| Site Index |
|
|
         |
|
|
|
|
|
|
|
|
|
|
Special
Feature -- Innovation and Transfer By Arthur K Huberman, MD; Hannah King, MPH; Jill Steinbruegge, MD The following edited excerpts are highlights from a day-long meeting held under the auspices of the Care Experience Council, November 18-19, 2004. As an outgrowth of the work of the Council's Transfer of Successful Practices Workgroup, 27 physicians and employees discussed the transfer of successful practices in Kaiser Permanente (KP). The goals were to develop recommendations regarding how to improve the rate and frequency of successful transfers in KP and to outline next steps. The meeting began with several presentations reviewing explicit knowledge generated within and outside the organization: Arthur Huberman, MD, discussed the KP Transfer Study (see "Stealing Shamelessly," page 52); Jill Steinbruegge, MD, reviewed relevant concepts from the books "The Tipping Point" and "Linked"; and Guy Chicoine summarized several important concepts from the work of Everett Rogers,1 who in 1962 wrote Diffusion of Innovations, a landmark book inspired by observations on the transfer among farmers of improved strains of hybrid seed. Participants then shared their experience (tacit knowledge), and finally discussed how to improve practice transfer in two specific areas: conferences/meetings and awards (Vohs and Lawrence).
Highlights Judy White: If we could figure out the key practices to replicate to create a more even patient experience, both in a clinical sense and in a service sense, it would elevate the performance of the whole organization. The whole organization has got to be successful together to deliver on the KP promise of personalized care, and easy and convenient services for our members. We have to prioritize and pick the things that really make a significant difference. How do you find the things that are truly meaningful that distinguish us from other organizations, then figure out how to replicate those? Jill Steinbruegge, MD: In the past, I thought that if we only knew what we know--if we could bring together the information from across the organization so we know what we know--then transfer would happen. And, we did and it didn't. There's a big gap between knowing and doing. Richard Brumley, MD: I've found to my surprise that when you have a program that improves patient care, improves patient and family satisfaction, and also dramatically reduces costs, and then you offer to give it away to everybody that you know, you still have difficulty replicating it. I'm beginning to think there's something about our DNA that prevents us from accepting innovation and trying to replicate. One of my goals is to figure out how to reprogram our DNA so we embrace innovation and new ideas. On Reinvention Tom Janisse,
MD: I think there are a couple things here: the practice and the people.
I think if you see yourself in it--as part of the transferred innovation--you
will like it better and be more motivated to follow through with the replication. Dr Brumley: We developed what we called "core components" of home-based palliative care that we thought were so important that you could not deviate from these eight core components. To allow some individualization, you could make about a 10% change per component and it would probably still work. William Marsh, MD: In a complex adaptive system, you only need to have a few critical minimum specs to accomplish your endgame. If we could identify what those were and then allow reinvention to occur, you actually go slow to go faster. Mary Ritner: We know the critical aspects of a project that promote transfer of successful practices. We also understand that adaptation is necessary and important to implementation. We need a way to assess if an adaptation represents a good change or not. If we don't balance local independence with transfer of innovation, we're not going to move from a good organization to a great one. Paul Wallace, MD: There's something about a middle ground that allows us to be clear about what we think is the right idea and why we think it's the right idea, but then also be open to the fact that there's a lot of smart people with unique experiences in their own environment. Our opportunity is to learn from them. On the Language We Use Dr Marsh: In Colorado, "rollout" is an unbelievably loaded term. We crippled the organization in Colorado in the mid 90s with rollouts associated with Primary Care redesign that were top down with little dialogue between leadership and the rest of the organization. It broke trust throughout the organization. We seldom use the word anymore. Dr Wallace: There will just be places where you find that the word "rollout" makes people crazy; so don't persist in calling it rollout. Ask them what they call that particular concept and realize that's part of the diversity of the Program. On Going Beyond "Gaining a Toehold" Dr Wallace: The process for gaining a toehold is a lot different than actually getting further penetrance and acceptance once you've got a toehold. Champions and passion are pretty good for winning over the early adopters but they put off the skeptics. We tend to declare a success once we've gotten the early adopters to sign on, but moving from the early adopters to the early majority is a huge task. Early adopters are often not very good at recruiting further folks to the change because the communication among early adopters is around passion, but the later adopting "curious" are generally more data-based and they take time carefully watching the early adopters practice the innovation. When you move from the curious to the next phase, which are the skeptics, they absolutely don't want to talk about passion. Rob Formanek, MD: There's a need for a certain kind of communication savvy. The risk with passion is that it can translate into "making the skeptic wrong" rather than "getting the skeptic's considerations" on the way to gaining buy-in. So, there's an art and it's a relationship skill associated with translating the passion into something that others can buy into, instead of building a polarity and generating a lot of resistance. Dr Marsh: There's one other thing about understanding the "traditionalists or laggards" in Roger's diffusion of innovation model: As you go up the diffusion curve, people look for minimal or no risk, and it's usually fear based.1 You've got to surface resistance rather than shy away from it. Maybe the fear of HealthConnect is simply "I'm going to look stupid in front of my patients. They will see I can't even type." As other clinicians move forward and describe their successes, even the "traditionalists" will join the journey. Pam McNab: That's what we teach in Accelerating