Summer Institute 2011Deep Dive into CommunityF. Daniel Duffy, MD, MACP

July 31, 2011

Why Community Medicine

Present

OK

Why are we here?

Present

OK

Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in care

Future

How might we do it?

OK

Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in care

Present Future

School of Community Medicine

How do we build it?

OK

Access for all Coordinated care Complete information Good communication Highest quality Affordable costs Altruism in service

Plan & design

Present Future

School of Community Medicine

Community Medicine is a Movement 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

Theory U

The way in which we attend to a situation determines how a situation unfolds: I see it this way, therefore it emerges that way.

Principles and practices for collectively creating the future that needs us to emerge.

Otto Sharmer, 2009

How does the “U” Journey Work?

LISTEN to others and to what life

calls us to do

SENSE Go to the places of most potential, observe and listen with our minds, hearts and wills wide open

CREATE Prototype a microcosm of the new to explore the future by

doing

EVOLVE ecosystems by acting from

the emerging whole

PRESENCE Retreat and reflect to allow inner knowing to emerge

Present Future

Co-Sensing: Listen, Discover, Connect

Dialogue GroupsDialogue Groups

Appreciative InquiryAppreciative Inquiry

Shadowing PatientsShadowing PatientsPoverty Simulation Poverty Simulation

Windshield SurveyWindshield Survey

Observe, observe, observe; suspend voice of judgment, cynicism, fear

Dialogue, listen deeply, connect with mind, heart, and will wide open

Harvest the themes of the whole system

Go out and see the community

World Café World Café

Anchoring LecturesAnchoring Lectures Learning from the past

Appreciative Inquiry Interviews

We use Dialogue to focus on the individual’s or group's most positive potential – not on their problems!

We inquire in order to appreciate another’s experience with an open mind, open heart and open will.

Our conversations appreciate rather than criticize and judge

Patient Dialogue

Challenges you face with your health

 Works well to help you Someone we should

recognize for helping you?

Other people or things that have helped you

Just one thing that would make the healthcare you receive better

Windshield Survey

Provider Dialogue Describe team’s

observations from patient How you and your practice

team help patients cope  What works well   Someone we should

recognize for their help  Challenges you face  Community agencies or

services enlisted  to help Just one thing that might

improve healthcare

Social, Healthcare, & Public Services Describe team’s

observations about challenges and successes

How you or your agency help patients and providers 

What works well  Someone we should

recognize for good work  Challenges you face  One thing you would change

to improve your service

Experiencing Others’ LivesPoverty Simulation Shadowing Patients

World Café Hospitable Café-like

setting Hosts Travelers

Answer meaningful questions about healthcare ecosystem

Everyone contributes Cross pollination Diverse perspectives

Create a summary Harvest themes about the

whole system

Patient, Provider, Social, Healthcare & Public Service Agency ObservationsTeam

Health ChallengesServices Provided

Works Well

Recognize ChallengesJust One

Thing

Themes about the Whole SystemINTERVIEW MAJOR THEME

Patient

Provider

Social Services

Healthcare Services

Public Services

Unifying Theme

Co-Presencing Professional Calling

Reflection on Professional Calling for our Lives

What are we collectively sensing about the professionals we being called to become?

How have we been moved by our travel into our community and our dialogue with patients, providers,

social, healthcare, and public services?

What service that is larger than ourselves are we being called upon to freely give ourselves to?

Wednesday Noon Start UP the U Observe prototypes of

community-based participatory action research

World Café What did you learn

from the research? What do agencies

need from us in healthcare ecosystem?

Co-Creating: Prototype 0.8

Create prototype 0.8 microcosms

Explore the future by doing rather than thinking about it

Quickly build an experiential microcosm of the future that needs you to come into being

Present work in progress before being fully developed

Get feedback to improve it and make it more useful

How will we build Prototypes 0.8? Marketplace of ideas

Self selected groups attracted to an idea

Group builds prototype Develop a prototype

microcosm of the future that prevents the problems of the present

Stakeholder feedback Select prototypes with

greatest potential

Prototype 0.8 Solution PosterIssue: Patient repeats history multiple times

Background/Measures• Patient survey 50% poor history• Nurse/doctor delays, patient waits

Root Cause AnalysisWhy? – Tradition Why? – Training students

Why? – Habit of practiceWhy? – Forms in EMR Why? – No time to

develop

Repeated questions

Current Condition

Future ConditionPatient

generated form

Title: Patient INFO to EMR Quickly

Team: JB.CD. RK. SW. FG HO

Countermeasures: Patient Questionnaire

Implementation Plan:Task Who When OutcomeForms J.B. 8/1 New formEMR C.D. 8/15 TemplateTraining RK 8/30 “can do”

Cost $600 Benefit Save time

Rapid Cycle Test of ChangeIM Clinic Team 1, SW, 9/1-10

Follow-up – Expected MeasurePatient wait time drops 50%

Prototype Feedback Rating FormCATEGORY QUESTION Rate 1 (lowest) to 10 (highest)

Issue Is the issue statement clear?

Background/Measures Do background data or measures describe issue?

Current Condition How easily can you grasp the current condition?

Root Cause Analysis Has analysis identified the root cause of the issue?

Title and Bylines Is the Prototype titled, with authors &date created?

