning Teams for Reflective Adaptation (2002-07)
B. F. Crabtree17Center for Research in Family Medicine and Primary Care
Capacity to Change Model
Reflection
Action
Trust
Miindful
Respect
Heedful Diversity
Social/Task
Rich/Lean
STORIES
Learning CULTURE
TeamworkSensemakingImprovisation
Build Memory
Dynamic Local
Ecology
Inquiry-Centered LEADERSHIP
B. F. Crabtree18Center for Research in Family Medicine and Primary Care
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
B. F. Crabtree19Center for Research in Family Medicine and Primary Care
National Demonstration Project
• Proof of concept of a new model of care for family medicine– Quality of care– Practice finances
• Determining the best process for transformation– Facilitated– Self-directed
B. F. Crabtree20Center for Research in Family Medicine and Primary Care
Components needed
• Access to care• Access to
information• Team approach• Point of care
services• Information
services• Redesigned offices• Management• Quality and safety
• Whole-person orientation
• Medical home• Patient-centered
care• Continuous
relationship
B. F. Crabtree21Center for Research in Family Medicine and Primary Care
B. F. Crabtree22Center for Research in Family Medicine and Primary Care
B. F. Crabtree23Center for Research in Family Medicine and Primary Care
B. F. Crabtree24Center for Research in Family Medicine and Primary Care
B. F. Crabtree25Center for Research in Family Medicine and Primary Care
B. F. Crabtree26Center for Research in Family Medicine and Primary Care
National Demonstration National Demonstration ProjectProject
Evaluation TeamEvaluation TeamCenter for Research in Family Center for Research in Family
Medicine and Primary CareMedicine and Primary CareCarlos R. Jaén, MD, PhD (PI)Carlos R. Jaén, MD, PhD (PI) Benjamin F. Crabtree, PhDBenjamin F. Crabtree, PhDPaul A. Nutting, MD, MSPH Paul A. Nutting, MD, MSPH William L. Miller, MD, MAWilliam L. Miller, MD, MAKurt C. Stange, MD, PhDKurt C. Stange, MD, PhD
&&Elizabeth Stewart, PhD (analyst)Elizabeth Stewart, PhD (analyst)
Reuben R. McDaniel, EdD (consultant)Reuben R. McDaniel, EdD (consultant)
B. F. Crabtree28Center for Research in Family Medicine and Primary Care
Domains of 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
B. F. Crabtree29Center for Research in Family Medicine and Primary Care
Sample Hypotheses• Practices that have motivated leaders that
promote patterns of frequent opportunities for reflection with internal and external partners and are patient-focused will be more likely to integrate the components of the TransforMED.
• Practices that have a more participatory decision making style and frequent opportunities for conversations about practice improvement will have higher levels of quality of patient care as measured by the chart audit and patient questionnaires.
B. F. Crabtree30Center for Research in Family Medicine and Primary Care
Design• Volunteer practices selected by technical
advisory committee from over 300 applicants
• Randomly assigned to two change approaches:– Facilitated– Self-directed
• 2 year follow-up (Possible extension)
• Mixed method assessment– RCT with pre/post and inter-group comparisons– Comparative case study
B. F. Crabtree31Center for Research in Family Medicine and Primary Care
NDP PracticesPractice Description Number of Sites
Facilitated
Self-directed
Solo and Solo +1 3 3Small (3 or less clinicians) 4 4
New 2 2
Medium (4-6 clinicians) 5 5
Large (7 or more clinicians) 4 4
Total 18 18
B. F. Crabtree32Center for Research in Family Medicine and Primary Care
Facilitated Practices
• Each practice assigned one of 3 facilitators with each facilitator having a panel of 6 practices
• Intervention included site visits, learning sessions, opportunities for sharing via conference calls and webinar, and connecting to consultants
• Overtly focused on TransforMED “bubbles”
B. F. Crabtree33Center for Research in Family Medicine and Primary Care
Self-Directed Practices
• The self-directed group has a very minimal intervention that will still allow this group to be a valid comparison group
• Have resources from TransforMED web page, but not facilitated
• Practices self-organized and created their own retreat
• Being in the national spotlight was a motivator
• Site visit by evaluation team
B. F. Crabtree34Center for Research in Family Medicine and Primary Care
Data Sources
• Key informant & informal interviews
• Contact logs
• Email strings
• Ethnographic observation
• Clinician/staff surveys
• Online discussions
• Medical record review
• Patient surveys
Qualitative Learning
Emerging themes one year into the NDP
B. F. Crabtree36Center for Research in Family Medicine and Primary Care
How are we learning?
• Facilitators field notes• E-mails logs, webpage postings• Logs of phone conversations• Notes of facilitators huddles, other
meetings• Weekly conference calls between
members of the evaluation team.
B. F. Crabtree37Center for Research in Family Medicine and Primary Care
NDP Early lessons
1. The most successful practices seem to have shared leadership systems rather than an individual physician leader
2. 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
B. F. Crabtree38Center for Research in Family Medicine and Primary Care
NDP Early lessons
3. A practice's capacity for change at baseline is a huge determinant for that practice's progress, and equally important is the facilitator's ability to increase that capacity
4. Technology in the New Model, while shining with possibilities, is not by any means an easy "plug and play" interface for the practices
B. F. Crabtree39Center for Research in Family Medicine and Primary Care
NDP Early lessons
5. Due in part to the ongoing challenges of technology, even the most successful practices are experiencing change fatigue
B. F. Crabtree40Center for Research in Family Medicine and Primary Care
NDP Early lessons
6. Depending on initial practice capacity assessment, may need one or more:a. Targeted consultation – e.g. Advanced
Access, EMR, finances, specific operations, etc.
b. Coaching – e.g. leadership, finances, etc.
c. Facilitation – e.g. relationships, reflection, leadership, etc (different intensity of joining practice and/or system, ranging from just being there to active facilitation).
More information
www.transformed.com
B. F. Crabtree42Center for Research in Family Medicine and Primary Care
B. F. Crabtree43Center for Research in Family Medicine and Primary Care
Questions?
B. F. Crabtree44Center for Research in Family Medicine and Primary Care
References• Organizational Change & Complexity
Science1. Cohen D, McDaniel RR Jr, Crabtree BF, et.
al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004 May-Jun;49(3):155-68.
2. 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, 1998 46(5):369-376.
3. 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):872-878.
B. F. Crabtree45Center for Research in Family Medicine and Primary Care
References
4. 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):438-446.
5. Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. J Gen Intern Med 2006; 21: S9-15.
B. F. Crabtree46Center for Research in Family Medicine and Primary Care
References
6. 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): 430-435.
7. Miller WL, Crabtree BF. Healing landscapes: Patients, relationships and optimal healing places. J Complementary and Alternative Med. 2005, 11 Suppl 1:S41-9.
8. Crabtree B. Primary Care Practices are Full of Surprises! Health Care Manage Rev, 2003, 28(3):279-283.
B. F. Crabtree47Center for Research in Family Medicine and Primary Care
References
9. Tallia AF, Lanham H, McDaniel R, Crabtree BF. Seven Characteristics of Successful Work Relationships Family Practice Management 2006 Jan; 13(1):47-50.
10.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. 2006 Mar-Apr;4(2):109-16.
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