Transcript Promoting Health through Organizational Change

Decmeber 2007: Healing Across
the Divides meeting with PMRS
Meeting Objectives
• Evaluation of community assessment/
readiness – 1 hr minutes
• Measurement of improvement in women’s
health and measurement of empowerment
as it pertains to health- 1 hr
Clinical versus public health perspectives on
diabetes (any public health issue)
Characteristics
Clinical Perspective
Public Health Perspective
Problem definition
Individual, lifestyle
Community, public policy,
environment
Target
Self-referred or recruited
samples
Populations and/or high-risk groups
Setting
Medical/specialized clinics
Community environments (work,
schools, primary care, home)
Provider
Trained professionals
Professionals, lay, automated
(internet, 1-800 service)
Intervention
Brief counseling or intensive,
multi-session
Brief, low-cost, self-change focus
Outcome
measure: HgbA1C
Measures: I feel that diabetes does
not interfere with my life: I have
access to affordable food; I have a
supportive community for exercising
Population of eligible
individuals screened
Small percentage
Large percentage
Cost-effectiveness
Lower
Higher
Rabbi Adin Steinsaltz
• "If there is any hope for change in this
world, people must turn to the only thing
that can indeed make a difference:
themselves"
Stages of change
1. Precontemplation: not thinking about change
2. Contemplation: unsure or ambivalent about
change
3. Preparation: ready to initiate change in next
four weeks
4. Action: taking steps toward the behavioral
goal
5. Maintenance: trying to maintain change over
the long term-at least 6 months
Social determinants of health
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Social gradient: the poorest and most disadvantaged are
especially affected. The poorest have the lowest diabetes control.
Copays on medications leads to poorer diabetes control.
Stress: social and psychological environment impact diabetes
control
Early life: importance of a good start in life
Unemployment: job security and satisfaction. Poor job security
impacts diabetes control
Work environment: impacts on health and risk of disease. Lack
of job control impacts diabetes control
Social support: positive role of friendship and social cohesion
Social exclusion: impact of social isolation and relative
deprivation. Rapid community change can impact decrease social
relations thus decreasing diabetes control.
Addictions: effects of tobacco, alcohol and other drugs
Food: access to reasonably priced nutritious food is a community
issue and its lack leads to poorer diabetes control.
Transport: better public transport, reducing driving and
encouraging healthier means (walking, cycling). Lack of culturally
encouraged exercising leads to poorer diabetes control.
Ten great achievements in
Public Health: Adding 25 years
to life expectancy in the
th
20 Century
Vaccination
• Eradication of small pox; elimination of
poliomyelitis; control of measles, rubella,
tetanus, diphtheria, Haemophilus
influenzae type b
Motor-Vehicle Safety
• Engineering efforts making vehicles and
highways safer; personal behavior change
(e.g., using seat belts, child safety seats,
motorcycle helmets, decreased drinking
and driving
Safer workplaces
• Control of environments: e.g., reducing
coal workers’ pneumoconiosis (black lung)
and silicosis; reduction in severe injuries
and death related to mining, construction,
manufacturing and transportation
industries
Control of infectious diseases
• Resulting from clean water and improved
sanitation. Typhoid and cholera
transmitted by contaminated water
reduced dramatically; discovery of
antimicrobial therapy to control
tuberculosis and sexually transmitted
diseases
Prevention of Heart Disease and
Stroke
• Risk factor modification such as smoking
cessation and blood pressure control
combined with improved access to early
detection and better treatment
Safer and healthier foods
• Decreases in microbial contamination and
increases in nutritional content;
establishing food-fortification programs to
eliminate diseases such as rickets, goiter
and, pellagra
Healthier mothers and babies
• Resulting from better hygiene and
nutrition, availability of antibiotics, greater
access to health care, and technologic
advances in maternal and neonatal
medicine
Family planning
• Access to family planning and
contraceptive services has altered social
and economic roles of women; smaller
family size and longer interval between
birth of children; fewer infant, child and
maternal deaths; using contraceptives to
prevent pregnancy and transmission of
HIV and other STDs
Fluoridation of drinking water
• Safely and inexpensively benefits children
and adults by effectively preventing tooth
decay, regardless of socioeconomic status
or access to care
Tobacco prevention
• Recognition of tobacco as a health hazard and
subsequent public health anti-smoking
campaigns changed social norms to prevent
initiation of tobacco use, promote cessation and
reduce exposure to environmental tobacco
smoke. Since the 1964 Surgeon General’s
Repot on the health risks of smoking, smoking
among adults has decreased substantially and
millions of smoking related deaths have been
prevented.
