An Introduction to Social Networks Methods in Health Services Research

1. An Introduction to Social Networks Methods in Health Services Research AcademyHealth Annual Meetings, 2007 Doug Wholey Health Policy & Management, School of Public Health, University of Minnesota David Krackhardt The H. John Heinz III School of Public Policy and Management, Carnegie Mellon University Social Networks Methods in Health Services Research

2. Presentation Organization • Introduction to social networks methods • Three examples of social networks research in health services research Social Networks Methods in Health Services Research

3. Presenters • Doug Wholey • Professor, Division of Health Policy & Management, School of Public Health, University of Minnesota • David Krackhardt • Professor of Organizations at the Heinz School of Public Policy and Management and the Tepper School of Business, Carnegie Mellon University • Center for Computational Analysis of Social and Organizational Systems (CASOS) • 2007 Summer Institute, June 25 - July 1, 2007 Social Networks Methods in Health Services Research

4. Handouts • Social Networks Resources • Life in the Pentagon • Presentation Social Networks Methods in Health Services Research

5. Introduction to Social Networks Methods David Krackhardt Social Networks Methods in Health Services Research

6. Examples of Social Network Studies in Health Services Research Doug Wholey Social Networks Methods in Health Services Research

7. Examples • Evaluating the Minnesota Cancer Alliance • Collaborator: Michael Pfeffer, MPH candidate • Evaluating an intervention to coordinate agencies providing services to people in prostitution in North Minneapolis • Collaborator: Kate Downing, MPH candidate • Teams and sub-teams in medical practice • Collaborators: David Knoke, Bill Riley, and Amy Wilson Social Networks Methods in Health Services Research

8. Issues in Studying Networks: Identifying Network Boundaries • Realist • Network exists as a social object, there is a defined boundary and membership, there is shared knowledge • Minnesota Cancer Alliance, medical groups, associations, rural health networks, assertive community treatment teams • Nominalist • Network membership is defined by research interests • Agencies serving people in prostitution agencies • Public health systems – organizations providing public health related services in a geographic area Social Networks Methods in Health Services Research

9. Issues in Studying Networks: Which Relationships? • Types of relations • Collaboration • Levels of collaboration • Who do you share information with about program development? • Who do you work with to develop programs? • Who are you collaborating with to obtain funding for programs? Social Networks Methods in Health Services Research

10. Issues in Studying Networks: Relational, Attribute, & Event Data • Relational data • N (actor) x N (actor) matrix • Who interacts with who? • Attribute data • N (actor) x A (attribute) • Can use to construct a relational matrix showing similarity between two actors (same gender, difference in age) • Event/Affiliation data • N (actor) x A (event) matrix • Can use to construct a relational matrix to who who attends the same meetings Social Networks Methods in Health Services Research

11. Issues in Studying Networks: Event Data to Relational Data = A (Event Matrix) AxA’ (Common Attendance) = Use UCINET’s /Data/Affiliations tool Social Networks Methods in Health Services Research

12. The Minnesota Cancer Alliance • A coalition of health care organizations founded in 2005 with the goals of • Reducing disparities in cancer screening and treatment • Improving access to information about locally-available services for cancer patients and their families • Increasing colorectal cancer screening • Increasing the tobacco excise tax and expanding clean indoor air • http://www.cancerplanmn.org/The_Minnesota_Cancer_Alliance.html Social Networks Methods in Health Services Research

13. Comprehensive Cancer Control Collaborative • For cancer prevention and treatment in a community, • Develop a shared comprehensive vision • Eliminate duplications, integrate efforts, reduce organizational and programmatic fragmentation • Plan and implement an evidence based program • Identify gaps and prioritize action • Reallocate resources • Advocate with one voice • “Increased coordination of partner activities and enhanced collaboration” (6). • Leslie S. Given, Bruce Black, Garry Lowry, Philip Huang, & Jon F. Kerner, 2005, Collaborating to conquer cancer: A comprehensive approach to cancer control, Cancer Causes and Control 16(Suppl): 3-14. Social Networks Methods in Health Services Research

14. Evaluation Who is active where? People Organizations How does participation evolve? Who is central in each committee? Who is central across committees? What is the structure of interaction Structure = repeated patterns of interaction Committees Community Health Worker Cervical Cancer Screening Colorectal Cancer Screening Access to Information Health Disparities Steering Committee Evaluation Committee Communications Committee Finance Committee Membership Committee Alliance Evaluation and Committees Social Networks Methods in Health Services Research

15. Methods • Data Source: Meeting Archives • Meeting Attendance • Individual - Organizational • Methods: • Used UCINET to translate affiliation data (copmmon meetings attended) to relational data • Number of meetings attended by both members of a dyad is strength of attachment to committee Social Networks Methods in Health Services Research

