Differences in Team Mental Models Associated With Medical Home Transformation Success.

PURPOSE: Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework. METHODS: We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings. RESULTS: Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps. CONCLUSIONS: Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale.

Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns.

AIM: Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress. METHODS: We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric). RESULTS: A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19-40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one. CONCLUSION: Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.

Improving Access to Care at Autism Treatment Centers: A System Analysis Approach.

OBJECTIVE: The prevalence of autism spectrum disorder is steadily increasing and placing more demands on already overburdened diagnostic and treatment systems. A thoughtful, systematic reorganization of autism service delivery may reduce delays and better meet the growing need. METHODS: Two clinical centers in the Autism Intervention Research Network on Physical Health, Cincinnati Children's Hospital Medical Center (CCHMC) and Nationwide Children's Hospital (NCH), undertook a year-long access improvement project to reduce delays to care by using system analysis to identify sources of delay and to target changes by using a set of defined access principles. Although both sites addressed access, they focused on slightly different targets (reducing number of patients with autism spectrum disorders waiting for follow-up appointments at NCH and reducing delay to new diagnosis at CCHMC). RESULTS: Both sites achieved dramatic improvements in their complex, multidisciplinary systems. A 94% reduction in number of patients on the waitlist from 99 to 6 patients and a 22% reduction in median delay for a new ongoing care appointment were realized at NCH. A 94% reduction in third next available appointment for new physician visits for children 3 to 5 years old was realized at CCHMC. CONCLUSIONS: This article demonstrates that 2 different clinical systems improved access to care for autism diagnosis and follow-up care by identifying sources of delay and using targeted changes based on a set of access change principles. With appropriate guidance and data analysis, improvements in access can be made.