Facilitating Change: Lessons from the TransforMED National Demonstrati

Slide Presentation from the AHRQ 2009 Annual Conferenc

Slide presentation from the AHRQ 2009 conference.

On September 14, 2009, Elizabeth Stewart made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (4.37 MB) (Plugin Software Help).

Slide 1

Facilitating Change: Lessons from the TransforMED National Demonstration Project

AHRQ 2009 Annual Conference
Sept. 14, 2009
Elizabeth E. Stewart, PhD
Independent Evaluation Team from Center for Research in Primary Care & Family Medicine


Slide 2

Evaluation Team

  • Carlos R. Jaen, MD, PhD
  • Paul A. Nutting, MD, MSPH
  • Benjamin F. Crabtree, PhD
  • William L. Miller, MD, MA
  • Kurt C. Stange, MD, PhD
  • Elizabeth E. Stewart, PhD


Slide 3

National Demonstration Project

  • Two-year project intended to 'test' the new model of family medicine as outlined in the FFM report.
  • AAFP provided funding; TransforMED was created to design and implement the project.
  • Independent evaluation team providing mixed-methods analysis for practice & patient outcomes.


Slide 4

NDP: Background & Timeline

  • 500 practices applied
  • 300 usable applications
  • 36 practices selected
    • 18 randomized: FACILIATED
      • 17 (F) practices finished
    • 18 randomized: SELF-DIRECTED
      • 15 (SD) practices finished

NDP start: July 2006
NDP finish: June 2008
Touchstone Group Begins


Slide 5


An image of a map of the United States is shown. The map has Small, Solo, Medium, Large, and New Practice types labeled.


Slide 6

Real Practices. Real Stories

A number of images of groups of people are shown on the screen.


Slide 7

Implementation Assistance


  • List serve & website access
  • 1 final NDP Learning Session
  • Some $$ for self-organized retreat midway through NDP
  • 6 practices/facilitator
  • Access to facilitator (site visits, phone calls, emails)
  • 4 NDP Learning Sessions
  • Monthly conference calls
  • Discounted technology
  • Access to national consultants
  • List serve & website access


Slide 8

Mixed Methods


  • Patient Health Outcomes (medical chart audits)
  • Practice Finances (surveys - limited)
  • Clinician/Staff Satisfaction (surveys)
  • Patient Perception of Care (surveys)
  • - Field notes, interviews, observations, email communication logs, conference calls, Learning Sessions, facilitator debriefs, list serve, documentation of model components.


Slide 9

Original TransforMED Model

An image of the Original TransforMED Model is shown.


Slide 10

The TransforMED Patient-Centered Model


Slide 11

A new way of thinking.

An image of an updated TransforMED Model is shown.


Slide 12

A new way of thinking.

  • Transformation is more than a series of incremental changes; it requires requires epic whole practice re-imagination and redesign.
  • Transformation to a PCMH requires substantial changes in the mental model of both physicians and practice staff.
  • It is more than implementing sophisticated office systems. it is about adopting substantially different approaches to patient care



Slide 13

What helps a practice transform?

"Core Structure" - includes ability to manage basic finances, clinical & practice operations during times of stability & modest change.

"Adaptive Reserve" - ability of practice to be resilient, to bend & survive under force. Facilitates adaptation during times of dramatic change.


Slide 14

What is Adaptive Reserve?