Future Condition How quickly can you grasp the future condition?

Implementation Plan Are tasks for “bringing to market” specified?

Cost Benefit Analysis How realistic is the cost & benefit analysis?

Follow-UP How effective is prototype as a microcosm of a future health care system?

Overall Design How well designed & user friendly is the prototype?

Prototype Poster

Prototype Poster Presentation

Co-Evolving: Act as Part of Ecosystem Grow innovation

ecosystems by seeing and acting from the

emerging whole

Systems governed by: Markets Hierarchy (regulation) Networking

Added governing force: Seeing from “presencing”

the emerging whole Acting from our crystallized

vision of the future

What Have We Learned from Summer Institutes?

Concepts from Anchoring Lectures OU-Tulsa committed to improving health & healthcare

Government leaders need our help in making wise policy Everyone can become vulnerable and need help from others OU-Tulsa can focus its discovery on the health of community The helping professions have a moral imperative to service

Dr. Clancy told of taking psych care from hospital to street The structure of community profoundly influences its health Social determinants of health change our genes Personal health habits cause disease and can be changed Market driven healthcare conflicts with ethics & social justice We can crystallize a vision for a future healthcare ecosystem

Early childhood education & trauma impact adult health Research is both innovation & system improvement Change in laws may change the healthcare ecosystem Successful collaboration yields healthcare results

2008

2009

2010

Lessons from Community Dialogues Tulsa’s history full of violence and community separation Social agencies eager to help – but disconnected from primary care Poverty is not a choice, can happen suddenly, is a hard lifestyle Health care institutions seem to be isolated from community needs Uninsured patients appreciate access to affordable careCollaboration changes health and healthcare We find it hard to appreciatively listen to each other Photovoice gives the silent members of our community a voice Moving from idea to prototype to system change is very hard work

Interdisciplinary education, care, and researchHealthcare Policy – Medicaid

Sooner HAN, Diabetes Bridge Clinic – coordination of carePatient Centered Medical Home – pay for coordination

Community-wide Health Information Exchange – MyHealth

Take it to the streets – Put a Bedlam clinic

at KIIPP Academy and use Community

Advocate to build trust

Prototype 0.8 2008Electronic Patient Portal – Improve access to care for

Bedlam patient with a patient portal to be

used for online visits

Center for Behavioral Health – Coordinate services for health behavioral

change, education and research in field Connecting Care –

Develop a Tulsa Health Information Exchange to “wire” Tulsa healthcare

services

Fewer Patients More Professionals – High

School Health & Health Career Development

Go Forth and Multiply – Create a

center for Geographic Information Systems to geo plot services across community

No Senior Left Aside - Community-based education in early

dementia with referral to services for help

Community Research

Infrastructure Faculty development and

resource tools and pilot project funding

Science of Cultural Competency–

Develop a curriculum in cultural competence

for OU Tulsa

YO-YO 96 – Community education

program that helps people prepare for self

sufficiency in a disaster

Prototype 0.8 2009Frequent Flyer ER

Clinic – Interdisciplinary team

clinic for care coordination of

frequent ED users

CANDLe3 – Interdisciplinary team

helps vulnerable neighborhoods learn

how to improveHUB – Program to build neighborhood

trust, through school-based clinic, health education, and safe

play

Spanish Immersion – Plan for elective in

conversational medical Spanish for

students and residents

Healthy Hornets – School-based medical

clinic and health education in high

school CHAMP– out of school enrichment

activities, leadership development and

community renewal for kids.

Service Share Foundation – Web based activity that

connects persons with social services

AH AH – Web-based social service agency contact database and

opportunities to volunteer

iVolunteer APP – An iPHONE application like UrbanSpoon that selects opportunities

for volunteering & rating them

Life Skills – You Can Do It Implementation

at Bedlam the N4N program that teaches life skills to the poor

Shock, Aha, Hugs – Day-long course for students, residents,

faculty, & staff to understand the lives of

patients served

Create Jobs in North Tulsa – Partner to create economic

opporutnities in North Tulsa

Prototype 0.8 2010Tulsans Teaching Tulsans Conduct

Community Forums to spreads knowledge about community

services

Soonergy – Bedlam-E patients get social service screening,

referral, SW follow-up

Filling the Gap – Mobile (1 stop) clinic provides preventive

care for children

OU-Bedlam Patient Portal - Virtual

Bedlam & Blog e.g. implement “DocVia” in

Bedlam

Breast Feeding is Best – Provide pre-natal and post-natal

education and support in OU ClinicsLay Health Liaisons

corrects inefficiencies of knowledge silos in the medical model &

encourage community collaboration -

Tulsa Community Connection –

Program for helping people find social

service in their neighborhood

Healthy Providers – Partner with providers, staff, and patients to develop role models

for healthy livingOKIE- Oklahoma

Knowledge Is Empowerment:

Health education & literacy program through libraries

YOUR Bus – transportation

resources to visits with videos & information on Bus – team with

OKIE

Immerse Yourself in Tulsa – Implement a program to engage

faculty, staff, students in volunteerism in

Tulsa

Healthcare Ecosystem

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

PhotoVoice – Celebrating Community

Enjoy your deep dive into shaping the future of community medicine