HomeLearning LabsEvaluators' Report #2

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

June 4th, 2007

by The Center for Research in Family Medicine and Primary Care
Elizabeth E. Stewart, PhD (NDP 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

Overview:

The National Demonstration Project is reaching the one-year mark. Twelve months ago, representatives from 18 facilitated practices converged in Kansas City, excited, optimistic and eager to begin their journey of transformation. Almost five months later, they again joined together to learn and share experiences, but this time a little more tired, a little more humbled, and a little more realistic about the change process. Since then, the majority really buckled down and prepared themselves for the long haul. Now halfway through the project, there is both a sense of tremendous progress and of tremendous fatigue. There are also several very important questions that potentially shape the future of the project. This report attempts to document some key insights the outside evaluation team has learned over the first year of the NDP.

To arrive at these insights, the evaluation team spent hundreds of hours reading and discussing thousands of pages of data: interviews, field notes, observations, conference calls, meeting notes, and email strings. Summary reports for each practice were prepared by a primary reviewer and validated or refined by a secondary reviewer. As each practice was examined in depth, learning at the practice level contributed to an on-going analysis of the project as a whole. Through this greater analysis, several working hypotheses emerged.

1. The most successful practices seem to have shared leadership systems rather than an individual physician leader. This thought was exemplified at the beginning of the NDP by a physician from one of the struggling practices who said, "you need to have a leader, and that leader cannot be a physician." Our analyses found that this statement is at least partially correct: practice change leadership cannot be only the physician.

Change does not occur easily in practices where only one physician takes the reins – even if there is only one physician. It appears that there needs to be a leadership system in place, a system that allows for shared responsibility of promoting change and following through. This hypothesis is still new and undergoing change itself; however, thus far the most promising leadership systems have three complementary pieces, each representing a critical piece of the practice's welfare. One critical piece of the system represents the physician - the visionary, the one who sets the tone for the practice and its philosophy on health care. Another represents the clinical and/or office manager; someone who gets down to brass tacks and gets the job done. This individual(s) helps translate the vision into reality with organization and follow through. Finally, the third represents some supervision of the financial piece of the practice. This might be a billing manager within the practice, a system director if the practice is within a system, or even an external board of directors. While the details are not yet definitive, it is clear that part of good leadership is financial viability, and part of financial viability is having someone help mind the store.

When the leadership system is in place, a practice's ability to adopt changes accelerates significantly. The NDP practices with such a system in place at baseline were not only farther along at baseline, but able to adopt change more rapidly. Practices without strength in all three system components often hit stumbling. For example, one NDP practice has a lead physician with vision and passion, coupled with a solid office manager to press through details. However, the practice has lacked the financial component, and consequently made poor financial decisions. At the start of the NDP, the physician was not drawing a salary and thus, faced with these kinds of core survival challenges, transformation changes are much more difficult.

One encouraging sign that has emerged is the possibility of building leadership systems from existing staff. One small practice at present lacks any professional management for either administrative or financial duties; the part-time physicians try to do it all and do not want to hire additional staff. Lack of administrative supervision has been a particular problem, resulting in everything from perpetually chaotic offices to lost paperwork. A promising medical assistant who had done some billing is now being groomed by both the facilitator and lead physician to take on a more substantial role of office manager –a great move for the practice, and the staff member.

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. Such problems ranged from tension between physicians, tension among physicians and staff members, tension between physicians and an umbrella health system, or all of the above. Sometimes the problem wasn't outright tension, but conflict avoidance that kept the practice at a stalemate. And many times, the root of the dysfunction seemed to be a lack of clear leadership.

Before the facilitators could begin making changes in these practices, they had to shore up and fortify the practice infrastructure. This often required weeks or months of intensive relationship building, played out through meetings, huddles, team work, and increased communication. In busy practices, there is no free time to "nurture" relationships, so the facilitators often used small TransforMED projects as opportunities to model and practice good teamwork and communication skills. For example, in one practice, the facilitator coached the physician how to delegate better and coached staff members on how to communicate better to the physician. While learning how to work as a team, the practice completed a project that had been stalled for more than a year.

