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{qy=_jnh嵏ތE*(|z1%.ZݠїvBs7._ًF\~m{հ7(WoA2֓͸|3.yu'(_GVP>}o;:/ o<W?? xvq:.VV\xkq2RkPn 7ARgPr5 ͟oh3~es델ls_~??oGynjMw돏n5bvh5ݽZd^O6j֚G9~Қc[8QkOWl]Ws^iE(@񅌚loH5Z䢞]n-u1||Sr7ueAm5w_s܌7jӭ[ꏏn{2Us\nšv\5'jjӭc34 d-2RsF]5gk۵ӭ5ZjǗKk?l9p*._lˎ㋽5ǿ ]sLn;jU5+~eNM>_?QG1i>WH/q̹.ۧ9_jݑE8˸ܭ۾K',쑫.&SƔe-&ps56oʭgG?ÿg-0{ugqz[ޛ?o]}>~GfY=ߙq◖g=Xҿ;,qۚg٧?Oܙ=ؼ/W}ճ*'`!Nj8ʽ516Z6'@{xX;oAۻ8EBAB !G"(yw4"!,! pz ZHHJR\Lr6zoՎ༖(!pnZ5W\} d>d*  04ppp@  G4BdBd}*  0uʚ;0ʚ;<4!d!d@l 0@<4dddd@l 0@<4BdBd@l 0@~0___PPT10 >___PPT9 / 0z#? %O =-5Facilitation in Practice: Location, Level, Intensity60Z6Anne Sales, PhD RN0_AtpDichotomy informs our view of what does and doesn t workFWe know more about how to change individual behavior than organizational behavior Although we don t know much about either Missing  layer may be a clue to why interventions work in one place and not in another The concepts of context and facilitation are probably keys to what works and how@RQRQPDescribing facilitationHuman vs. technological facilitation Human Characterized by hierarchy, roles, other dimensions Technology Almost always requires human intermediationL+4 ,+4 ,QkAssessment of a Quality Improvement Intervention to Promote VA National Lipid Electronic Clinical Remindersl0ZlLAnne Sales Ashley Hedeen Meg Plomondon John Rumsfeld VA HSR&D Service 01-040M0_MRWhy electronic reminders?Hypothesis: Principal reason for gaps in lipid management is lack of provider attention Competing priorities Insufficient time for preventive care Lack of awareness that patient is at risk Data from qualitative study conducted in six VAMCs NYe3Ye3S,Reminders raise awareness and are actionablefElectronic clinical reminders in CPRS deliver patient-centered information to providers at the point of care clinic encounter or visit Meta-analyses describe studies showing that reminders are effective in some cases in increasing amount of preventive care Well-designed reminders allow providers to take action to correct gaps in care through the dialog boxes Interact with order entry, lab and pharmacy data, and draft progress note\ZzZhZJZzhJT8Sample of CPRS reminders: Reminder due list on Notes tab9Z9 U!Initial Dialog: IHD Lipid Profile"" VEvaluation Sites and MethodsfTwo National IHD Lipid Reminders installed in three sites in eastern half VISN 19 (Rocky Mountains) Four sites in western half of VISN used as comparison sites Conducted process evaluation of installation and implementation of reminders in intervention sites over 16 months June 2002 through September 2003>d<d<W%Reminders Require a Two Stage ProcessTInstallation National software patch to local clinical information system VA s information architecture involves local systems with national input Installation was mandated; patches are sequential Implementation Required local IT support Mapping terms Training providers Learning reporting systems  ZZZZ<ZZ <  XImplementing RemindersOne of three intervention sites implemented reminders without effort within a month of intervention starting Two original sites were merged mid-way through intervention period Formed large health care system with tertiary center and several large outpatient clinics Outpatient clinics had implemented reminders within first two months; tertiary site was slower in implementing reminders Third site implemented reminders approximately two-thirds of the way into the intervention period^ZZZyZbZZyb  Y0Use of reminders varied among intervention sitesZ%Information from formative evaluationSites where reminders were not fully implemented were detectable before the end of the project Stopped attending conference calls Poor response to requests for information Defensive reactions to questions about progress&_}_}_More descriptionInternal vs. external Limited vs. holistic Formal vs. informal Other continua& aDw>Internal facilitation: providers/professionals as facilitatorsRoles include Opinion leader Change