HomePartners & Projects Evaluators' ReportsReport #2

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

December 5th, 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

TransforMED: Transition Between Learning Sessions
June 2006 – November 2006

Overview:

This report focuses on the first five months of TransforMED's National Demonstration Project (NDP), particularly some critical transitions that became apparent between the first two learning sessions (1st session in June, 2006 and the 2nd session in October, 2006).  Both learning sessions provided invaluable outlets for practices; however, it was apparent that some critical experiential learning took place within the practices themselves between the sessions so that th e tenor and atmosphere of the two sessions was quite distinct.  In this report, we will refer to the time between the two learning sessions as Action Phase 1, a time when the practices transformed from track sprinters to long distance tri-athletes.

1st Learning Session, Kansas City, June 3-4, 2006
As the practices gathered for the kick-off learning session in Kansas City, practice participants were awash with unbridled enthusiasm and unbounded optimism.  They knew they had been selected from a large application pool because they were "best of the best."  One of the goals of this 1st Learning Session was to generate energy and excitement, and at this it succeeded beautifully.  The combination of expert consultants, strutting their stuff, a team of top-notch facilitators dubbed the "Dream Team," and the collective electricity of all practices together created an atmosphere of confidence and readiness.  Throughout the two day learning session, their confidence and egos were  bolstered by a steady stream of knowledgeable consultants and energetic presentations.  Understandably, the majority of participants appeared to exude the attitude, "Let's get this show on the road, let's get it done!"  For example, after the demonstration of a sophisticated computer-based disease registry (CINA), one participant had said, "This is too good to be true! This is like discovering there are airplanes!" Another comment, heard frequently, was, "So... when do we get started?!"

It was evident that many of the practices were already doing things that made them the exception, not the norm, of practices the evaluation team had worked with in the past.  Many of the physician participants had a sophisticated grasp of the research literature and were particularly familiar with the FFM report and the New Model components.  Several practices already had some "TMED bubbles" in place, such as websites and advanced access scheduling, and most had electronic medical records in place.  One new physician shared the story that when he was interviewing for his first job, he would ask each practice about the FFM report and how that affected their work. When he discovered that none of the practices he interviewed with even knew about the FFM, he decided to start his own practice, based completely on New Model concepts.

At the June Learning Session, a small fraction of practices revealed some vulnerability and expressed hope that TransforMED would "help us survive."  They appeared to view TransforMED as somewhat of a knight in shining armor, capable of implementing amazing technology with minimal trouble.  Another small handful of practices showed some recognition of how much work the change management process required. These practices were already engaged in some change processes (e.g., advanced access, integrated technology) and therefore knew it required effort and buy-in.  However, even with the more "seasoned" change management practices, and certainly the majority of others, it was evident that most underestimated the level of disruption and intensity of effort that whole practice redesign would require.  They understood the exciting opportunities within the "TMED bubbles," but had a lesser understanding of the reality it would take to achieve those bubbles. 

Leaving Kansas City, the spirit and mindset of the practice representatives was akin to a pack of sprinters taking their places at the starting blocks, ready to roar ahead on a course of improvement.  At the time, the course seemed flat and straightforward, and so as long as the physicians sustained their energy, they probably assumed they could maintain their speed.  For many, returning home would introduce the first bump in the road and the first important learning of the project.

Action Phase 1, June, 2006-October, 2006
The acute readiness established by the 1st Learning Session set an unusual precedent for the facilitators making their first visits to the practices.  Many practices started emailing requests and questions before the facilitators ever stepped foot in the door.  Nevertheless, evidence from the first five months of TMED implementation began to reveal that even these high-performing practices were not quite as prepared as they had initially thought.  For example, when facilitator Jim Arend gave his presentation on finances and the TMED financial form at the 1st Learning Session, one physician commented "Isn’t everyone doing this already?" and most physicians around him agreed.  However, when the facilitators distributed the forms to complete, the majority of practices struggled to complete the information and needed extensive coaching and "hand-holding" to answer questions related to revenue, overhead, and hours worked. 

Soon after the 1st Learning Session, the three facilitators began initial site visits with each of the practices in their portfolio (6 each).  The facilitators needed to get an honest assessment of each practice in order to obtain a better practice-level understanding in terms of the motivation of stakeholders and the overall capacity to change.  This assessment was done via two days or more of direct observation of the practice and interviewing a range of practice participants.  This initial assessment was guided by the IMPACT Change Model (Cohen, et al., 2004), with an early task of identifying the motivation of key stakeholders within the practice.  Such stakeholders included the physician(s) who submitted the NDP application, key leaders in the practice (office managers, other physicians, etc), and sometimes people outside the practice who had a vested interest in seeing its success. For example, one practice has a board of directors, so identifying the motivation of these stakeholders was a critical first step for the facilitator.  The facilitators also had to identify and seek the support of outside motivators and stakeholders. This was most common in practices that are part of a much larger health system. The facilitators often encountered some fear or trepidation from different levels of administration, and thus had to spend time explaining and campaigning for TMED.  During the first site visit, the facilitators also assessed each practice for its capacity to change. Did it have teams in place? What were the functional communication channels, such as regular meetings? How many were on board for change? Finally, the facilitators had to help each practice assess their choices for change, organizing the opportunities within the "TMED bubble," essentially deciding which of the multiple New Model components should be tackled first.

