Practice in a networked health care system

1. Practice in a networked health care system David Patrick Ryan, Ph.D. C.Psych. Director of Education, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto

2. Objectives Situate practice as a networked phenomenon Consider the continuum of tight and loosely coupled networks Provide an overview of concepts from network and systems theory Review network analytic tools Reflect on the implications of networked practice for the knowledge to practice process

3. The ubiquitous ‘network’ concept National health networks (see Mur-Veeman et al 2003) Multisite hospital networks Research networks Disease/population focused networks Primary Care Networks Family Health Networks Local Health Integration Networks

4. Network Name Focus Clinical Services Funding Role The Child Health Network population no no Plan, collaboration standard setting Cancer Care Ontario disease yes base Service, research, leadership Ontario Family Health Networks population yes base A managed care network The Cardiac Care Network disease Wait list mgmt project Monitor analyze and advise MOH Northern Diabetes Health Network disease yes base Assess needs, contract services, evaluate, educate GTA Rehab. Network population no no Plan, research, educate, advise ABI Network population data base mgmt mixed Lead, advocate educate collaborate RGP Network population yes and no mixed Advocate educate leadership, service Dementia networks disease no startup   Advocate educate collaborate Some of Disease/Population Networks in Ontario

5. Network studies and related themes Intraspeciality medical networks (Coleman et al. 1966) Networks within practices (Scott et al. 2005) (Miller et al 2001) Comparisons of discipline specific networks ( West et al 1999) Primary care research networks (Mold & Peterson, 2005) Shared care (Hickman et al. 1994) Coordination versus continuity (Pinkerton et al 2004) Inter-teamwork (Ryan, 1996) Communities of practice (Parboosingh, 2002 ) Practice collaboratives (Mittman, 2004)

6. What a difference a decade makes or maybe not “Despite the ubiquity of the network concept in planning programs, the issue of how networks of health care facilities affect the delivery of services has not been intensively studies. Although there are references in the organizational literature . . . very few studies have documented the effects of these programs. . . . Further, the value of network programs in actually improving the dissemination of new treatment technologies or disease management has not been adequately explored on either a theoretical or an applied level” (Fennell & Warenecke, 1988 p.12) “Ever since the seminal work of Coleman et al (1966), networks have been seen as important in the process by which clinicans adopt (or fail to adopt) new innovations in clinical practice. Yet very little is actually known about the social networks of clinicians in modern health care settings” (West et al., 1999 p. 633)

7. Do we need the network concept? Convergent validity – is it different from other organizational forms e.g. are networks different from teams? Heuristic validity - is the network concept rooted in a body of knowledge that has led to useful theory? Operational validity – are there standardized and validated measures? Predictive validity – does the theory and measures predict behavior?

8. On teams and networks

9. The collaboration prerequisite When environments require complex interdependency the quality of collaborative alliances may predict outcomes better than the internal processes of individual teams (Pfeiffer, 86) Just as simply putting health professionals together to work in teams seldom leads to effective teamwork so simply putting teams to together to work seldom leads to effective inter-team collaboration (Ryan, et al. 1996)

10. Words of advice for young people Minimizing variation to reduce error and increase the quality of health care through the use of standardized guidelines “has not been as successful as traditional logic might suggest” (Miller et al 2001) There seems to be little relation between the quality of the evidence and its diffusion into practice(Fitzgerald et al 2002) The ways people actually work usually differ fundamentally from the ways organizations describe that work (Mintzberg & Vander Heyden,, 1999) Our beliefs to the contrary, a great deal of human behavior is illogical (Kruger & Dunning, 1999) (Tversky & Kahneman, 1967) Beneath each espoused culture lies another that is implicit, informal and unacknowledged (Argyris,

11. Social Network Theories Structural holes (Burt) Resource mobilization and connectedness (Lin) Peripheral participation (Wenger) Strength of weak ties (Granovetter) Trust and strong ties (Uzzi) Networked individualism (Wellman)

12. A network analysis diagram (Burt, 1999)

13. Social Network Diagram of a Family Practice (from Scott et al 2005)

14. Social Network diagram of another family practice (from Scott et al 2005)

15. What does this mean for practice networks Practice networks should be construed as a local complex adaptive systems with the high levels of uncertainty, contextual uniqueness and surprise. Like other complex adaptive systems, practice networks self-organize, reveal emergent behavior, and co-evolve. Successful practicse networks minimize errors, make good sense of what is happening, and effectively improvise In this context variation rather than standardization is to be expected and a good coach is essential from Miller et al (2002)

16. Health Professional Advice Network ( from Coleman et al 1966 p. 75)

17. Health professional discussion network (fromColeman et al 1966 p.76)

18. Health professionals friendship network ( from Coleman et al 1966 p. 78)

19. Network character, type of change and prescriptive interventions (McGrath & Krackhardt, 2003)

20. Forming Evolving Maturing Growth Joint planning Program evaluation Joint marketing Expanding service line New services Program integration Efficiency Benchmarking Standard setting Administrative consolidation Shared services Service relocation Value Resource manuals Peer networks Member directory Grant writing Shared investments Common budgeting Resource planning Network stages of development Adapted from Brown et al (2001) Strategic Planning in Rural Health Networks available online at www.academyhealth.org/ruralhealth/ strategicplanning.pdf

21. Please find a copy of the reference list for this talk online at the url below http://rgp.toronto.on.ca/article.pl?sid=05/08/30/1936247