Empowerment: Definition
• increasing the capacity of individuals and
groups to make choices and to transform
these choices into desired actions and
outcomes
Self-Management Goals
• Identify self-management tools, including the
following:
– an action plan that includes goals and describes
behavior (e.g., increasing activity by walking 15
minutes 3 times per week)
– A review of the patient’s personal barriers (e.g.,
too busy to exercise)
– Steps to overcome barriers
– The patient’s confidence level (e.g., on a scale of
1 to 10, how confident are you that you can meet
your goals?)
– follow-up plan
Historical analysis of the development of
health care facilities in Kerala State, India
• Though poor by standards of per capita
income, industrialization or agricultural
production, the Indian state of Kerala has
shown that these constraints need not
hinder the development of social sectors.
The state has achieved near universal
literacy for both males and females and
the health care indices are comparable to
countries with more advanced economies
Illustration
If a team were trying to assess the degree of
political empowerment of women as it pertains to
health, information would first need to be
gathered on the existence of women’s access to
health services. Then the question would be
asked, do women choose to access these
services and why/why not? Finally, the team
would assess the health outcome of these
choices; that is, does the health of women
actually improve?
Empowerment is dependent on interplay of two
inter-related factors: agency and opportunity
structure.
• Agency is defined as an actor’s ability to
make meaningful choices; that is, the actor
is able to envisage and purposively
choose options.
• Opportunity structure is defined as those
aspects of the context within which actors
operate that affect their ability to transform
agency into effective action.
cont
• Making poverty a public, moral, and political
issue often helps the poor gain leverage. Rightsbased approaches are similarly dependent on
politicization. One problem with bringing
empowerment issues into the political sphere is
that political capacity is gained at the cost of
conceding power to a political system and its
own autonomous logic, which may be less than
hospitable to poor people.
Holland and Brook suggest three
types of empowerment indicators:
• data generated through household and
other surveys;
• intermediate and direct indicators derived
from existing survey instruments;
• and indicators not yet captured by existing
instruments.
Human rights are a priori about
power relations.
cont
• despite the ideals of participation, “people
become empowered not in themselves,
but through relationships with outsiders;
and not through the validation of their
existing knowledge and actions, but by
seeking out and acknowledging the
superiority of modern technology and
lifestyles, and by aligning themselves with
dominant cultural forms”
Direct Indicators of
Empowerment
• Direct indicators of empowerment relate to the
four forms of empowerment identified by the ME
study: passive access, active participation,
influence, and control. These indicators measure
empowerment in the following three areas:
• 1) Opportunity to use influence/exercise choice;
• 2) Using influence/exercising choice; and
• 3) Effectiveness of using influence/exercising
choice in terms of the desired outcome.
Three types of quality problems or
‘defects’ in health care:
1.
2.
3.
Underuse: failing to identify conditions or offer
treatments of know effectiveness (e.g., failure in
primary care to diagnose and treat depression in
almost half of cases: Wells et al., 1989)
Overuse: subjecting patients to tests, procedures or
medications that are unnecessary or of questionable
value on scientific grounds (cf., RAND corporation
study, estimated that 30% of acute care is
unnecessary: Chassin et al,. 1987)
Misuse: errors (e.g., medication errors) and poorly
executed tests and procedures (cf., Harvard Medical
Practice Study of hospitalizations found adverse
medical events in over 3% of patients: Brennan et al,.
1991)
Six aims for improvement
• Safe: avoiding injuries to patients form the care that is
intended to help them
• Effective: providing services based on scientific knowledge to
all who could benefit and refraining from providing services to
those not likely to benefit (avoiding underuse and overuse,
respectively)
• Patient-centered: proving care that is respectful of and
responsive to individual patient preferences, needs, and
values and ensuring that patient values guide all clinical
decisions
• Timely: reducing waits and sometimes harmful delays for
both those who receive and those who give care
• Efficient: avoiding waste of equipment, supplies, ideas and
energy
• Equitable: providing care that does not vary in quality
because of personal characteristics, such as gender, ethnicity,
geographical location and socioeconomic status.
