HomeLearning LabsEvaluators' Report #1

Evaluators' Report on the National Demonstration Project to the Board of Directors of TransforMED

October 20th, 2006

by The Center for Research in Family Medicine and Primary Care
Elizabeth E. Stewart, PhD (Qualitative Analyst)
Carlos R. Jaén, MD, PhD
Benjamin F. Crabtreee, PhD
Paul A. Nutting, MD, MSPH
William F. Miller, MD, MA
Kurt C. Stange, MD, PhD

Disclaimer: We are an evaluation team, not an implementation team. This brief initial report represents how an outside observer sees the TransforMED National Demonstration Project (NDP) implementation process is going at a very early point in time.  In fact, we perceive it to be going extremely well, thanks to the enormous work and effort of the three TransforMED facilitators. However, it is important to acknowledge the inherent challenges that each and every practice faces as they attempt to completely transform themselves.  Highlighting these challenges should not be seen as a pessimistic view but rather, an opportunity to learn about how practice transformation affects all levels of the practice. What we learn from the challenges these pioneer practices face and overcome will be enormously helpful to other practices in the future.  It will also give TransforMED, Inc. a realistic assessment of the facilitation strategies and time requirements needed for "going to scale" once the NDP is completed.

Methodology: The Evaluation Team works closely with the TransforMED qualitative analyst (QA), who works from the Kansas City TransforMED office. The QA gathers, organizes, and disseminates a large amount of data for the Evaluation Team to review on a weekly basis. The data sources include the following: field notes from the facilitator site visits; email streams between the facilitator and the practice (some of which are 50 pages or more); field notes from phone calls with the practices or conference calls among the practices; postings from the TMED website; field notes from the facilitators informal huddles; and interviews and de-briefings with the facilitators after site visits, phone calls, etc.  The data are uploaded into a password protected server maintained and backed up daily by the Principal Investigator's IT team.  Ongoing analysis within a formal qualitative database (Atlas.ti. 5.0, Berlin, Germany) has already begun.  In addition, the Evaluation Team and staff meet weekly by phone with the QA, Research Nurse, and TMED Executive Director to discuss the research logistics of the NDP. The Evaluation Team also meets privately by phone once a week with the QA to discuss the data and work on emerging themes. Sometimes these "private" phone calls include the TransforMED facilitators.

The intense work with NDP practices began June, 2006, so the insights in this report reflect the very early stages of the NDP intervention that took place over 3 to 4 months through the end of September, 2006.  From the early work it is clear that these are innovative, high-performing practices, but also that TransforMED NDP requirements are not simply plug-ins.  As the preliminary themes below suggest, much of the early work has been about ‘laying the groundwork' for success.  If we tracked the various New Model components being implemented by TransforMED in the NDP using a variation of the "Prochaska transtheoretical model" (e.g. contemplators, action stage, maintenance), we would find that for most New Model components the practices are committed, but still contemplating with very little yet accomplished in terms of concrete things.  Nevertheless, we see tremendous groundwork has been laid by the facilitators for a thoughtful and realistic transformation, but one that will likely require the full two years to accomplish.

Perhaps a useful metaphor is that of need to upgrade an airplane, with the upgrade needing to be done while the plane is still flying.  In this case, most practices are more like a 1950's era twin prop DC-3 and they need to upgrade into a TransforMED era Star Ship Enterprise.  While some are still in the hangar and have never flown, many are flying at 500 feet and don't have a lot of room to maneuver.  None can afford to turn the engines off and do the upgrades and none has time or resilience to land and park at the hangar.  Even those at 30K feet will drop quickly if you turn the engines off.  Part of the change process the facilitators are doing is teaching them how to glide; how to get breathing space to allow them to gain altitude.  Those now at treetop need a little more altitude before they can do changes, since each is guaranteed to lose 10K feet when making the required changes.  In addition to the need to have adequate altitude, external factors (like the weather) affect all other systems, so it is necessary to have change process that monitors every system and every system needs to report back to one another.  The NDP facilitators are there to help weather the storm; helping the pilots, the flight attendants, and passengers communicate with each other.  The entire process of TransforMED transformation is not without risk – if they don't do well they could crash.

The following preliminary themes have emerged from our early analysis of the qualitative data.

THEME 1: 

Implementing the TransforMED practice components is a monumental undertaking, requiring change of a magnitude well beyond what most practices have done in the past and are able to accomplish with current capacities.  Many of the practices have no effective and systematic processes for making and sustaining fundamental change in practice operations and procedures.  Although the rapidly shifting health care environment of the last decade has required that practices make changes, many of these are relatively small changes in single processes and pale in comparison to the multi-system transformation of practice operations required by the NDP.  Practices can easily suffer from "change fatigue" – practices have always made single changes and then taken a year or two to rest up before making another change.  NDP practices can't do that and are going to have to continually make one change after another for the next two years or more.  The critical challenge for all practices (and the Facilitators) is to foster more effective communication among all members of the practice, in order that fundamental change (that literally impacts all practice members) can be achieved and sustained.  Many of the physician practice champions appear to believe that change can be accomplished with a ‘top down' or ‘just do it' approach.  A large body of published research now documents that without wide-scale buy-in at all levels of the practice staff, change can neither be made nor sustained.

