On-site collaboratives unify far-flung clinics
On-site collaboratives unify far-flung clinics
After try-it-and-see’ approach, wait times drop
At a health care system as spread-out and diverse as the Mayo Clinic system, implementing change is no easy task. The system spreads over several states and includes the disparate cultures of providers who are new to the organization. All told, the Mayo Clinic system consists of the core hospital and outpatient clinics in Rochester, MN, plus 35 ambulatory care practices and seven hospitals in southern Minnesota, northern Iowa, and western Wisconsin. The ambulatory practices vary in size from single physician offices to full-service medical groups of 150 physicians.
Considering the inherent challenge of implementing change over such a diverse system, encompassing 615 physicians and 9,050 health care workers, decision makers turned to an internal collaborative model. Gene Dankbar, continuous improvement coordinator, figured it could inspire a collection of teams with enough excitement to prompt bold action. At the meetings people would learn the PDSA (plan, do, study, act) model for change. Also, they would increase their content knowledge on the collaborative topic, whether it was reducing wait times or standardizing exam room layout. Between meetings, participants would have regular contact on-line, by phone, and through visits from faculty.
Mayo chose to enact the model in-house rather than sending staff to external collaboratives. The decision essentially came down to cost, but not just travel costs, notes Jill Swanson, MD, a community pediatric and adolescent medicine practitioner in the Mayo system.
"National collaboratives are sometimes planned months or years in advance. But if the passion for change in your organization is there now, and you can’t find a national collaborative [that fits] your goals, you have to reckon with the cost of delay," she notes. Internal collaboratives are flexible enough to catch the organization’s spirit for change at its peak.
For the Mayo system, where some clinics have only one physician, the internal collaborative allows staff to cover for one another and to stagger attendance at collaborative events "rather than sending them all away in one blast," she adds.
The internal collaborative serves multiple teams at the same time. That speeds the infiltration of skills and the sheer delight of making rapid change in patient outcomes and service delivery. The costs include meeting rooms at local hotels; consulting fees for outside experts; food for the attendees; educational materials, such as three-ring binders and handouts; and salaries of the attendees and faculty.
However, the internal collaborative has these drawbacks:
• The odds of breakthrough learning are slightly lower. "It’s harder to sell new ideas when they know you," observes Dankbar.
• Competitiveness could lead participants to withhold knowledge.
• Fear of reprisal could cause people to gloss over problems.
• Lack of experience by meeting facilitators or planners could result in problems with the logistics of team meetings.
Participants in last year’s program gave it a thumbs up. Fifteen of the 20 team leaders responded to an opinion survey; 95% deemed the collaborative model worth continued support and agreed it should be offered to other teams.
To be eligible, applicants for the collaborative had to be interdisciplinary teams. "The faculty outlined the team structure by title," Swanson explains. Included were a physician and a key nursing person such as nurse supervisor. "Sometimes the passion for change came from a nonphysician team member, and that was all right. But the physician still had to be in place as a team member," notes Swanson.
"And we mean firmly in place," adds Dankbar.
In group practices, it was often the physician from the collaborative who introduced changes to staff back at the ranch and piloted the new processes. If that physician was not an active participant in the pilot, "it did not enhance the success of the project," she notes.
Dankbar admits that some doctors inched their way from "healthy skepticism to hearty endorsement. But in time, the vast majority did come around. So don’t give up if you don’t get their full-hearted support early on."
The Mayo Clinic’s strategic plans dictated the long list of collaborative topics. But human factors determined the short list. Topics with implied emphasis on defect reduction — adverse drug events or reducing cesarean rates — didn’t receive wide acceptance. Perhaps they foreshadowed a depth of change for which few clinicians were ready.
But the prospect of doing something for the patient appeared more palatable, at least the first time around. Collaboratives on improving patient access, service delivery, or care of chronic diseases scored heavy participation.
Collaboratives are pricey. Even so, Swanson says the Mayo system can no longer afford to run only one at a time. "We’re pushing for a multicollaborative initiative because we now know how much we can achieve through collaboratives. It costs so much to do them, but it costs so much not to do them," she says.
And who could argue with results like these:
• At one internal medicine office, early morning waiting lines shrank from 18 patients to three patients over a five-month period.
• At another clinic, the wait time for the third available appointment dropped from 21 days to three days over a three-month period.
• At one of the smallest practices, waits for the next available appointment dropped from 14 weeks to two weeks over a six-month period.
With three or four collaboratives running simultaneously, a team that ran aground earlier could hop on and complete its goal. The veterans sometimes act as trainers for current teams.
These insights from Mayo’s experience could increase the probability of success in your next QI project, whether it’s a collaborative or some other approach:
• Clinics, hospitals, or departments, rather than individuals, should sign up for collaborative membership. This sets the expectation that the whole unit will get behind the initiative and follow through on implementation.
• The application process sets the tone for fast-paced, tightly-focused work with:
— written statement of the team’s improvement goal;
— list of team members;
— statement of agreement to the terms of participation, including attendance at meetings, completion of follow-up and reporting assignments, and phone conferences between topic sessions.
• If possible, set time frames of less than one year.
• Assure the teams that any change is provisional until they can determine whether the new way is worth keeping.
• Give people immediate feedback about progress from the teams with visual displays of graphs and charts, as well as brief narrative reports.
• Persuade the CEO to jump-start the collaborative or improvement project with some words of support.
• Don’t let the boss forget about you once the collaborative is under way, Swanson says. "We’ve gained court with our senior leadership by continually supplying them with concrete evidence of improvements. Our goal is for them to amalgamate the collaborative process into strategic plans for the organization."
Need More Information?
For more on implementing internal collaboratives, contact:
Gene Dankbar, Continuous Improvement Coordinator, Mayo Clinic, 200 First St., Rochester, MN 55905-0001. Telephone: (507) 266-2698. E-mail: [email protected].
For more on national collaboratives, contact:
Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215. Telephone: (617) 754-4800. Web site: www.ihi.org.
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