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To predict and influence professional cooperation in health care

To predict and influence professional cooperation in health care. Common pool resources and the Price equation:. An evolutionary , CBS- compatible , approach. Gustaf Waxegård , PhD Spec. clinical psychology , The child - and adolescent clinic

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To predict and influence professional cooperation in health care

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  1. To predict and influenceprofessionalcooperation in healthcare Common pool resources and the Price equation: An evolutionary, CBS-compatible, approach Gustaf Waxegård, PhD Spec. clinicalpsychology, The child- and adolescentclinic Växjö Central Hospital, Region Kronoberg, Sweden

  2. The presented research wassupported by FORSS, the Research Council in the Southeastof Sweden; and the R&D-unitof Region Kronoberg, Sweden Pleaserememberyourcredits!

  3. Presentation is based on: Waxegård, G., & Thulesius, H. (2016). Trust testing in care pathways for neurodevelopmental disorders: A grounded theory study. Grounded Theory Review, 15(1), 45-58.Waxegård, G., & Thulesius, H. (2016). Integrating care for neurodevelopmental disorders by unpacking control: A grounded theory study. International Journal of Qualitative Studies on Health and Well-being, 11. doi:10.3402/qhw.v11.31987Conceptualizing professionals’ strategies in care pathways for neurodevelopmental disorders. (Doctoral dissertation).The Price equation explains professional behavior in care pathways for neurodevelopmental disorders. (In preparation)

  4. Whatarecarepathways for neurodevelopmental disorders? Populations of semi-autonomous, interdependentprofessionalsthatarestructuredintogroups and levels, working in a strainedresourcecontextwith an extreme densityof (shared) strategies, norms and rules. Or A multi-professionalsettingusingexpertise to helppeople/patients to deal withcomplex problems. Groups: Clinics; teams; special interest clusters; professions; private social networks; managers; and more. Levels/tiers: Primary/preventivecare; well-childprogramme; generalist psychiatriccare; specializedpsychiatriccare; habilitation; inpatientcare; somaticcare.

  5. Care pathways • Dueto the complexityof ND*, patients movethroughthesestructures , which (ideally) become a carepathway. • *(e. g. APA, 2013; Akutagava-Martins, Salatino-Oliveira, Kieling, Rohde, & Hutz, 2013; Chen, Peñagarikano, Belgard, Swarup, & Geschwind, 2015; Bishop & Rutter, 2009; D'Souza & Karmiloff-Smith, 2017; Feldman & Reiff, 2014; Jones, Gliga, Bedford, Charman, & Johnson, 2014; Lai, Lombardo, & Baron-Cohen, 2014; Thapar, Cooper, Eyre, & Langley, 2013)

  6. Care pathways for neurodevelopmental disorders Well-documentedquality problems across the board • Academicunderstandingof CP:s is theoreticallyfragmented (e g Van Houdt, Heyrman, Vanhaecht, Sermeus, & De Lepeleire, 2013; Van Houdt, Sermeus, Vanhaecht, & De Lepeleire, 2014). • Non-evidencebasedassessment/treatments • Pooraccessabilitytocare • Poorlycoordinatedcare • Under- as well as overdiagnosing going on • Differences in prescriptionofmedicatonacross sites… What is going on?!

  7. I will suggest a theory

  8. Whatarecarepathways for neurodevelopmental disorders? A recap: • A resourcefor professionals; specificallytheyareOstromian CPRs (e g Ostrom (1990/2015) see also Ostrom,1999, 2000, 2010; Ostrom, Burger, Field, Norgaard, & Policansky, 1999; Walker, 2015). • The central resource is non-privatized, non-monopolized: • Improvement in patient Functioning by ApplyingProfessionalExpertise (IFAPE) • Just like anyothernaturalresource! • Collectivelymanaged by manyprofessionals • Highlycomplex and rely on verbal (RFT-)processesto be possibletoextract or mine.

