1. Week 1 Introduction Translating Evidence Into Practice: System-Centered Implementation Strategies Week 1 Introduction Laura Schmidt, Ph.D, MSW, MPH Jim Kahn, MD, MPH Philip R. Lee Institute for Health Policy Studies Clinical and Translational Institute Training in Clinical Research Program

2. Roadmap for today’s introductions This Course T2 Translational Research Organizational Theory at the Systems Level

3. Introduction: PART 1 THIS COURSE

4. Your Fearless Leaders

6. PART ONE: Introduction to systems change TODAY: Introduction to T2 Research Organizational Environments WEEK 2: Policy Implementation WEEK 3: Changing Systems

7. PART TWO : Selected tools for systems-level change DATESPEAKERTITLE 4//21 Hal Luft Redesigning Benefits Structures: Health Coverage 4/28 Michael Cabana Changing Practice Patterns: Practice Guidelines 5/5 Adams Dudley Changing Organizations via Feedback on Quality 5/12 Diane Rittenhouse Restructuring Organizations: Medical Homes 5/19 Helen Lipton Redesigning Benefits Structures: Drug Formularies 5/26 Molly Cooke Influencing Providers via Professional Societies 6/2 Chris Millet Pay for Performance

8. COURSE REQUIREMENTS SHOW UP, DO READINGS, ENGAGE THINK ABOUT WAYS TO APPLY T2 SYSTEMS INTERVENTIONS TO YOUR AREA OF EXPERTISE DEVELOP ONE LOI/BRIEF PROPOSAL

9. Introduction: PART 2 WHAT IS TRANSLATIONAL RESEARCH?

10. T1 and T2 TRANSLATION BENCHBEDSIDECOMMUNITY

11. Translation as Institutional Initiative NIH Roadmap for Medical Research Promoting patient-oriented research Research Teams of the Future New models for scientific cooperation New Pathways to Discovery Novel research on biologic systems Re-engineering the clinical research enterprise

12. DEFINING THE PROBLEM “Silos:” Institutional and programmatic boundaries had created fragmented research efforts, training programs and resources that would be effective if integrated. “Fragmentation:” The lack of centralized infrastructure has been a huge barrier to conducting clinical and translational research. “Balance:” Declining interest in patient-oriented research “Lack of collaboration:” Need for a team approach—breaking down barriers between basic and clinical scientists

13. Two Spheres of Translational Research T1 “Roadblock” -to harness knowledge from basic sciences to produce new drugs, devises and treatment options -to transfer new understanding on diseases mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy and prevention T2 “Roadblock” -ensuring that new treatments and research knowledge actually reach the patients or populations for whom they are intended and are implemented correctly -helping clinicians and patients make more informed choices, providing reminders and point-of-care decision support tools, and strengthening the patient- clinician relationship

14. Two Spheres of Translational Research T1 Research methods - molecular biology - genetics - basic sciences - clinical sciences Settings - strong laboratories - cutting edge technology Challenges -biological & technological complexities - trial recruitment - regulatory concerns T2 Research Methods -”implementation science” & org theory -evaluation studies - clinical epidemiology -communication theory - public policy -health services research Settings - community and practice-based settings - population-based interventions Challenges -organizational inertia -resource constraints -inability to control “noise” -power relations/vested interests

15. Translational Research Infrastructure NIH Clinical and Translational Science Awards 24 CTSIs (“academic homes”) already formed Goal of 60 CTSIs by 2012 Budget of $500 million per year Multi-Stakeholder Translational Research Programs European Commission – program centerpiece Two new journals: Translational Medicine Journal of Translational Medicine

16. THE PROMISE OF T2 TRANSLATION It could ultimately save more lives than T1 T2 could make the health care system perform better in delivering what we have Greater fidelity in delivering aspirin to eligible patients could prevent more strikes that developing more potent antiplatelet agents Increasing patient safety, access and equity could do more to improve health than a new imaging device or class of drugs.

17. Introduction PART 2 HOW DO WE UNDERSTAND T2 IMPLEMENTATION AT THE SYSTEMS LEVEL?

18. Organizational Environments Intra- VERSUS Inter- Organizational Theory Environment supplies resources to organizations (money, people, power, legitimacy) Organizations are focused on survival not efficiency Resource Dependency: Power flows to places within the organization that attract resources

19. Organizational Fields: One Way to Think about Environments To ensure mutual survival, organizations form a social order or “organizational field”

20. Characteristics of Organizational Fields A power structure Shared goals, rules and assumptions Meaningful roles Government organizations are part of the field

21. The HEALTH CARE SYSTEM AS AN ORGANIZATIONAL FIELD

22. The Health Care System Large Employers Government Insurance Plans (e.g., Medicare, Medicaid) Managed Health Plans (e.g., HMOs, PPOs) Hospital Corporations “Providers” and “Consumers” SUPPLIERS BUYERS

23. Who has power? LARGE BUYERS: EMPLOYERS AND GOVERNMENT PURCHASERS

25. Government Organizations Play Different Roles Government as “venture capitalist” Rule maker and enforcer (e.g., FTC, courts) Largest Buyer in the market (e.g., Medicare, Medicaid)

26. Other Players in the Field Health Plans (providers + insurers) Organized Provider Groups (AMA, ANA) Quasi-governmental agencies (NCQA) Supplier corporations (Pharma) Consumer groups (AARP, Unions) Educational institutions (UCSF) Science institutions (NIH, RWJF)

27. What is a Health Plan? provider+ insurance = MANAGED groupplan HEALTH PLAN

29. CASE STUDY: The U.S. Health Care Transformation (1965-1995) The reorganization of a field

31. Dr. Marcus Welby: WHAT HAPPENED?

32. The Health Care Transformation Before 1965 Doctor-controlled order Protect doctor-patient relationship Independent, nonprofit organizations Non-interference in medical affairs After 1980 Buyer-dominated market Increase efficiency and cost accountability For-profit medical corporations Stimulates competition and steers the market System of Power Shared Goals Roles for Organizations Government’s Role

33. Summary T2 has at least two parts: intra- and inter- organizational change strategies Sociology of Organizational Environments provides a frame for understanding systems Key aspects of systems: power structure, shared goals, roles for organizations and government