1. A Multimethod Tailored QII for Sustainable Practice Change Mary C. Ruhe, B.S., R.N. Kurt C. Stange, MD, PhD Research Association of Practices (RAP) & Case Western Reserve University

2. PBRN Collaboration in a Line of Inquiry Primary care setting Practice as the focus of change Patient care and practice enhancement the goal

4. Competing Demands Theory Many worthwhile services compete for time on the agenda of primary care patient visits. When primary care clinicians are not doing one activity under scrutiny (e.g. preventive services), they may be doing something else that is more compelling. Jaén CR, Stange KC, Nutting PA. The competing demands of primary care: A model for the delivery of clinical preventive services. J Fam Pract. 1994; 38:166-171. Stange KC, Fedirko T, Zyzanski SJ, Jaén CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract. 1994; 38:231-237.

5. Transdisciplinary, multimethod approaches Stange KC, Zyzanski SJ. Integrating qualitative and quantitative research methods. Fam Med, 1989; 21:448-451. Stange KC, Miller WL, Crabtree BF, O’Connor PJ, Zyzanski SJ. Multimethod research: Approaches for integrating qualitative and quantitative methods. J Gen Intern Med. 1994; 9:278-282. Crabtree BF, Miller WL, Addison RB, Gilchrist VJ, Kuzel A. Exploring Collaborative Research in Primary Care. Thousand Oaks, California: Sage Publications, 1994. Crabtree BF, Miller WL. Doing Qualitative Research. 2nd Ed. Thousand Oaks, California: Sage Publications, 1999. Crabtree BF, Miller WL, Stange KC. Understanding practice from the ground up. J Fam Pract, 2001; 50:881-887.

6. Multimethod Research Quantitative methods Counting descriptions Testing a priori hypotheses Seek to isolate phenomenon from context Qualitative methods Rich descriptions Discovery; testing evolving hypotheses Seek to understand meaning and context Integrated use Qualitative, then quantitative Quantitative, then qualitative Simultaneous

7. Understanding before, during and after Intervening

8. STEP-UP Group RCT in 77 practices Individualized intervention based on multimethod assessment process (MAP) Control group gets (refined) delayed intervention with pre/post evaluation Goodwin MA, Zyzanski SJ, Zronek S, et al. A clinical trial of tailored office systems for preventive service delivery. The Study To Enhance Prevention by Understanding Practice (STEP-UP). Am J Prev Med. 2001; 21:20-28. Kottke TE, Solberg LI. STEP(ing)-UP to deliver clinical preventive services. Am J Prev Med. 2001; 21:20-28.

9. MAP Observation –Practice operations –Patient visits Key informant interviews Practice genograms* Focus on understanding practices’ –Key stakeholders and motivation –Current approach to preventive service delivery –Capacity to change and levers for change *McIlvain H, Crabtree BF, Medder J, Stange KC, Miller WL, Dodendorf D, Aita V. Using “practice genograms” to understand and describe practice configurations. Fam Med, 1998; 30:490-496.

10. Practice Genogram A tool for gathering data on and depicting the structure and relationships of primary care practices Enhances understanding of practices as complex adaptive systems Can help identify levers for change McIlvain H, Crabtree BF, Medder J, Stange KC, Miller WL, Dodendorf D, Aita V. Using “practice genograms” to understand and describe practice configurations. Fam Med, 1998; 30:490-496.

13. Practice-Tailored Intervention Multimethod practice assessment Practice meeting Facilitation of implementation Continued feedback

14. Expanded from: Goodwin MA, Zyzanski SJ, Zronek S, Ruhe M, Weyer SM, Konrad N,Esola D, Stange KC. A clinical trial of tailored office systems for preventive service delivery: The Study to Enhance Prevention by Understanding Practice (STEP-UP). Am J Prev. Med 2001; 21:20-28. Global Preventive Service Delivery Mean % eligible services up to date

15. 0 2 4 6 8 10 0.91.01.11.21.31.41.51.61.71.81.9 Rate Ratio - 12 months to baseline Number of practices Global Preventive Service Delivery

16. Health Behavior Counseling 0 1 2 3 4 5 6 7 8 9 0.751.001.251.501.752.002.252.502.753.003.253.503.75 Rate Ratio - 12 months to baseline Number of practices

17. Implications A tailored quality improvement intervention has variable, but sustained effectiveness, even in a changing health care environment Greater individualization of intervention approaches is needed, based on greater understanding of practice variation

18. STEP-2 Greater individualization Evaluation and reflection on (general and prevention specific) –Values –Structures –Processes –Outcomes

19. EPOCHS Enhancing Practice Outcomes through Communities and Healthcare Systems RCT of 30 primary practices in 3 systems Engagement of resources from Practice Healthcare system Community organizations Tailored Appreciate Inquiry intervention Multimethod process assessment Funded by a grant (5R01 CA60862) from the National Cancer Institute

20. Understanding (and working with) Practices as Complex Adaptive Systems

21. Facilitating Practice Change The edge of chaos –Innovators (live on the edge) –Outside forces move toward the edge –QI intervention moves toward the edge Change is difficult to predict Tailor facilitation to malleable moments Motivated change agents –Work with the already motivated –Increase motivation by Linking to values or other needs Peer comparison feedback Once motivated, address instrumental needs Ruhe MC, Weyer, SM, Zronek S, Wilkinson A, Wilkinson PS, Stange KC. Facilitating practice change: Lessons from the STEP-UP clinical trial. Prev Med. 2005; 40: 729- 734.

22. Primary Care Practices are Complex Adaptive Systems Complex behavior emerges from relationships among agents Simple rules Recurrent patterns Co-evolution Dependence on initial conditions Non-linearity Strategies for intervention Joining Transforming Learning Miller WL, Crabtree BF, McDaniel RA, Stange KC. Understanding primary care practice: A complexity model of change. J Fam Pract, 1998; 46:369-376. Miller WL, McDaniel RA, Crabtree BF, Stange KC. Practice Jazz: Understanding variation in family practices using complexity science. J Fam Pract, 2001; 50:872-878.

23. Using Complexity Science to Inform a Reflective Practice Improvement Process Understanding practices’ vision and mission is useful in guiding change Creating time and space for learning & reflection helps organizations to adapt & plan change Tension & discomfort are essential & normal during change Diverse perspectives foster adaptability & new insights for positive change Sustainable change requires supportive leadership Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. Using complexity science to inform a reflective practice improvement process. Jt Comm J Qual Patient Saf, 2005; 31: 438-446.

24. Implications of a complexity science perspective Relationships are critical. Sensemaking is more important than decision-making Learning is more important than knowing. Problems cannot be solved by muscle, but require creativity and improvisation. Thinking about the future without prediction is a key to progress

25. Conclusions Efforts to improve practice should be preceded by efforts to understand practice. Individualizing intervention approaches based on a MAP can lead to sustainable practice improvement.

26. Conclusions Continued learning, sensemaking and relationship building is critical to fostering positive co-evolution of practices and systems