  9. Large Image Price equationdynamics going on inside of a common pool resource

  10. the Price equation E. g. Okasha (2008) MLS1 scenario; McElreath & Boyd, 2007; Baum; 2017 Expectedchangebetweencycles/repetitions Change in a measurabletrait Covariationbetwenfitness and the trait Variation Selection Recurrence/ Heritability

  11. How can I suggest this theory?

  12. 6+ yearsofstudyingprofessionals’ behavior in mental healthcare (ND) pathways • Inductive, bottom-up approach to theoryconstruction • Multi-level data, bothquantitative and qualitiative • Classic GroundedTheory (Glaser 1978; 2001; 2003; 1998/2010) is oneoffew explicit models for systematically generating new, usefultheory for the social sciences. • About as misunderstood and misrepresented as behavorism ;-) • Clearlycompatiblewith CBS-principles (e.g. fit, workability, modifiability, relevance, grab) 1. Do not restrict data and their interrelations untilyouhaveseen/collectedthem. 2. Specify the data and their interrelations cautiously and continually in an on-going comparative process 3. CBS; CPR:s and the Price equation a theoretical ENDPOINT – not a startingpoint

  13. Onemoreslide on method… • Do wesometimesforgetthat CBS/FC reliescompletely on a qualitative, conceptual, stance? Wechooseourvalues; weconceptualizebehaviors and functions; wehonourourphilosophicalroots; etcetera. • Yetquantitativemethodsdominate CBS to the extreme. • CGT (multilevel data; adaptstoemerging data = flexible, allows for nonlinearity; ideosyncratic-inductive; monistic; pragmaticphilosophy in the backboneof the method) morecompatiblewith CBS assumptionsthanmostquantiativemethods in use (linearassumptions; mechanistic, hypothetico-deductive; restrictedtoonetypeof data; no flexibilityafterstudy is started…) • CGT method is actuallyveryreminiscentofhow Elinor Ostromconductedher research. She got the Nobel Prize!!!

  14. Variableprofessional praxis 1 Squeezing Professionalcontrol over strategies, structures and methods in carepathway Increaseefficiency/output, not resources Professionalfitness Unpackingcontrol covariation Ideologizing Variableprofessional praxis 2 Promotingspecificclinical and/or managerialideology. covariation covariation Expandingconstructive space Variableprofessional praxis 3 Social dilemmas Increasedegreesoffreedom in life for patients. covariation Trust testing Isolating Variableprofessional praxis 4 Protect team/workplaceintegrity Monitoringunpackingcommitmentofotherstakeholders in carepathway.

  15. the Price equation E. g. Okasha (2008) MLS1 scenario; McElreath & Boyd, 2007; Baum; 2017 Expectedchangebetweencycles/repetitions Change in a measurabletrait Covariationbetwenfitness and the trait Variation Selection Recurrence/ Heritability

  16. Theoreticaltranslation Collectivelevelselection Individuallevelselection Transmission bias duetogrouppsychologicalmechanisms I.e: Do you get rewarded for contributingtoincreased patient turnover in this organisation?

  17. The (non)spreadof altruism/cooperation in the CPR: How the Price equation explains emergence of cooperative behaviour, according to Turchin (2016). Permission to reprint obtained from the author. Published under the CC-BY-license (https://creativecommons.org/licenses/by/4.0/). Costs for engaging in cooperativebehaviors, selectionbetweenindividuals Dissimilaritiesbetweengroupswithregardto mix ofcooperators vs freeriders Costs for freeriding, selectionbetweengroups Withingroupcompositionofcooperators vs freeriders Positive assortment/”transmission bias”. - +

  18. Insight: The carepathways is (unintentionally) sort ofdesignedto fall apart. Cooperate to compete! Competition! Competition! Competition??? E>Is>Id>S E>S>Is>Id Id>E>Is>S S>Id>E>Is E>Id>Is>S S>Id>E>Is Different weightswithregardtoselectionstrengths on individuals and groupswill be applied in eachlevel, resulting in multilevel selection.

