Implementing Change in Hospitals

1. Implementing Change in Hospitals The Technical Assistance & Mentoring Program (TAM) Rivka Gordon, PA-C, MHS Senior Consultant, Technical Assistance and Mentoring Program

2. 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.

3. 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

4. Training & Resource Development Data Collection & Analysis Equipping Primary Areas of Work

5. Training and Resource Development Data Collection and Analysis Equipping Primary Areas of Work Prioritize geographic areas Develop “master mentors” Develop and implement curriculum and training tools Disseminate model to partners 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 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. Four Predictable Stages of Mentoring Negotiation Participation Preparation 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

14. 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

15. 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

16. Criteria for Selecting Participating Institutions • Completion of site assessment • Geographic priority areas • Opportunity windows: • Committed change agent • Clear institutional goals • Commitment to training residents in all technologies • Committed leadership • Appropriate facilities

17. TAM: The Pilot Year May 2005 – June 2006

18. 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

19. TAM: Institutional Picture

20. Participation in TAM Activities • Interventions reached attendings, residents, advanced-practice clinicians and nurses • Between 12 and 74 participants were reported at varying sites

21. Equipping TAM Participating Institutions

22. New York (HHC) Multiple hospitals that are part of a public, urban system Colorado 1 hospital Illinois 3 hospitals, including 1 Family Medicine department, and another OB/Gyn department Pennsylvania 3 hospitals, including 2 University-based centers California 2 hospitals, including one ED; 1 large, multi-center network Texas 2 hospitals, including 1 University-based centers Where TAM Has Worked

23. New York: Objectives • 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

24. New York: Precursors to Success • NARAL Pro-choice New York research and advocacy • 2002 Mayor Michael Bloomberg mandates Women’s Options Initiative • Ipas role established through • Partnerships • Communication • Technical assistance • Mentoring

25. New York: Outcomes to Build Upon • Developed a basic outline for orientation and training • Initial discussions and site assessment • Initial onsite visit • Overview presentation, Grand Rounds didactic and practicum components • Administrative support • Ongoing mentoring relationship

26. 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

27. Chicago: An Institutional Picture • One OB/GYN department • Goal: improve elective abortion care • One Family Medicine department • Goal: provide miscarriage management • Two strong change agents • Collaborated effectively • Strong institutional support

28. 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

29. 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

30. California: Collaborations • Collaborating with partners to expand: • Reach • Potential for service delivery change • Opportunities to foster additional Mentors

31. 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

32. 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

33. 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

34. 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

35. The Future of TAM Moving toward a new system of care for Early Pregnancy Loss

36. 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

37. 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

38. 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

39. TAM Cultural Change Model Disseminate findings High Quality EPL Services throughout the US Monitor & Evaluate Foster relationships with partners Mentoring Ongoing assistance