Other practices had festering dysfunctions that required head-on interventions before any project could be tackled. Sometimes this meant a mediated conversation between involved parties to clear the air on years-old issues. Other times it required the lead physician ? often with support and assistance from the facilitator – to make tough decisions regarding staffing. Many times the facilitator worked with the lead physician on his or her leadership skills, which gradually reduced dysfunction precipitated by lack of leadership. Sometimes the only remediation left was to let time take its natural course of action, and then wait for the right moment to approach the practice anew.

Tackling the problem and building strong relationships required enormous amounts of time and energy by the facilitators. Nevertheless, a few practices continue to struggle and these are the practices that have been the least able to implement parts of the TransforMED model.

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. The Evaluation Team uses a practice change model known as the IMPACT Model (Insights from Multi-Method Practice Assessment) to assess, among other things, each practice's capacity for change.¹ Not surprisingly, such capacity is dependent upon some of the key elements that the facilitators worked to foster in the beginning: a web of healthy relationships, including mutual trust, respect, and mindfulness; strong leadership and decision making; and teamwork. Capacity for change also includes a culture of learning, sensemaking, work environment, and attention to fitness landscape.

A few practices started out with a high capacity for change, truly the leaders among this NDP group of early adopters. These practices boasted the strong leadership systems noted above and often had a supportive macro-system (umbrella health system or external board of some sort). The facilitators did not have to spend much time on relationship repair, leadership, or basic communication skills, and could instead plunge right into the implementation process. At the mid-study point, the four practices with the highest capacity for change at baseline are leading the way in the implementation of TransforMED change components.

One very encouraging sign has been the role that facilitation plays in helping practices enhance their capacity for change. From the NDP sample there are several specific examples of practices who started out with significant deficits in leadership and trust and either outright conflict or severe passive-aggressive behavior. Through the relationship repair work outlined above, several practices were able to increase their capacity for change by the end of the first year of the study. For example, in one practice, the physicians were on the brink of a "practice divorce" but are now working side by side to share technology information and are now leading the way for other NDP practices in the improvement of e-visit templates. In another practice, debilitating scars from past conflicts finally healed over as the practice works together to implement Advanced Access scheduling and chronic disease management. With other practices, results are still pending, but look promising.

4. Technology in the New Model, while shining with possibilities, is not by any means an easy "plug and play" interface for the practices. This is true not only for the specific technology offered by TransforMED (e.g., CINA, Medfusion, videoconferencing), but also technology offered by different companies outside of TransforMED. As one physician phrased it, "None of the technology will talk to each other, and if they do, it's a different language."

Currently the technology landscape for medical practices resembles a pile of different jigsaw puzzles all thrown together. It takes time, energy, and relentless problem-solving to try to find the right pieces to finally fit together. Most practices, especially the small ones, do not have this kind of time or technological expertise. Large practices connected to health systems may have technology assistance, but sometimes not a mutual understanding of what the physicians need. The TransforMED facilitators play a critical role in putting the pieces of the puzzle together. They make the phone calls to the necessary companies, they bird-dog the details of interface, they push the issues when needed, and generally provide support and follow-through. Despite the hard work on all ends, the challenges continue into the second year of the NDP.

For example, videoconferencing through the web has the potential to enhance communication with and among practices. However, setting up the equipment and system on the practice end has proved to be cumbersome and ineffective. If a solo physician does not have hired assistance or a natural aptitude for technology, setting up the system is daunting and time-consuming. If the practice is connected to a system with technology assistance, there are often multiple firewalls that must be worked through. TransforMED continues to search for a videoconferencing system that is affordable and easy enough for primary care practices to implement.