Implementation Methodology. Laggards are the people who have deep resistance. Until we understand what their resistance is, we can't address it. We actually want to surface that resistance, encourage them to tell us what's bothering them. On The Permanente Journal as a Connector Dr Huberman: TPJ may be most useful as an adjunct to help connect people, to raise awareness of things that can be used. Some people just need to read something and then they go do it, some people need to talk to others, and some people need to go see it. Tom Janisse, MD: Yes, and journal articles have also been used as support devices for transfer when they are used as data or evidence and added in reference lists. On Leadership Christi Zuber, RN: There's a big opportunity within KP to reward and develop those leaders who are comfortable going out into the field with people who are providing care and services to our patients. Our project teams saw a significant difference in outcomes between leaders who think all the work happens in their offices and conference rooms versus the leaders who believe the real work happens when they get out from behind their desk and collaborate with the people who provide hands-on care to our patients on a daily basis. Recommendations After dividing into groups to discuss ways to increase the frequency of successful practice transfer related to 1) Awards and 2) Conferences and meetings, recommendations were developed for each. These quotes were developed by group leaders to present a summary of participants' comments. Recommendations Regarding Awards (Vohs, Lawrence) 1. Sponsorship "Sponsorship is critical. Very often part of the problem is that there's insufficient sponsorship to move ideas into practice. We should initiate a more formal process for establishing sponsorship for those ideas that we want to move forward and not assume that transfer will happen spontaneously. First, we suggest that we clearly define the role and responsibility of the sponsor(s) in terms of financial support, time, and people needed to move a practice forward. That should be clearly articulated and result in a sponsorship contract. We also should formally create a sponsorship map for a given practice that we're trying to transfer." 2. Language Counts "You can come up with really great ideas and really great things that you want to do; however, it's more difficult to spread if it's not written or described in an engaging way. It must be presented in a way that is easy to understand and piques interest. Be clear on what it is you're trying to do, watch the language you use. Be sensitive about organizational and cultural differences. Develop materials that meet the needs of multiple learning styles. We have a tendency to just "PowerPoint® presentation" people to death sometimes." 3. Match the Needs of Recipients "First, there needs to be a process to provide objective data to identify performance gaps. Second, the project should be reframed to the meet the recipient site's needs and their top regional priorities. Those can't be assumed: you need to go to the region, find out what the needs are, and reframe the project. Finally, take advantage of and line up existing regional networks to help overcome resistance. For example, in terms of the Vohs award, we could use the data to show a region how its performance is different or isn't being measured in a comparable way with the awardee. We could then demonstrate how the innovative process really is saving lives. Then, we would go to the regions to see what their other priorities are, what they are working on, and how the proven successful practice could be linked." 4. Use and Reuse Implementation Networks "As you use and reuse networks, the marginal cost of the next project decreases. So, instead of recreating a new network each time, reuse applicable elements of the network you used before." 5. Make Transfer Part of Someone's Job "Once you've identified a project to diffuse, identify someone to be responsible for implementation and diffusion. Do no simply load this on top of everything else. This takes time; planning and follow-up are important." Recommendations Regarding Meetings and Conferences 1. Do Work "Upfront" "It is important to identify the right people and send them to the appropriate interregional meetings and conferences. This includes both sponsors and implementers to increase the chance of successful transfer. Where some large successes have been observed, like at the Primary Care access conference, the full complement of the right team was there focusing on the issue together. Sponsors should set expectations and accountabilities in advance so that the participants will return and become effective hubs." 2. Pay attention to Conference Names and Design "Naming is important. It creates an attractor and helps define the group that's attracted to the meeting. An example is the 'Perinatal Safety Conference,' which was really about surgical safety. Had it been named the 'surgical safety conference,' it would have attracted surgeons. Instead, risk managers and safety officers attended--no surgeons or operating suite people. The very naming of the conference can have an influence on getting the right people there." "We also need to provide content that meets peoples' needs. Is this something that people really care about? Will it encourage them to transfer? On day one have a Whitman Sampler of the ten great ideas uncovered last year, but on day two focus on two of those topics with the right people in the room. They get the high-level recipe and then, in smaller groups, the source team explain the details." 3. Use Checklists and Tools to Support the Transfer "There is an enormous amount of premeeting work and postmeeting work for a conference. We can anticipate what that is and put together a tool or checklist that helps us run good interregional meetings and conferences. This tool would include determining, in advance, real needs, the best people to attend, and sponsorship needs. In addition, conference participants should use a tool that helps them organize what they've learned and next steps in order to be able to transfer knowledge and practices upon returning to their region." 4. Provide Support for Replication "It is important to plan financing for replication; transfers have been more successful when that's done. There needs to be infrastructure; this means designating replication project managers with the capability and accountability to ensure successful transfer. Capability about dollars and resources and accountability is the sponsorship conversation. Finally, we must continue to emphasize the importance of recognition and reward for replication."
Reference
|
|
|
|
|
|
|
|
|
|
|
 |
|
