The BC Clinical Care Management Initiative as a Case Study in Large Scale Change

CARES International Conference on Realist Approaches, October 29, 23014

Allan Best, PhDInSource Research Group

allan.best@in-source.ca

Objectives for this Roundtable

• Introduce InSource

• Overview project

• Summarize methods and findings

• Position work in larger context of health system transformation

Old London Bridge, circa 1600s

Why Do We Need Health System Transformation Research?

The healthcare system is complex•Increasing chronic disease and ageing population•Rising costs •Fragmentation and increased complexity

Complex problems require complex solutions•Need to understand enablers and constraints to achieve systems transformation •Need to know “what works, for whom, under what circumstances”

What is Systems Thinking?

“a discipline for seeing wholes, … a framework for

seeing interrelationships rather than things, for

seeing patterns of change rather than static

snapshots” (Senge, 1990)

•Sees systems as organic, dynamic, non-linear

•The whole is greater than the sum, reductionist

thinking and command and control practice won’t

work

•Demands continuous learning and adaptation

1. Apply complex adaptive systems lens iteratively

to develop understanding of enabling,

constraining, and contextual factors to CCM

as a case study for Large Scale Change

2. Make recommendations to:

– Improve implementation of guidelines

– Apply implementation strategies to other

health system issues

The Client’s Objectives

Not Included in Our Study

• An evaluation of CCM outcomes/impact

• Data did not allow comparison of specifics

across initiatives or Health Authorities

• A prescriptive road map for the future

• Context matters• Organizational culture has a substantial

effect on implementation of change• Anticipate variation across regions and

programs with respect to enablers and constraints but similarities are expected to outweigh the variation

• Each stage of the project will build upon the earlier findings iteratively

Project Assumptions and Approach

BCMAMoH Politicians

CCM

BCPSQCLSC

Implementation Lead

M&E Clinical leads

CEO/Exec

CCMSC

Patients and Community

LSC

Green = clinical functionBlue = research functionPink = Supportive function

HA Board

QualityQuality

Delivery team

Stakeholder Map of CCM Initiative

MSFHR

LSC

POLITICAL

EXECUTIVE

CLINICAL

• Email survey with the Measurement and coordination Working Group

• One on one interviews with CCM cross cutting and clinical leads

Preliminary Framework

(December)

• 37 key informant interivews

• 6 focus groups representing all participating HAs

• Scoping literature review

• Quality Forum small group discussion

FrontlineData Collection(January - February 11) • Validation

survey• Feedback

from CCM team

Validation(end of March - April)

Final Report Due

Mid June

A Brisk Project Timeline

Top Leverage Points for Change – Survey data

• Themes were our initial step to building a set of lessons learned

• We found high levels of consistency across interviews, focus groups, forum and survey

• Themes address various levels - provincial, HA, hospital site, clinical and patient

Emerging Themes

What Does It Take to Build Local Ownership?

• Enabling committed and distributed leadership• Promoting two way communication • Aligning incentives• Encouraging local ownership• Enabling access to data and information systems• Affecting culture change• Promoting integrated guideline implementation• Promoting and coaching collaborative clinical

teams

• Prepare for change initiatives such as CCM to evolve

• Clear a path through the complexity• Promote shared clinical leadership• Strengthen knowledge management• Implement an on-going (long-term)

communication strategy to promote shared understanding, engagement and broad-based ownership of change initiatives

• Recognize the effectiveness of networks

Emerging Themes

16

Causal Loop Diagram – CULTURE revised

• Enduring, embedded collaboration• Tools for developing systems conversations,

within and across levels, and with the public• Structural change – siloes, professional

autonomy and compensation, time to learn, university and funding priorities

• Comprehensive measures, feedback loops, learning platforms

Future Priorities for Large Scale Change

18

Integrating Learning, Continuous Change and Accountability

Developmental Evaluation

RealistApproaches

Outcomes and Accountability

Thank you!

allan.best@in-source.ca

http://bcpsqc.ca/blog/knowledge/a-case-study-of-bcs-clinical-care-management-initiative/

Additional Reading:Best et al. Large system transformation in health care: A realist review and evaluation of its usefulness in a policy context. Milbank Quarterly 2012, 90(3), 421–456.

Willis et al. Systems thinking for transformational change in health. Evidence and Policy 2014, 10(1), 113-126.

Willis et al. Sustaining organizational culture change in health systems. Journal of Health Organization and Management, in press.