Social determinants of health
1.
Social gradient: the poorest and most disadvantaged are
especially affected
2. Stress: social and psychological environment
3. Early life: importance of a good start in life
4. Unemployment: job security and satisfaction
5. Work environment: impacts on health and risk of disease
6. Social support: positive role of friendship and social
cohesion
7. Social exclusion: impact of social isolation and relative
deprivation
8. Addictions: effects of tobacco, alcohol and other drugs
9. Food: access to nutritious food is a political issue
10. Transport: better public transport, reducing driving and
encouraging healthier means (walking, cycling)
Clinical versus public health perspectives on
smoking cessation
Characteristics
Clinical Perspective
Public Health Perspective
Problem definition
Individual, lifestyle
Community, public policy,
environment
Target
Self-referred or recruited
samples
Populations and/or high-risk
groups
Setting
Medical/specialized clinics
Community environments
(work, schools, primary
care, home)
Provider
Trained professionals
Professionals, lay,
automated (internet, 1-800
service)
Intervention
Brief counseling or intensive,
multi-session
Brief, low-cost, self-change
focus
Outcome
Higher quit rates (20-30% over
1 year)
Lower quit rates(5-15% over
1 year)
Population of smokers
reached
Small percentage
Large percentage
Cost-effectiveness
Lower
Higher
Stages of change
1. Precontemplation: not thinking about change
2. Contemplation: unsure or ambivalent about
change
3. Preparation: ready to initiate change in next
four weeks
4. Action: taking steps toward the behavioral
goal
5. Maintenance: trying to maintain change over
the long term-at least 6 months
Miller and Rollnick (1991) describe five basic
principles for enhancing motivation:
1. Express empathy: listen rather than tell
2. Develop a discrepancy: distinguish between
where a patient is now (i.e. risk behavior) and
where he/she wants to be (goal).
3. Avoid argumentation: the force of argument
alone rarely convinces patients
4. Roll with resistance: avoid meeting patient
resistance head-on
5. Support self-efficacy: instill hope and support
patients’ belief that they can change.
The use of these principles requires health practitioners
to take a very different stance (e.g., nonconfrontational)
with respect to the patient. The basic goal is to develop a
‘shared’ understanding of the health issue and to
stimulate the patient’s commitment to change.
Improving the organization
It’s easy to get the players. Getting’ ‘em to play together
that’s the hardest part.
-Casey Tengel
Approximately 85% of opportunities for improvement lie
with system changes such as role assignment, whereas
15% lie with people - Deming
Cohen (1983) found that a simple change in the clinic
routine had a profound effect on physicians’ behavior
regarding preventative care of diabetic patients. Whether
or not the physician performed a foot examination was
largely determined by whether the nurse instructed the
patient to remove his/her shoes and socks before being
seen by the physician. Physicians were almost five times
as likely to examine the feet when patients presented
barefoot (70%) than when wearing shoes (15%).
The Group Health Cooperative of Puget Sound (GHC),
located in Seattle, Washington, is a consumer-governed
Health Maintenance Organization (HMO) with almost
500,000 members residing in the greater Puget Sound
area and approximately 675,000 members overall in
Washington and Idaho. The GHC employs approximately
1000 physicians (40% in primary care). The population
served by the GHC is similar to that in the surrounding
area in terms of age, race, gender distribution and
income. What sets GHC apart from other HMO’s in the
region (and in the country) is its approach to primary and
secondary prevention. Indeed, this focus has been
evident since the GHC’s inception in 1947; the original
bylaws decree:
The Cooperative shall endeavor to develop some of the
most outstanding hospitals and medical centers to be
found anywhere, with special attention to preventive
medicine.
Bicycle safety
This program uses research on barriers to, and
effectiveness of, bicycle helmet use and relies on broadbased community participation to achieve its positive
outcomes. GHC was one of 18 community groups
participating in this campaign, which included extensive
media coverage and discount coupons for helmets.
Participation by primary care physicians in distributing
the discount coupons was a significant component.
Between 1987 and 1992, a 67% decrease was found in
the rate of GHC emergency department attendee head
injuries due to bicycling in the target population of
children aged 5 to 14 years.
The essentials of GHC’s success
Lesson1. Clear vision and direction are essential
to a preventive care provision system.