16. Health Disparities Committee(Three or More Meetings) Social Networks Methods in Health Services Research

17. Health Disparities Committee(Four or More Meetings) Social Networks Methods in Health Services Research

18. Health Disparities Committee(Four or More Meetings) Social Networks Methods in Health Services Research

19. Colorectal Cancer Committee(1 or More Meetings) Social Networks Methods in Health Services Research

20. Colorectal Cancer Committee(6 or More Meetings) Social Networks Methods in Health Services Research

21. Colorectal Cancer Committee(14 or More Meetings) Social Networks Methods in Health Services Research

22. Further Analyses: Which actors are central across committees? … Disparities Access to Information Cervical Colorectal Social Networks Methods in Health Services Research

23. What Can We Learn from Meeting Attendance • Which members within the committee? • Are there core and peripheral members? • How stable are relationships? • Which actors coordinate/bridge across committees? Social Networks Methods in Health Services Research

24. Next Steps • Initial analyses took advantage of unobtrusive measures: Meeting attendance • Why are some members more involved than others in a committee? • What is the content of the relationship? Watching? Collaborating? • Research to develop a better understanding of committees and involvement • Field experience by Michael Pfeffer • Develop a survey to understand involvement and describe networks better Social Networks Methods in Health Services Research

25. Improving Service Delivery for People in Prostitution • Research and Intervention led by Folwell Center for Urban Initiatives • North Minneapolis, MN • Lauren Martin, Ph.D. • Kate Downing, MPH Candidate Social Networks Methods in Health Services Research

26. The Problem – North Minneapolis and Prostitution • Poverty • Population of Color • Mental Health and Substance Abuse • A doubly stigmatized, vulnerable population Project Focus Area, North Minneapolis Social Networks Methods in Health Services Research

27. The Problem: Service Delivery • Access to Services • Few prostitution specific services • Politics of Delivery • Ideological Barriers • Funding Scarcity • A difficult context to organize Social Networks Methods in Health Services Research

28. The Evaluation • Evaluate an intervention to coordinate agencies • Network Analysis • Understanding the mechanism • Pre-Post Evaluation • Funding search in progress for intervention and evaluation Social Networks Methods in Health Services Research

29. The Evaluation • What does Collaboration really mean? • What does it mean to ‘work with?’ • Asking probing questions: • Do you go to the same meetings? • Do you collaborate on programs? • Do you go after funding together? Social Networks Methods in Health Services Research

30. The Intervention: Northside Women’s Space • A point of connection: • For service providers to work together • For women involved in prostitution to find safety, community and services • The space will offer: • Resource guide • Non-judgmental referral services • Workshops • Safe sex supplies, snacks, etc. Social Networks Methods in Health Services Research

31. The Intervention:Northside Women’s Space • One central actor managing the space • Folwell Center for Urban Initiatives • Kate Downing • Support development and research • Other agencies will staff the space • Adhering to soon available best practices Social Networks Methods in Health Services Research

32. Challenges • The questions we can’t ask… • Maintaining neutrality and building bridges • Developing trust and keeping it • Unknown, invisible population size • A barrier to political will, funding • Identifying agencies to survey Social Networks Methods in Health Services Research

33. More network ties Central node for the Northside Women’s Space Care integration Improved quality of care and service Improved outcomes Success means: Greater visibility of the problem Improvement in service delivery Continuing needs assessment Advocacy for change through collaboration Shift from crisis oriented care to primary prevention Expected Outcome:Northside Women’s Space Social Networks Methods in Health Services Research

34. The Context & Argument Health care is becoming more differentiated New technologies and technicians Professional jurisdictions shifts Care is shifting towards chronic rather than acute conditions Chronic conditions require integration of a large variety of services: Social, mental, and medical services Lack of care integration results in inadequate care for individuals with chronic conditions The Mechanism Care teams Interdisciplinary teams serving a population Task work (service provision) coordinated with team work (systems, coordinating service delivery) Hope Integrated care Greater productivity through reduced waste (lean management, QI) Better patient outcomes Better team member outcomes Care Teams in Medical Practice Social Networks Methods in Health Services Research

35. Care Team Examples • Chronic Care Teams http://www.improvingchroniccare.org / • Assertive Community Treatment (ACT) Teams (http://www.actassociation.org/actModel/ ) • Prepared Practice Teams (http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/ImprovementStories/PursuingPerfectionReportfromHealthPartnersonPreparedPracticeTeams.htm) • Medical Homes and Patient Homes Social Networks Methods in Health Services Research