Measured with the Clinician/Staff Questionnaire

  • Anonymous questionnaire - 3x during project
  • Based on validated PSQ and 'The Magnificent 7'
  • Represents the perceptions of those living in the practice

89 questions total, pared down to 9 final categories through factor analysis:

  • Respectful Interaction
  • Learning Culture
  • Reflection
  • Work Environment
  • Strong Leadership
  • Sense making
  • Diversity
  • Mindfulness Communication


Slide 15

Change in Adaptive Reserve*

28 months7078

*Adaptive reserve includes measures of leadership, sensemaking, diversity, mindfulness, communication, respectful interaction, learning culture, reflection and general work environment. Baseline vs. 28 months for facilitated group is statistically different. (p<0.01)
Measure of Adaptive Reserve


Slide 16

The Role of Facilitation

  1. Consulting
  2. Coaching
  3. Facilitating Adaptive Reserve


Slide 17

Facilitation: Consultant

  • Huddles & Meetings
  • Workflow analysis
  • Metrics, PDSA cycles
  • Specific projects

HIT assistance – vendor liaison, implementation


Slide 18

Facilitation: Coach

Staff: Empowerment, task delegation
Practice Managers

  • Project Mgt
  • Personnel/HR
  • Finances
  • Communication
  • Empowerment
  • Support
  • Leadership
  • Finances
  • Delegation
  • Time Mgt
  • Communication
  • Support


Slide 19

Facilitation: Adaptive Reserve

  • Staff Retreats with Pre-Work & Follow-up
  • Intense Coaching
  • Conflict Resolution
  • Rich & Lean Communication

Facilitated Learning Sessions w/other practices


Slide 20

Patient Outcomes Surveys

  • Mailed to cross-section of 120 pts/practice, 3x
  • Based on multiple validated surveys and intended to measure 7 attributes of patient-centered primary care.*
  1. Superb Access
  2. Patient Engagement
  3. Clinical Information Systems to Support Care
  4. Care Coordination
  5. Integrated & Comprehensive Team Care
  6. Routine Patient Feedback to Doctors
  7. Publicly available information

Also assess patient enablement & patient satisfaction.

* Commonwealth Fund


Slide 21

 POS Core Elements to Measure

  1. Patient Enablement (PEI)
  2. Empathetic Care (CARE)
  3. Comprehensive Care (CPCI)
  4. Accumulated Knowledge (CPCI)
  5. Inter Personal Com (CPCI)
  6. Coordinated Care (CPCI)
  7. Advocacy (CPCI)
  8. Health Promotion (ACES)
  9. Cultural Responsiveness
  10. Family Context (CPCI)
  11. Organizational Access
  12. Community Context (CPCI)
  13. Usual Provider Continuity (CPCI)
  14. Interpersonal treatment
  15. Recommend Doctor
  16. Rating of Doctor (1-10)
  17. Med Home (PCPE)
  18. Same Day Access Available
  19. Overall health status (1-5)


Slide 22

Self-Directed Practices: Some Decreases

 Baseline9 months28 months
Empathetic Care.87.20.84**0.20.84**.20
Comprehensive Care.84.160.820.16.81**.15
Interpersonal Com..81.18.78**
Health Promotion.14.34.24***

Only showing core elements with significant changes from baseline:
*= p <05; ** = p <.01; *** = p <.001


Slide 23

Self-Directed Practices: Some Decreases

 Baseline9 months28 months
Community Context.71.22.67**0.22.66***.22
Interpersonal treatment.91.17.89*.17.91.16
Recommend Doctor.94.15.91*.15.92.14
Rating of Doctor.91.15.88*.15.88.15
Same Day Access.41.48.34*.48.40.49
Overall health status3.38.943.44*.943.50*.92

Only showing core elements with significant changes from baseline:
* = p<.05; ** = p <.01; *** = p <.001



Slide 24

No Significant Change in Facilitated Practices

  • Facilitated practices showed relatively small, if any, changes in any of the 19 categories over time.
  • Despite tremendous changes going on at the practice, the core elements of the patient experience appeared unchanged.
  • This may suggest that facilitation had a buffering effect. Patients in the SD practices may have felt the chaos of change but pts in the facilitated practices did not.


Slide 25

Thank you.

Current as of December 2009
Internet Citation: Facilitating Change: Lessons from the TransforMED National Demonstrati: Slide Presentation from the AHRQ 2009 Annual Conferenc. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/stewart/index.html