Implementing Change in Hospitals

The Technical Assistance & Mentoring Program (TAM)

Rivka Gordon, PA-C, MHSSenior Consultant, Technical Assistance and Mentoring Program

Learning Objectives:

Describe the organizational cultural change model for implementing service-delivery change.

List the components of the mentoring process.

Apply components of the mentoring process to case examples and home settings.

What is TAM?

Cultural change model Provide sustainable technical

assistance and mentoring Result in service delivery change Influence standards around

management of early pregnancy loss

Primary Areas of Work

EquippingData Collection & Analysis

Training & Resource Development

Primary Areas of Work

Training and Resource

Development

Training and Resource

Development

Prioritize geographic areas

Develop “master mentors”

Develop and implement curriculum and training tools

Disseminate model to partners

Data Collection and

Analysis

Data Collection and

Analysis

Identify research questions related to incidence, trends and management of Early Pregnancy Loss (EPL)

Develop sound outcomes targets

Collect program data

Publish and disseminate quantitative and qualitative data

EquippingEquipping

Support and implement systems in hospitals to incorporate MVA

Assist provider systems with group purchasing and product development

Update market analyses

Develop educational and marketing materials for health systems and consumers

History of TAM: 2002

January: NARAL Pro-choice New York advocacy led to Mayor Bloomberg mandate that residents in public hospitals be trained in provision of abortion care.

March: Ipas visits 5 NYC hospitals

May: Ipas and partners lobby NY City Council for funding, resulting in $2.1 million for construction of Women’s Options Center at Kings County Hospital

History of TAM: 2003

January: HHC system-wide Grand Rounds; Improvements in Family Planning and Abortion Care at Jacobi Hospital

March: Lincoln Medical and Mental Health Center – Grand Rounds Practicum and Clinical Training

History of TAM: 2004

January: Queens Hospital Center – Grand Rounds, Practicum, Clinical Training

September: Dedication Women’s Options Center at Kings County Hospital

November: Kings County Hospital – Grand Rounds, Practicum, Clinical Training

December: Coeytaux & Wells Report completed

History of TAM: 2005

January: Service Delivery Handbook and Toolkit for Management of Pregnancy Loss and Abortion developed

February: Elmhurst Hospital – Grand Rounds, Practicum, Clinical Training

March/April: APGO meeting & NAF meeting → requests for Ipas mentors

January - May: TAM Project Planning

History of TAM: 2005, cont.

May 15 – 17, 2005:

Technical Assistance and Mentoring Project Training

8 clinicians participated(OB/Gyn, Family Practice, Pediatrics, CNM, PA)

Training vs. Mentoring

Mentoring and training strategies complement one another for service delivery change

Training-Brief and finite period of time

-Outcomes relate to knowledge and skills

Mentoring-Sustained process

-Outcomes relate to relationship building and support

A Combined Strategy

Mentoring clinicians and health systems through service delivery change

Training clinicians to safely and effectively perform outpatient uterine evacuation

Developing and disseminating tools and resources to assist in service delivery change

Advocating for improved standards and guidelines

Four Predictable Stages of Mentoring

Preparation

Negotiation

Participation

Closure

Explore motivation, skill level and learning needs

Create an agreement and a work plan

Practice, build competency and confidence levels

Transition on-going responsibilities to continue at institution

Criteria for Selecting Mentors Involvement in successful integration of

MVA into ambulatory settings Current MVA trainer Ability and willingness to complete scope of

work Personal characteristics

Listening, flexibility, devotion to high quality care, ability transfer passion, ability to appreciate and affirm personal / organizational diversity

Criteria for Selecting Change Agents Participation in Ipas hospital assessment

and/or request for Ipas technical assistance Current engagement in effect staff

relationships Willingness to meet expected level of

commitment: Weekly listserve participation Coordinated telephone communication with

Ipas mentors Coordinated site visit with Ipas mentors

Criteria for Selecting Participating Institutions

Completion of site assessment Geographic priority areas Opportunity windows:

Committed change agentClear institutional goalsCommitment to training residents in all

technologiesCommitted leadershipAppropriate facilities

TAM: The Pilot Year

May 2005 – June 2006

Pilot Year: Results

Performed interventions at 25 institutions, 22 of whom are engaged in ongoing work with TAM

Approximately 450 clinicians and staff participated in TAM activities

More than 20 active Change Agents work together and with Mentors to influence service delivery change

TAM: Institutional PictureTAM Institutions

N=22

Private36%

Public64%

0 2 4 6

Non- Profit

For Profit

Unknown

Private Institutions

o Interventions reached attendings, residents, advanced-practice clinicians and nurses

o Between 12 and 74 participants were reported at varying sites

Participation in TAM Activities

Equipping TAM Participating Institutions

Equipping hospitals where the TAM worked 2005-2006 current as of the end of FY 2006

