Summer Institute 2010 Deep Dive into Community

1. Summer Institute 2010Deep Dive into Community F. Daniel Duffy, MD, MACP July 31, 2010

2. Why are we here? Present

3. Why are we here? School of Community Medicine Present Future • Access for all • Coordinated care • Complete information • Good communication • Highest quality • Affordable costs • Altruism in care

4. How do we do it? School of Community Medicine Present Future • Access for all • Coordinated care • Complete information • Good communication • Highest quality • Affordable costs • Altruism in care Plan & design

5. YES, BUT…Community Medicine • Moves from isolated and self-interested silos to connectedness and care for the whole • Shifts from problems to be solved to our community’s positive potential • Encourages collaboration in creating the future that cares for the whole

6. Theory U The way in which we attend to a situation determines how a situation unfolds: I attend this way, therefore it emerges that way. Principles and practices for collectively creating the future that wants to emerge. Otto Sharmer, 2009

7. How does the “U” Journey Work? Present Future LISTEN to others and to what life calls us to do EVOLVE ecosystems by acting from the emerging whole SENSE Go to the places of most potential, observe and listen with our minds, hearts and wills wide open CREATEPrototype a microcosm of the new to explore the future by doing PRESENCERetreat and reflect to allow inner knowing to emerge

8. Social activities • Anchoring lectures • Stakeholder dialogues • World-Café: discover the whole • Professional meaning groups • Prototyping the future • Evolving Community Medicine

9. Co-Sensing: Listen, Discover, Connect Anchoring Lectures Learning from the past Dialogue Groups Learning journeys into community Appreciative Inquiry Dialogue, listen deeply, connect with mind, heart, and will wide open PhotoVoice Poverty Simulation Observe, observe, observe; suspend voice of judgment, cynicism, fear Shadowing Patients World Café Allow the system to see itself

10. Appreciative Inquiry Interviews Dialogue focuses on the individual’s or group's most positive potential – not on problems! Our conversations appreciate rather than criticize and judge We inquire to learn with an open mind, open heart and open will.

11. World Café practice • Hospitable Café-like setting • Hosts • Travelers • Meaningful questions • Everyone contributes • Cross pollination • Diverse perspectives • Listen together for deeper insights • Harvest discoveries

12. Co-Presencing: Professional Meaning Our authentic self is in touch with truth, generosity, and love and is the source of inspiration, compassion, and creativity Our public self is shaped by life experiences and masks the authentic self beneath rationalizations, excuses, and resentments that stem from fear, blame, and sorrow in our relationships with each other. • The call to service, to give ourselves to something larger than ourselves, and to become what we were meant to become. Professional Meaning “Presencing” Conversations

13. Co-Creating: Prototype 0.8 • Quickly build an experiential microcosm of the future that needs you to come into being • Present ideas or work in progress before they are fully developed Create prototype 0.8 microcosms • Get feedback to improve it and make it useful • Explore the future by doing rather than by analyzing

14. Co-Evolving: Act as Ecosystem Part Grow innovation ecosystems by seeing and acting from the emerging whole • Systems governed by: • Markets • Hierarchy (regulation) • Networking • New governing system: • Seeing from “presencing” the emerging whole • Acting from our crystallized vision of the future

15. What Have We Learned from Summer Institutes?

16. Summer Institutes 2008 2009 Dr. Clancy’s story Health & community structure Determinants of health Behavior change Ethics & social justice Crystallize a better future • Rationale & Vision for School of Community Medicine • Plight of Uninsured • Vulnerable people need us • Developing knowledge • Moral imperative • Tulsa’s history full of violence and community separation • Social agencies are eager to help – but are uncoordinated • Low density, separated, low social capital, auto, poor air, accidents • Poverty is not a choice, can happen suddenly, is a hard lifestyle • Health care institutions somewhat isolated from community needs • Uninsured patients appreciate access to low cost care

17. Prototypes 0.8 2008 2009 Yo-Yo 96 Frequent flyer – ER clinic CANDLe3 HUB Spanish Immersion Healthy Hornets CHAMP Service-Share Foundation AH-AH i-Volunteer app Life Skills – you can do it Shock Aah, Hugs • Take it to the streets • Electronic portal • Center for behavioral health • Connecting care – Tulsa HIE • Fewer patient more professionals • Go forth and multiply • No senior left aside • Community research infrastructure • Science of cultural competency

18. Healthcare Ecosystem Complex adaptive system integrating human biology economics, socio-political organization, psychological factors, and health care delivery to produce health.

19. The Patient is at the Center of the Health Care Ecosystem

20. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities The structure and function of community government and services affects the health of everyone

21. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Family Food Home Money Spiritual Friends School An individual’s genetics, family, culture, education and society affect health

22. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits Personal Lifestyle choices and access to healthy options affects everyone’s health

23. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits Medical Home Health care begins with a Medical Home

24. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits …and a network of services Pharmacy Lab Tests Medical Home X-Ray Specialist

25. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits …and more services Pharmacy Lab Tests Medical Home X-Ray Nursing Home Hospital Specialist Surgery

26. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits Emergency Pharmacy Lab Tests Medical Home Rehab X-Ray Nursing Home Hospital Specialist Surgery

27. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits Emergency Pharmacy Lab Tests Medical Home Rehab X-Ray Nursing Home Hospital Specialist Surgery

28. Public Health Citizenship Law & Order Safety Agencies Transportation Utilities Child Care Family Food Fat Home Fitness Money Support Spiritual Friends Yoga Leisure School Habits Emergency Pharmacy Lab Tests Medical Home Rehab Research X-Ray Nursing Home Hospital Specialist Surgery

29. Innovations that Improve the Health Care Ecosystem Supplier Process Process Customer

30. Disruptive Technology (LEAN) • Disruption – makes simpler and more affordable • Technology – a way of combining inputs of materials, components, information, labor and energy into outputs of greater value. • Business Model – work that creates value someone will buy

31. Value Stream Map Value to patient

32. Triage 1.------- 2,------- Scheduler 1.------- 2,------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Value Stream Map Value to Patient Report 1.------- 2,-------

33. Triage 1.------- 2,------- Scheduler 1.------- 2,------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Report 1.------- 2,-------

34. Triage 1.------- 2,------- Process Step That Can Be Improved Scheduler 1.------- 2,------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Report 1.------- 2,-------

35. Triage 1.------- 2,------- Scheduler 1.------- 2,------- Nurse 1.------- 2,------- 3.------- Clinician 1.------- 2,------- 3.------- Wrap-Up 1.------- 2,------- 3.------- Check-In 1.------- 2,------- 3.------- Bright Idea For Improvement or Innovation in a Process Step In the Work Report 1.------- 2,-------

36. Prototype 0.8 Solution Poster Title: Patient INFO to EMR Quickly Team: JB.CD. RK. SW. FG HO Issue: Patient repeats history multiple times Future Condition Patient generated form • Background/Measures • Patient survey 50% poor history • Nurse/doctor delays, patient waits Current Condition Repeated questions Countermeasures: Patient Questionnaire Implementation Plan: Task Who When Outcome Forms J.B. 8/1 New form EMR C.D. 8/15 Template Training RK 8/30 “can do” Root Cause Analysis Why? – Tradition Why? – Training students Why? – Habit of practice Why? – Forms in EMR Why? – No time to develop Cost $600 Benefit Save time Rapid Cycle Test of Change IM Clinic Team 1, SW, 9/1-10 Follow-up – Expected Measure Patient wait time drops 50%

37. A small group of committed people can change the world. In fact nothing else ever has! Margaret Mead

38. Enjoy your deep dive into shaping the future of community medicine