GHC began in 1947 with a mission statement that
emphasized prevention-quite unique at this time. Guided
by its mission, GHC determined exactly what it needed to
constitute an ideal or ‘gold standard’ system for
preventive care. Clearly articulating the details of a
prevention system ensures organizational cohesiveness,
sets the directions of efforts, plans the route and
establishes the criteria by which an organization tests its
interventions.
Lesson 2. Leadership and on
organizational focus are key
Because a wide variety of GHC departments and
individuals are involved in preventative care, effective
leadership and good communication is critical to ensure
that prevention remains a priority and that preventive
efforts are effectively coordinated.
The work of a Preventive Care Task Force in 1973 led to
the establishment of the Department of Preventive Care.
The Department undertook the following initiatives:
•Committee on Prevention: a broad-based committee
that develops and facilitates implementation of guidelines
and provides implementation oversight.
•Center for Health Studies: conducts epidemiological
and health services research, established by Dr. Edward
Wagner and now lead by Dr. Susan Curry
•Center for Health Promotion: the principal planning
and implementation partner.
Elements of an ideal Preventive
Care System
• A population-based, multilevel planning approach is used.
• Direct your efforts at major causes of morbidity and mortality
as determined by epidemiological research. Consider both the
epidemiology of “needs” (disease and risks) and the
epidemiology of “wants” (desires of patients and practitioners)
• Evidence for intervention effectiveness is available, or will be
generated by well designed program evaluations.
• Functions linked at multiple levels of care: one-to-one,
infrastructural, organizational, community.
• Use prospective and automated programs to the maximum
extent feasible.
• Health is the result of shared decision-making between
practitioners and patients. Informed consent encourages
shared planning and input from patients.
Criteria used to evaluate prevention
issues
1.
2.
3.
4.
5.
6.
The condition (disease/risk factor) is important to the individual and
society. What is the burden of suffering due to the condition (individual,
community, population perspectives)?
The risk factor or disease has a recognizable pre-symptomatic stage.
The natural history of the disease is known.
Reliable methods for detecting the risk factor or disease exist. Consider
screening test validity: sensitivity, specificity, and predictive values.
Intervention effectiveness is considered. Modification of the risk factor or
intervention a the pre-symptomatic stage reduces morbidity and mortality
more than intervention after symptoms appear.
Facilities or capacity to address the identified risk factor or condition
exist.
The cots/harms and potential benefits of implementing a state of the art
approach have been considered.
The intention to perform a behavior
is determined by:
• Attitudes and beliefs about a specific
action and the value attached to the
outcome.
• The person's belief about likely social
reactions (approval or disapproval) from
certain individuals or groups regarding the
behavior, and the person’s motivation to
comply or not with what others think.
Miller and Rollnick (1991) describe five basic
principles for enhancing motivation:
1. Express empathy: through listening rather
than telling
2. Develop discrepancy: between where the
patient is now (i.e., risk behavior) and where
he or she wants to be
3. Avoid argumentation: do not try to convince
patients by the force of your argument
4. Roll with resistance: rather than meet patient
resistance head-on
5. Support self-efficacy: instill hope and support
patients; belief that they can do it (change)
Miller and Rollnick (1991) divide motivational counseling
into two major phases. The first phase, Building Motivation
for change, is directed at patients who are fairly early in
their readiness for change (precontemplation). They may
be reluctant about change or even show marked resistance
at the outset. Using eight related strategies the aim is to
work with the patient in ways that will tip the motivational
balance in favor of change; that is, increase perceived
concerns of change.
Four elements that are common to
successful initiatives include
(Berwick & Nolan, 1998)
1.
2.
3.
4.
Aim: organizational improvement is not seen as an
accident but as the result of a clearly intended aim
Measurement: data collection and feedback show that
a system change has actually resulted in an
improvement
Good Ideas for Change: multiple sources are drawn
upon to identify opportunities and alternatives for
change.
Testing: ideas for change are promptly tested on a
small scale, adjustments are made based on test
results and redesigns are tested in an iterative fashion.
Three organizational prototypes
• Reactive organizations lack direction, have
poor morale and are caught up in the present
‘fighting fires’.
• Proactive organizations are more supportive,
have a clearer sense of purpose, and have
systems aligned to achieve results
• High performing organizations have excellent
morale, a long range vision and emphasis on
continuous improvement throughout the
organization.