Location of the Institution FY 2005 Sales FY 2006 Sales

New York City: Multiple Hospitals $5179 $13,666

Texas: 2 Hospitals $853 $5135

Pennsylvania: 2 Hospitals $0 $892

Colorado: 1 Hospital $0 $2,384

Illinois: 2 Hospitals $0 $6038

California: 2 Hospitals $0 $30

TOTAL $6,032 $28145

New York (HHC)

Multiple hospitals that are part of a public, urban system

Pennsylvania

3 hospitals, including 2 University-based centers

Illinois

3 hospitals, including 1 Family Medicine department, and another OB/Gyn department

California

2 hospitals, including one ED;

1 large, multi-center network

Colorado

1 hospital

Where TAM Has Worked

Texas

2 hospitals, including 1 University-based centers

Improve quality of abortion and miscarriage services delivered by public hospitals that serve poor and marginalized women in NYC

Increase the number of clinicians trained to provide abortion services in the US by institutionalizing abortion training in teaching hospitals in NYC

Document Ipas’s service delivery improvement model of dissemination and replication in other areas of the US

New York: Objectives

NARAL Pro-choice New York research and advocacy

2002 Mayor Michael Bloomberg mandates Women’s Options Initiative

Ipas role established throughPartnershipsCommunicationTechnical assistanceMentoring

New York: Precursors to Success

Developed a basic outline for orientation and trainingInitial discussions and site assessmentInitial onsite visitOverview presentation, Grand Rounds

didactic and practicum componentsAdministrative supportOngoing mentoring relationship

New York: Outcomes to Build Upon

Chicago

An example of the potential for change in service delivery due to concentrated mentoring efforts

Mentors and Change Agents worked deliberately through the four predictable stages

Change Agents at different institutions collaborated and supported one another

Chicago: An Institutional Picture

One OB/GYN departmentGoal: improve elective abortion care

One Family Medicine departmentGoal: provide miscarriage

management Two strong change agents

Collaborated effectivelyStrong institutional support

Chicago: Mentoring and Training Activities

Pre-intervention visits Grand Rounds on miscarriage

management MVA in-service MVA pelvic model practicum MVA clinical training Journal club

California: New Frontiers

Taking TAM to larger systems Leveraging built-in monitoring systems Piloting a model for Emergency

Departments Collaborating to influence professional

guidelines Leveraging built-in monitoring systems Broad, diverse geographic reach

California: Collaborations

Collaborating with partners to expand:ReachPotential for service delivery changeOpportunities to foster additional

Mentors

California: Reaching New Systems of Care Geographically diverse, multi-facility HMO

More than 3.2 members in region Member of large national organization

8.4 members enrolled nationally Provides care in 30 medical centers 8 Residency Programs 431 offices 11,000 physicians

Capacity for internal data collection and documentation

Based on 2005 data

Success Stories

“ Tension at our site was lowered because we spent so much time together – multiple interactions solidified trust and by the time we were really working on MVA, we were already ‘in’. It was good to talk with people who we perceive to be barriers to change even if working with them won’t bear any fruit – they are glad to be included as part of the team intervention now, and could be bigger barriers in the future if not included.”

-Change Agent, Chicago

Success Stories

“ After Ipas’s work with us, we now care for all our women ‘the Ipas way.’ We are using much less anesthesia, providing them with all options, and making sure they have birth control immediately after their procedures. We have seen a dramatic change.”

Chief of OB/GYN, Large urban public hospital

Success Stories

“ Two days ago, in OB triage, I had an Hispanic, non-documented patient with no financial support, missed abortion and no resources, desperate for help that I felt so lucky to be able to use my MVA since OR and L&D were booming and we could not utilize the OR even if we wanted to. It worked great, and I got to train one of the other 2nd year residents on it. It’s great. She was so appreciative and her family was so grateful. She almost had no pain. When I told her we were done, she could not believe it.”

- Change Agent, 3rd year OB/GYN resident, Texas hospital

The Future of TAM

Moving toward a new system of care for Early Pregnancy Loss

Institutional Change

Sustain and improve mentoring process

Continue to work in priority regions Focus on systems of care, to

influence more settings Monitor and evaluate changes Collect and disseminate findings

Monitoring and Evaluation

Build capacity of TAM Research Core

Develop map of priority research questions

Collect baseline data and ongoing data at intervention sites

Disseminate findings

Influence Professional Guidelines

Work with partners Utilize data from intervention sites Collect and synthesize evidence-

based standards of care Present findings to institutions

responsible for setting professional guidelines

TAM Cultural Change Model

High Quality EPL Services throughout the US

Monitor & Evaluate

Mentoring

Ongoing assistance

Foster relationships with partners

Disseminate findings