36. Teams • “A team can be defined as • (a) two or more individuals who • (b) socially interact (face-to-face or, increasingly, virtually); • (c) possess one or more common goals; • (d) are brought together to perform organizationally relevant tasks; • (e) exhibit interdependencies with respect to workflow, goals, and outcomes; • (f) have different roles and responsibilities; and • (g) are together embedded in an encompassing organizational system, with boundaries and linkages to the broader system context and task environment.” • Steve W. J. Kozlowski and Daniel R. Ilgen. 2006. "Enhancing the Effectiveness of Work Groups and Teams." Psychological Science in the Public Interest 7:77-124 (79). Social Networks Methods in Health Services Research

37. Issues in Identifying Care Teams • Boundary specification – who is a team member? • Floaters? Visiting consultants? Anyone who has anything do do with care delivery? • Teams and sub-teams • Assertive Community Treatment & Individual Treatment Teams • Football teams • Formal and informal teams • Emergent teams • Inertial teams Social Networks Methods in Health Services Research

38. Identifying Teams and Sub-teams Social Networks Methods in Health Services Research

39. Using Interdependence to Identify Teams • Organizational theory and complexity theory: “Organizing at the edge of chaos” • Tim Carroll and Richard M. Burton. 2001. "Organizations and Complexity: Searching for the Edge of Chaos." Computational & Mathematical Organization Theory 6:319-337. • David Krackhardt, 1994, "Constraints on the Interactive Organization as an Ideal Type." In Charles Heckscher & Anne Donnellan (eds.), The Post-Bureaucratic Organization. Beverly Hills, CA: Sage, p. 211-222. • Who do you work with to provide patient care? • Work with means that you and the other person are interdependent during work – your actions affect each other directly. It does not refer to the situation where you and the other person contribute separately to clinic performance while you work in the same location. Please answer these questions for all others with whom you work (e.g., physicians, rooming nurses, staff, laboratory technicians, and receptionists). • Patient care means all direct patient care and patient care related activities (e.g., ordering tests, calling in prescriptions, talking with patients on phone). Social Networks Methods in Health Services Research

40. Identifying Teams Using Structural Equivalence • (g) are together embedded in an encompassing organizational system, with boundaries and linkages to the broader system context and task environment. • Groups based on structurally equivalence: “Two nodes are said to be exactly structurally equivalent if they have the same relationships to all other nodes.” • (a) two or more individuals who • At least two actors • (e) exhibit interdependencies with respect to workflow, goals, and outcomes; • Dense interdependence • (f) have different roles and responsibilities; • Occupational heterogeneity • (b) socially interact (face-to-face or, increasingly, virtually) • Informal consulting • Inferred • (c) possess one or more common goals; • (d) are brought together to perform organizationally relevant tasks; Social Networks Methods in Health Services Research

41. A Work With Sociomatrix: Pediatrics Clinic Social Networks Methods in Health Services Research

42. Graphing the Full Sociomatrix: Pediatrics Clinic Social Networks Methods in Health Services Research

43. Structurally Equivalent Actors: Pediatrics Clinic 2 N Occupational Grouping 6 MDs, 1 N 4 N 1 N Social Networks Methods in Health Services Research

44. Graphing the Full Sociomatrix: Family Practice Clinic Social Networks Methods in Health Services Research

45. Structurally Equivalent Actors: Family Practice Clinic 2 MD, 1 ST Teams 2 MD, 2 N 2 MD, 5 N 4 ST 2 MD, 1 N, 2 ST, 1 T N, 3 ST, T 2 ST Social Networks Methods in Health Services Research

46. Predictive Validity for Interdependence Method for Identifying Teams • Informal consulting • is more likely to occur within teams than between teams • Is greater in more cross-functional and interdependent teams • Teams consistent with clinic staffing rules • Pediatrics – pool staffing • Family practice – practice teams • Consistent with organizational and complexity theory • Organizing at the edge of chaos Social Networks Methods in Health Services Research

47. Usefulness of Methodology • Where are sub-teams in • Chronic care teams? • Primary care practices? • Assertive community treatment teams? • How are sub-teams connected? • Is it too many? Process loss and perturbations? • Is it too few? So loosely coupled system is not integrated. Social Networks Methods in Health Services Research

48. Social Networks Research Challenges (And Benefits) • Observing relations rather than actors • Defining network boundaries • Defining relations to measure • Friendship? Respect? Work-with? Helping? • Level of detail • Obtaining high response rates Social Networks Methods in Health Services Research

49. Managerial Benefits of a Social Network Approach • Managing relations is a key function of management • Relations can be managed with relatively simple interventions (staffing) • Measuring networks supports • Accurate understanding of network structure, which supports effective management Social Networks Methods in Health Services Research

50. Research Benefits of a Network Approach • Evaluate interventions designed to integrate care • Understand the black box between formal and informal structure • Paths (or lack of paths) for information flow • Disconnects • Too many connections Social Networks Methods in Health Services Research