Facilitation in Practice: Location, Level, Intensity

Anne Sales, PhD RN

Quality Enhancement Research Initiative

Dichotomy informs our view of what does and doesn’t work

• We know more about how to change individual behavior than organizational behavior– Although we don’t know much about either– Missing “layer” may be a clue to why interventions

work in one place and not in another

• The concepts of context and facilitation are probably keys to what works and how

Describing facilitation

• Human vs. technological facilitation

• Human– Characterized by hierarchy, roles, other

dimensions

• Technology– Almost always requires human

intermediation

Assessment of a Quality Improvement Intervention to Promote VA NationalLipid Electronic Clinical Reminders

Anne SalesAshley HedeenMeg PlomondonJohn Rumsfeld

VA HSR&D Service 01-040

Quality Enhancement Research Initiative

Why electronic reminders?

• Hypothesis: Principal reason for gaps in lipid management is lack of provider attention– Competing priorities– Insufficient time for preventive care– Lack of awareness that patient is at risk

– Data from qualitative study conducted in six VAMCs

Reminders raise awareness and are actionable

• Electronic clinical reminders in CPRS deliver patient-centered information to providers at the point of care– clinic encounter or visit– Meta-analyses describe studies showing that

reminders are effective in some cases in increasing amount of preventive care

• Well-designed reminders allow providers to take action to correct gaps in care through the dialog boxes– Interact with order entry, lab and pharmacy data,

and draft progress note

Sample of CPRS reminders:Reminder due list on Notes tab

Reminders Due List on the Notes Tab.Clicking on a reminder name opens the reminder dialog.

Initial Dialog: IHD Lipid Profile

Summary of guidelines

Link to the Clinical Maintenance screen

Point-and-click options that resolve the reminder

Progress note generated

Evaluation Sites and Methods

• Two National IHD Lipid Reminders installed in three sites in eastern half VISN 19 (Rocky Mountains)– Four sites in western half of VISN used as

comparison sites

• Conducted process evaluation of installation and implementation of reminders in intervention sites over 16 months– June 2002 through September 2003

Reminders Require a Two Stage Process

• Installation– National software patch to local clinical information

system– VA’s information architecture involves local

systems with national input– Installation was mandated; patches are sequential

• Implementation– Required local IT support

• Mapping terms• Training providers• Learning reporting systems

Implementing Reminders

• One of three intervention sites implemented reminders without effort within a month of intervention starting

• Two original sites were merged mid-way through intervention period– Formed large health care system with tertiary center

and several large outpatient clinics• Outpatient clinics had implemented reminders within first two

months; tertiary site was slower in implementing reminders

• Third site implemented reminders approximately two-thirds of the way into the intervention period

Use of reminders varied among intervention sites

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mean o

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1 2 3

Information from formative evaluation

• Sites where reminders were not fully implemented were detectable before the end of the project– Stopped attending conference calls– Poor response to requests for information– Defensive reactions to questions about

progress

More description

• Internal vs. external

• Limited vs. holistic

• Formal vs. informal

• Other continua…

V ie w o f h e a lth ca re d e live ry

H ig h le ve l p o licyd e c is io ns

S tra te g ic d e cis io n s u su a llyg e t m a de he re

o r he re

C O N T E X T

W O R K G R O U P

Increas ing d is ta nce fro mpatient and p rov ide r

P enetration is hard

P atien t

I n d iv id u al p r o v id er

T eam / M icr o sy stem

U n i t/ C l in i c

O r g an iz atio n

Sy stem

I n d u stry

E n v i r o n m en t

Internal facilitation: providers/professionals as facilitators

• Roles include– Opinion leader– Change agent– “Facilitator”/troubleshooter– Convener

External facilitation

• Outside experts– Consultants– “Gurus”– Researchers– People from a higher level of the system or

organization

Limited vs. holistic facilitation

• May interact with concept of intensity• Limited

– Focus on specific problem or behavior change– May also reflect lower level of intensity

• Holistic– Global– Focus not on specific, but general behavior

change

Facilitation and leadership: Formality vs. Informality

• Primacy of leadership– Initiating change– Managing change– Judging change

• When is it complete… enough?• How to measure successful change

Leadership occurs at all levels

– Senior management leadership• Formal authority, power structure, hierarchy

– Mid-level• Also authoritative, less power, moderate hierarchical

influence

– Front-line• Peer respect and influence, networks

– Ancillary• People connectors, networks, information chain

• Leadership is often emergent rather than planned

Question of effectiveness

• How are people trained to be effective?– What works?– What do we know?– Need for evidence base here

• Self-awareness and intentionality– Counter to the “Nike/Just do it” mentality– Goal-orientation and intentionality

contribute to ability to work through barriers

More keys to effectiveness

• Support– Support groups– Realism on the part of micro (local) and

macro (senior) leaders that change isn’t free

• Resource commitment is essential• Rewards are critical

The dark side

• Negative opinion leaders• Questions of resistance

– Can arise from many sources:• Conflicts over evidence• Fear of change• Loss of status• Lack of alignment of personal priorities with

organizational priorities– Personal triumphs– ego gratification, inappropriate

pursuit of power

Living in a thunderstorm

Anatomy of a thunderstorm cell

• Leading edge• Middle misery• Trailing edge

– Resistance• Terminal resisters• “Drug-resistant” forms

– Resistance to change built through successive abortive change efforts

– Recidivism

Tools for coping

• Adequate planning– Anticipation

• Adequate provisions

• Sufficient support

Facilitators generally

• Need nurture and support

• Recognize and plan for barriers– Adequate resources and support

• Recognize that values are important component