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Transcript of Sue Stableford - What happens when policy hits the ground? The diffusion of innovation meets complex...
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What happens when communication policies hit the ground?
Sue Stableford, MPH, MSB, DirectorUniversity of New England Health Institute
September 2013
The Diffusion of Innovation meetsComplex Adaptive Systems
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Assumptions
• Communication focus: Terms and 2 major strategies
• Moving strategies into practice = CHANGE • Core issue for better health and public health
outcomes
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What’s Ahead
1. The challenge of change2. Context: Policy and history3. What happens when policy
hits the ground?4. How change happens:
Interweaving theories5. Opportunities to improve practice
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The Challenge of Change
[Atul Gawande. Slow Ideas. New Yorker, July 29, 2013]
• Adopted quickly: Anesthesia– Ether introduced 1846 and universal in 7 years
• Adopted slowly: Antiseptic techniques– Lister report 1867: Carbolic acid– Generation(s) passed; still challenges
• Public health example: Limes on British ships
Relationship to plain language and teachback?
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Context: Policies, Guidelines, Standards, Tools
Triple Aim
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More Policies, Guidelines, Standards, Tools
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Context of Change: History in 1 Slide
2013
1985 Doaks and Root publish “Teaching Patients With Low Literacy Skills”
All major national policy and accreditation bodies recommend/require clear health communication
1999 AMA ‘White Paper’
2003 2nd National Assessment of Adult Literacy (NAAL)
1992 1st National Adult Literacy Survey (NALS)
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Policy hits the ground
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Healthcare and public health:Stormy environments
• Complex• Many players• Multiple stakeholders• Limited resources• Competing agendas
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Competing for Attention
• External forces– Finances– Politics– Regulations– Safety & quality
• Internal agendas
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Time pressures acute
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Impact on improving communication?
More like this Than this
Results
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How can we get to better communication practice?
• Not easily!• Change theories converge– Public Health: Diffusion of Innovation– Medicine: IHI Model for Improvement– Business: Kotter’s 8 step action model– Popular press: Switch
Tipping Point
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Core Concepts of Change
• Establish need– Engage head and heart
(data and stories)• Engage trusted leaders• Show the way/Start small• Clear obstacles• Measure and celebrate• Spread, build, and anchor
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What promotes broad-scale change?
• Relative advantage• Compatibility• Simplicity• Trialability• Observability
(visibility)
“Diffusion of Innovation” (Everett Rogers)
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Lacks 4 of 5 key elements of easy diffusion • Visibility• Simplicity• Relative advantage• Compatibility with
‘usual care’
Barriers to Communication Change
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Another Framework for Understanding Change
– Nonlinear– Self organizing– Emergent– Dynamic– Adaptive
Healthcare and public health as Complex Adaptive Systems (CAS)
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The CAS framework and communication practice change
“Health care providers, patients, officials and the many other stakeholders in a health system interact with each other through a web of complicated relationships, influenced by communities of practice, neighborhoods, and social networks. Scaling up health services involves intervening in these networks and engaging in dynamic, health system relationships.”
Paina L & Peters D. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy and Planning, 2012: 27.
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Diffusion of Ideas and Behaviors
Core Concepts of
Change
Complex Systems inComplex
Environments
Common theme: Social Relationships
Policies, Guidelines,Standards, Tools
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Showing the way: Models of Success
• IOM Health Literacy Roundtable, April 2013– Focused on organizational change– Care systems using change frameworks
and systems thinking to integrate plain language and teachback
• Public health: ecological paradigm
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So, what does it take to change communication practices?
1. Core concepts– Prioritize, Invest, Measure
2. Diffusion of Innovation– Compatibility and
simplicity– Emphasize advantage
3. Systems & social theory– Flexibility and creativity– Points of leverage
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Support for Improved Communication Practice
• ACA payment reforms• Links to high-profile issues
e.g. Cultural Competence• Accreditation requirements• Academic changes• Links to proven programs
e.g. TeamSteps and Choosing Wisely
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What about technology solutions?
• Technology: A supporting player, not the star• Change– A social process– Person to person
• Gawande: “People talking to people is still how the world’s standards change.”
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Will it make a difference?
Yes! Evidence on communication impact:• Patients• Providers and care systems• Public health
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Finale
Atul Gwande referencing Everett Rogers:
“Every change requires effort, and the decision to make that effort is a social process.”
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Selected Additional References• Foster-Fishman P, Nowell B, Yang H. Putting the system back into systems
change: a framework for understanding and changing organizational and community systems. Am J Community Psychol, 2007. 39:197-215.
• Hawe P, Shiell A, Riley T. Theorising Interventions as Events in Systems. Am J Community Psychol, 2009. 43:267-276.
• Hibbard JH and Greene J. What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs. Health Affairs, 2013. 32(2):207-214.
• Langley GJ et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Francisco: Jossey-Bass, 2009.
• Meadows D. Thinking in Systems. Vermont: Chelsea Green Publishing, 2008.• Patton MQ. Developmental Evaluation: Applying Complexity Concepts to
Enhance Innovation and Use. New York: The Guilford Press, 2011.• Rogers E. The Diffusion of Innovation. New York: Simon & Schuster, 1962.• Sterman JD. Learning from Evidence in a Complex World. Am J Public Health,
2006. 96(3):505-514.• Trickett EJ et al. Advancing the Science of Community-Level Interventions.
Am J Public Health, 2011. 101(8):1410-1419.