Theme 1 examples: Many NDP practices, both large and small, have no systematic change processes in place and struggle with basic communication and planning. Before the NDP, several practices had stalled on projects within the TransforMED vision (e.g., an online lab ordering system or Advanced Access) because, in their words, "we couldn't get anything done and the meetings made it worse." Not surprisingly, many practices perceived meetings to be "Dilbert-ish" (translation, a waste of time) and were very resistant to even give them a try. The facilitators first had to persuade them to try meetings and explain their potential for moving projects along. Next, they gave them materials and worksheets on running effective meetings, and then modeled or moderated several meetings, sometimes on-site or sometimes by phone. Finally, the facilitators continue to follow up on their practices and make sure meetings are still working and if not, encourage mid-course correction. This very basic step has been instrumental in laying down groundwork in allowing change to take place.

THEME 2: 

Many of the practices do not function as a coordinated system and lack insight into the complexity of their practice.  Coupled with the hectic pace of all primary care practices, the lack of a history of preserving a time and space for sharing ideas and getting a coherent practice-level change strategy limits the practice's ability to develop a more effective change process required by the NDP.

Theme 2 examples: Many practices and practice participants have found it easier in the short-run to break off into small pieces and function within their own "silo." Sometimes this is dictated by physical locations (a practice on two separate floors or a practice in two different buildings), but often it is dictated by intra-office conflict or daily survival mode. For example, several practices have a number of pods or stations with which there is some combination of clinicians, nurses, and schedulers. The pods are able to maintain a relatively comfortable status quo by working independently and autonomously. Often there is conflict or competition between these fragmented pieces of the practice. If a practice-wide change is to take place, such as adding an EHR or other system wide New Model component, it is imperative that the practice work as a whole - and many practices are finding these to be a new and difficult experience. Because of this, the facilitators have exerted great energy in trying to bridge together practice pieces and help them focus on working as a team.

THEME 3: 

The complexities of the changes required by the NDP are activating the larger organizational systems in ways that were not obvious to the practices when engaged in smaller efforts for change.  In many practices, critical stakeholders (external to the immediate practice group) are aware of the fundamental transformations required by the NDP and are becoming more active in the practices as a result.  This is apparent as some of the larger systems within which participating practices reside begin to exert more control over the process than was initially anticipated by the practice champions.

Theme 3 examples: Stakeholder skepticism has emerged in many of the practices connected to hospitals or health care systems. For example, one physician working within a large hospital system had assumed that since he had his own office and practiced independently, he could make his decisions concerning the NDP implementation. It wasn't until the facilitator arrived onsite and started asking questions that the physician realized that every decision would require approvals and clearance at higher levels. Luckily, the facilitator was able to enhance connections with key hospital administrators and bring them on board with the process. Another practice received negative feedback from their hospital administration as soon as they arrived home from the first NDP learning session. This is a progressive practice that has already been working on practice innovations for several years. The hospital was very concerned that TransforMED might re-invent the wheel, or, worse yet, steal their thunder. Again, it took many face-to-face meetings, phone calls, and emails between the facilitator and administration to gain stakeholder support and trust of TransforMED and the NDP. The effort it has taken to win over the support of external stakeholders speaks to the sheer magnitude of change the NDP presents. If the practice wanted to change just one thing, such as add group visits, it is doubtful this would make waves. But the concept of entire practice transformation has motivated outside stakeholders to sit up and take notice.

THEME 4: 

Many of the practice champions are finding it a challenge to balance their intense commitment to their patients with the New Model and TransforMED emphasis on more efficient office systems.  For example, the need for specific time slots and maintenance of patient flow for 10 or 20 minute visits seems in conflict with their inclination to spend as much time as a patient seems to require.  Many of these physicians are also challenged by the perception that the New Model moves from a physician-centric approach (physician is the sole provider of care) to a team model for chronic care.  The magnitude of change required in TransforMED challenges many of the physicians to shift their own personal paradigm for patient care and modify old values and behaviors – they want to preserve the nostalgic "Marcus Welby model."  For many physicians, the New Model may also require transformation at a personal level as well. The challenge for these physicians (and for TransforMED) is to effectively transform practices to New Models of care without sacrificing the important physician-patient relationships and a patient-centered focus to practice operations.