For many TMED champions, the excitement of the 1st Learning Session evaporated when the reality of change hit. Practices within hospital systems encountered road blocks by fearful administrators, while other practices found roadblocks within their own ranks from staff satisfied with the status quo.  In one new practice, the two champions discovered their visions clashed to a point beyond compromise.  Other practices struggled to find time for weekly meetings, much less the intensive efforts the bubble implementation would take. A common yearning by many of the TMED champions was to locate a partner within the practice, someone with which to share the vision and help carry the load. 

The above stories are chronicled through the work of the facilitators, primarily through extensive email dialogues and phone conversations.  The data reveal intense collaboration between the facilitators and key stakeholders in the practice, as together they problem solve and brain storm through the described challenges and others.  As early as August, it was apparent to the facilitators that a 2nd Learning Session was needed (and soon!) to provide the practices with a boost of motivation, as well as to provide a focus on the pragmatic details of specific "TMED bubble" implementation.

2nd Learning Session, Kansas City, October 27-28, 2006
While the 1st Learning Session was intended as a kick-off to energize the practices with expert consultants and enticing technology, the 2nd Learning Session was designed with very different goals in mind.  First, it was critical that the practices had a chance to talk and share with each other. They needed to see that all practices were experiencing the same "changing pains," a chance for a shared affirmation that transformation was much more difficult than they had envisioned.  Second, it was important that practices had the chance to show off what they had accomplished. This was achieved through the "Practice Update" presentation, in which a practice representative spent 5 minutes discussing their transformation efforts and took questions from other participants. Post learning session evaluations confirmed these updates were the most popular portion of the program. Finally, this learning session focused on the nuts and bolts of the specific TMED bubbles that the majority of practices were in the process of implementing – in particular, group visits, advanced access, and care team efficiency.

In contrast to the 1st session, the TMED champions at the 2nd session formed a visibly more serious, determined, and realistic group. They were not pessimistic or downtrodden, simply sober with the realization that transformation was not an easy or straightforward road – and certainly not a sprint around the track.  In the five months between learning sessions, they had changed their training shoes, learned to use new equipment and skills, and shifted into a different stride.

Communication between practices was rich and abundant during all portions of the learning session. The aura of competition was conspicuously absent as practices rallied around each other with a spirit of "we're in this together." Physicians were open and forthcoming in sharing struggles and challenges from their own practices as well as sharing ideas and insights with other practices.  It was common to have a physician take the microphone and say, "does anyone else have this problem... ?" and then have five or six participants clamor to answer with ideas and encouragement.  Topics ranged from reimbursement to marketing to staffing issues to leadership skills. Although the consultants at this session were well prepared and engaging, it became apparent that the practices were starting to look to each other for answers. In a sense, they were becoming their own consultants.

Summary:

It was evident that strong bonding had occurred between the facilitators and practices, as numerous practices publicly praised their facilitators and expressed deep appreciation for their efforts. The practices seemed to understand that the facilitators were there to help them help themselves rather than provide easy answers.  It was a pleasure for everyone to hear the success stories. One practice described how some physicians were finally making eye contact and talking to each other after years of resentment and misunderstandings. Another physician explained that once he saw a simple analysis of his efficiency patterns, he had a watershed moment and decided to finally change years of ingrained habits.  One physician who had finally mastered advanced access assured other practices with a simple but powerful statement: "it's a leap of faith, but you can do it."  Despite the different stories, nearly all the TMED champions seemed to agree on some key learning themes from their 1st five months of facilitation and change:

Transformation is a team effort; the champions could NOT do this alone.  Some physicians expressed difficulty in getting others in the practice on board, while others admitted that they themselves had a tough time giving up some control.  Some physicians revealed they were "pleasantly surprised" at how well their teams could function without them, the physician, taking charge every minute.

Transformation cannot be achieved merely through new technology. In fact, many practices realized they first needed to repair and reinforce "relationship infrastructure" before they moved forward with any large-scale projects such as CINA or Medfusion.  Several physicians spoke of now seeing the importance of building teams which could work together to see complicated projects through until the end.  One of the most technologically advanced practices publicly praised the power of a simple, low-tech "huddle" every morning, and how this has made a tremendous difference in communication in their practice.

Transformation will take time and unexpected turns in the road. The race shoes have been traded in for a myriad of different shoes and training equipment. The smooth track is now a hilly course with unknowns around every turn. Hearing other practices express the same sentiment seemed to energize the group at large and strengthen their resolve, as they realized they are not alone. One physician's words captured the essence of this learning session: "Hearing what everyone else is doing... and what they're also facing... has really motivated me!"