agent  Facilitator /troubleshooter Convener&BB`External facilitationOutside experts Consultants  Gurus Researchers People from a higher level of the system or organization&YYb!Limited vs. holistic facilitationMay interact with concept of intensity Limited Focus on specific problem or behavior change May also reflect lower level of intensity Holistic Global Focus not on specific, but general behavior changeT/W :/W :Cv7Facilitation and leadership: Formality vs. Informality Primacy of leadership Initiating change Managing change Judging change When is it complete& enough? How to measure successful change N1>1> FxLeadership occurs at all levels-Senior management leadership Formal authority, power structure, hierarchy Mid-level Also authoritative, less power, moderate hierarchical influence Front-line Peer respect and influence, networks Ancillary People connectors, networks, information chain Leadership is often emergent rather than plannedZ-Z Z@Z Z%Z Z/Z1Z- @ %  /1HzQuestion of effectivenessHow are people trained to be effective? What works? What do we know? Need for evidence base here Self-awareness and intentionality Counter to the  Nike/Just do it mentality Goal-orientation and intentionality contribute to ability to work through barriersT(Z9Z"Z~Z(9"~I{More keys to effectivenessFSupport Support groups Realism on the part of micro (local) and macro (senior) leaders that change isn t free Resource commitment is essential Rewards are critical:f6f6J| The dark side Negative opinion leaders Questions of resistance Can arise from many sources: Conflicts over evidence Fear of change Loss of status Lack of alignment of personal priorities with organizational priorities Personal triumphs ego gratification, inappropriate pursuit of powerV1ZZ~ZEZ1~E K}Living in a thunderstormMAnatomy of a thunderstorm cell\Leading edge Middle misery Trailing edge Resistance Terminal resisters  Drug-resistant forms Resistance to change built through successive abortive change efforts Recidivisml)Z Z*ZFZ Z) *F NTools for copingEAdequate planning Anticipation Adequate provisions Sufficient support6 ' 'OFacilitators generallyNeed nurture and support Recognize and plan for barriers Adequate resources and support Recognize that values are important component69.9./pK [ \ ]|;  0` ̙33` ` ff3333f` 333MMM` f` f` 3>?" dd@ |?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> 7767(    6 *  "P *  T Click to edit Master title style! !$  0 *  " *  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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B2  'Quality Enhancement Research Initiative.-՜.+,0L    On-screen ShowVAPSHCS !Times New RomanArial Book Antiqua Arial BlackPresentation1MS Organization Chart 2.06Facilitation in Practice: Location, Level, Intensity9Dichotomy informs our view of what does and doesnt workDescribing facilitationlAssessment of a Quality Improvement Intervention to Promote VA National Lipid Electronic Clinical RemindersWhy electronic reminders?-Reminders raise awareness and are actionable9Sample of CPRS reminders: Reminder due list on Notes tab"Initial Dialog: IHD Lipid ProfileEvaluation Sites and Methods&Reminders Require a Two Stage ProcessImplementing Reminders1Use of reminders varied among intervention sites&Information from formative evaluationMore description Slide 15?Internal facilitation: providers/professionals as facilitatorsExternal facilitation"Limited vs. holistic facilitation8Facilitation and leadership: Formality vs. Informality Leadership occurs at all levelsQuestion of effectivenessMore keys to effectivenessThe dark sideLiving in a thunderstormAnatomy of a thunderstorm cellTools for copingFacilitators generally  Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles _@0cmmillercmmiller  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnpqrstuvxyz{|}~Root EntrydO)PicturesFCurrent UserwSummaryInformation(ERPowerPoint Document(@DocumentSummaryInformation8o