Many practices are implementing technology not offered by TransforMED, but play an important role in the transformative change process. The challenges of implementing such technology paint a discouraging picture thus far. One large practice is on the tail end of their EHR implementation. Facilitator notes document this practice's repeated attempts to get assistance from their EHR vendor, often with little or no response. Another practice finally implemented their electronic lab order interface, although problems still occur. Remarkably, this practice is 1 of only 2 practices in the country attempting such an interface, thus their isolated attempt has not garnered much help from their lab company. Finally, the promise of chronic disease management through CINA (Clinical Integrated Networks of America) has been tempered some by reluctance of EMR venders to cooperate with CINA, as many are hoping to offer a similar service someday.

In all these examples, and many others, the facilitators continue to play an important role in moving things forward. Their assistance begs the question of what can practices do to improve their technology if left to their own devices, and this is the critical question to be examined in the ?Self-Directed Practices'. The practices doggedly working to move forward despite repeated roadblocks are pioneers, and their experiences will provide a wealth of learning at the end of the NDP. At present, it is clear that much of the vaunted technology is not ready for integrated use in primary care, and much work lies ahead to create one puzzle with easily interlocking pieces.

5. Due in part to the ongoing challenges of technology, even the most successful practices are experiencing change fatigue. It can take months of effort to successfully nail down one piece of technology, and then that milestone must be quickly followed by plans for continuous maintenance and upkeep. Implementing the technology, along with other components of the New Model, is taxing and time consuming. Each new piece places stress on the relationship infrastructure of the practice – thus, the importance of strengthening those structures at the beginning of the project, even if it means delaying progress in other areas.

The practices are holding strong but ?change fatigue' is evident. One physician describes a recent technology task as "the hardest thing I've ever done." Another physician laments that morale is low, while an office manager says the staff is simply running out of steam. What has been particularly telling is how the strain of strategic change affects a practice that is also dealing with changes brought on by extenuating circumstances such as staff turnover and administrative decisions. Practices are successfully implementing the model, but they are tired. The NDP has selected some of the most highly motivated practices in the country, put them on a national stage, and given them a nearly impossible task to complete in two years. It will be important for TransforMed to monitor the practices closely in the second half of the NDP to detect early and avoid any ?change casualties.'

Given the threat of change fatigue, it is critical that the next step of the transformation process re-energize and motivate the practices in a way that makes them feel "this is transformed medicine? this is worth it".

During the first year of the NDP, the prevailing strategy was to focus on practice re-design. The facilitators worked tirelessly with the practices to implement, improve, and enhance a myriad of interdependent components. Access was improved through Advanced Access scheduling, virtual office visits, email communication, practice website and improved phone systems. The judicious use of technology, when coupled with a strategic workflow process, makes office life easier and holds potential for patient care. Group visits provide an exciting opportunity for patients and staff to interact in new ways and for patients to take greater charge of their own health. The establishment of teams improved both office and clinical care, and strong financial management underlies all practice policies and procedures, as evidenced by the familiar adage, "no margin, no mission."

All these redesign pieces are dependent on one another. Advanced Access scheduling cannot happen with improved work flow, improved work flow cannot happen without good use of clinical teams, and so forth. These redesigned practices can tell a difference, and they like it. However, it appears it is not enough. The data of recent months reveal an underlying question from several successful practice leaders who ask, "Where's the transformation?"

Some practices are ready for "more," though no one really knows what that more is. What IS known is that the initial strategy of the NDP was very successful in first focusing on practice re-design and getting the majority of the pieces in place. Now it appears that some practices are ready to start using those pieces in a completely transformed way that leads to improved patient care. The ultimate challenge of the second year of the NDP will be to create and crystallize a transformation that improves care and truly changes the way family medicine is practiced.

1 Cohen, D., McDaniel, R, Crabtree, B, et al. 2004, A Practice Change Model for Quality Improvement in Primary Care Practice. The Journal of Healthcare Management. 49(3):155-168.