  19. What´thepoint? IFAPE appropriationtheory

  20. General conclusion One parsimonious prediction: The cultural/professional practice most associated with professional fitness will be the one that spreads in the care pathway. Requires deep thinking about how to design care pathways for ND/mental health.

  21. Practical implicationsof the theory: • Go right aheadwith PROSOCIAL and Ostrom’s Design principlestoworktoimprovecarepathways! • Design carepathwaystooptimizecovariationbetween UC and desiredprofessionalbehavior. • Actualcontingenciesdecide, not ”policy” or ”what is desired”. • Evolution in complex adaptive systems such as these is not possibletomicromanage. Professionalnetworking = better. • Confidentlyapply a CBS-perspective in future research. • Most relevant changevariables: • Dialoguequalitybetweenprofessionals in the carepathway • Degreeof match betweenprofessionalcompetence and patient problems • Patient outcomes

  22. Implications I: Ostrom´s 8 principles • Commons-theorists have delineated principles for successful governing of common pool resources (e. g. Agrawal, 2002, pp. 47-70). In the case of Elinor Ostrom (1990/2015, p.90), these are: • Clearly defined boundaries with respect to who can appropriate and to the boundaries of the CPR itself. • Congruence between appropriation and provision rules and local conditions. • Collective choice-arrangements, meaning that most people involved in the CPR have the chance to influence operational, day-to-day rules. • Monitoring. Monitoring of the CPR is in place and the ones who monitors are accountable to, or are, the appropriators. • Graduated sanctions. When any stakeholder free-rides or break operational rules s/he faces effective sanctions. • Conflict resolution mechanisms. These should be of low cost and with rapid access. • Minimal recognition of the rights to organize. Appropriators must not be prohibited to act jointly by external authorities. • Nested enterprizes. For larger CPRs, they should be successfully nested into the larger structures and multiple layers of society which impacts provision, supply, rules, conflict resolution, and more.

  23. Societalnesting CPR-suppliers Individualprofessional Professionalgroup Professionalgroup Individualprofessional Squeezing X Cov? Ideologizing X1 Cov? Unpackingcontrol Expandingconstructive space Professionalgroup X2 Professionalfitness Cov? Individualprofessional Isolating Trust testing X3 Cov? Professionalgroup x-x3 = Viable and replicableculturalprofessionalpractices.

  24. Further CPR-like aspectsofcarepathways for neurodevelopmental disorders: IFAPE is subtractable, renewable and exhaustible. Appropriation problems and provision problems on bothdemandside and supplyside. The principleofdiscount rate applies. Empiricalrules/areas for sound CPR functioningare central. Locallevelcriticallyimportant. Appropriators/ professionalstakehighlyactiverole in management.

  25. CGT corecategoriescomparableto CBS ”middlelevel terms” Functionto orient the readertoward a certaindomainofattempted solution-strategies. Main concern Corecategory Experientialavoidance Hexaflexing/ Psyflex

  26. Monitoringunpackingcommitmentofotherstakeholders in carepathway. Professionalcontrol over strategies, structures and methods in carepathway Unpackingcontrol Trust testing Squeezing Ideologizing Expandingconstructive space Isolating Shielding team or workplace from organizationalchange. Increasingefficiencywithoutincreasingprofessionalresources Useofunpackingcontroltoincreasedegreesoffreedom in life for patients. Promotingspecificclinical and/or managerialideology.

  27. implications II • The PROSOCIAL-framework (Combining ACT matrix & Ostrom’s design principles). • https://www.prosocial.world + add the aspectofUnpackingcontrol, professions theory, and ND complexity on contentlevel. + measure process- and qualityindicators. = Research intervention for NDCP:s.

  28. Studytimeline

  29. The CGT-process

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