Fostering Implementation o f Sta ff s Creative Ideas to Improve - - PowerPoint PPT Presentation

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Fostering Implementation of Staff’s Creative Ideas to Improve Patient Health Care Experiences

Yuna S.H. Lee, PhD, MPH

Yale School of Public Health Current Affiliation: Columbia Mailman School of Public Health

Paul D. Cleary, PhD, MS

Yale School of Public Health

Ingrid M. Nembhard, PhD, MS

Yale School of Public Health and Yale School of Management

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• New ideas to improve the quality of health care delivery needed (Institute
• f Medicine 2012)
• Many aspects of U.S. health care benefit from innovation: ideas,

practices, policies or technologies that are new to the context (Rogers, 2003)

• Creativity, the generation of novel and useful ideas (Amabile, 1988), is required

for innovation, and may be useful for quality improvement

Background

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Fostering Creativity for Quality Improvement

• Many health care organizations encourage their clinical staff (e.g.,

physicians, nurses) to generate creative ideas for quality improvement

(Terwiesch, Mehta and Volpp 2013)

• Improving patient care experiences is a quality improvement priority

(Agency for Healthcare Research and Quality, 2015)

• Fostering creative ideas requires organizational effort
• Creative ideas may pose tension in health care settings (Gilson, 2005)

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Issue: Little is known about creativity in health care organizations.

• 1. To examine the impact of implementation of creative ideas
• n patient care experiences
• 2. Relationship between idea creativity and implementation
• 3. Moderators of the relationship between idea creativity and

implementation

¡ Research Aims

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+ +

¡ ¡ ¡ ¡

¡

Staff-legitimizing Factors Idea Creativity

Collaboration

Organizational Tenure Network Centrality Creative Idea Implementation Patient Care Experiences

• +

+ + +

Conceptual Framework

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Study Setting

• 12 federally qualified community health centers (CHCs) in one system,

in one state

• Provide comprehensive primary care services to over 130,000 patients

a year

• CHCs involved in an improvement initiative from September 2013 to

March 2015

§ Initiative focused on generating and implementing ideas to improve patient care experiences

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Study Design

220 improvement ideas generated 72 improvement team members from 12 CHCs 2,201 patients cared for by these individuals

Longitudinal (18-months), mixed-methods study

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Study Data

• Patient Care Experiences Survey
• Improvement Team Meeting Transcripts
• Staff Work Experiences Survey
• Wearable Sociometric Sensors

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Variable type Variable and Source Measured by Dependent Variable Patient Care Experiences (source: patient survey)

• Care Coordination (items)
• Provider Rating

Independent Variable Proportion of high-creativity implemented ideas per center (source: meeting transcripts)

• Each idea rated for novelty and usefulness
• Averaged creativity scores per idea across 5

raters (Icc=0.79)

• Per center: # of high-creativity ideas

implemented / total ideas Covariates Patient-level covariates (source: patient survey)

• Age, gender, education, race/ethnicity,

length of relationship, number of visits

• General health status, mental health status

Center-level covariates (source: patient survey, meeting minutes, staff survey)

• Percent of patients’ uninsured, percent of

patients with Medicare, patient visits per full-time employee

• Total number of ideas
• Psychological Safety

Methods: Analysis 1

Multivariate, mixed models (clustered at provider and center-level)

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Implementation Outcome/Level of Creativity Low Creativity (score <3) High Creativity (score ≥ 3) Idea Implemented Identify local community partners and develop a resource with contact details Set up iPad in waiting room with tutorial on patient portal to increase adoption of patient portal at home Idea Not Implemented Schedule weekly meeting between medical assistant and primary care provider Staff create a podcast to educate patients about managing hypertension

Examples of Improvement Ideas

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Dependent ependent Var ariable iable Car are C e Coor

• ordination

dination (out of 5)

• ut of 5)

Provider R vider Rating ating (out of 10)

• ut of 10)

Independent ndependent Var ariable iable β (SE) (SE) β (SE) (SE) Proportion of high-creativity, implemented ideas per center 1.33 (0.56) ** 2.15(0.96) ** Implementation of creative ideas is positively associated with better patient care experiences

N = 2,201; *p<0.05, **p<0.01, additional covariates included in analyses but not shown

Results: Analysis I

Correlations Full Model

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Variable type Variable and Source Measured by Dependent Variable Idea Implementation (source: meeting transcripts) Idea implemented Independent Variable Idea Creativity (source: meeting transcripts) Average creativity score per idea Moderating Variables Collaboration (source: meeting transcripts) Two or more people jointly raised idea Organizational Tenure (source: staff survey) “How long have you been employed?” (Less than 6 months” to “10 or more years” Network centrality (source: wearable sensors) Betweenness Centrality=normalized (0-1) number of times an individual acts as a bridge along the shortest path between two other individuals (Wasserman & Faust 1994) Covariates Staff-level covariates (source: staff surveys) § Professional role (primary care provider, nurse, medical assistant, behavioral health provider), § Gender Center-level covariates Center fixed effects

Methods: Analysis II

Cox Proportional Hazards Models (clustered at staff and center-level)

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Dependent ependent Var ariable iable

Independent ndependent Var ariable iable Idea Idea Implementation mplementation Hazar Hazard R d Ratio ( atio (CI) CI) Idea Creativity 0.40 (0.28-0.55) **

N=220; *p<0.05, **p<0.01, additional covariates included professional role, gender and center

Idea creativity is negatively associated with idea implementation

Results: Analysis II

0 ¡ 0.05 ¡ 0.1 ¡ 0.15 ¡ 0.2 ¡ 0.25 ¡ 0.3 ¡ 0.35 ¡ 0.4 ¡ 0.45 ¡ 1 ¡ 2 ¡ 3 ¡ 4 ¡ 5 ¡ Idea ¡Implementa+on ¡Hazard ¡Ra+o ¡ Idea ¡Crea+vity ¡

Idea Cr Idea Creativit eativity and Idea I y and Idea Implementation mplementation

Correlations Full Model

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Results: Analysis II

Full Model

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Key Findings

• Paradox of creative idea implementation in health care
• Understanding how creative ideas may improve the organization and delivery of

care could inform ongoing efforts to discover and evaluate new ideas

• Resistance to creativity in health care similar to other industries
• Legitimizing factors may serve as countervailing force
• Generation and implementation of creative ideas are different

processes, with each process affected by different staff characteristics and behaviors

• Creativity in health care organizations requires focused, concerted effort

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§ Cannot conclude causal relationship nor specify if individual ideas had direct impact on patient care experiences § Results may not generalize to all primary care clinics § Intra-organizational factors that may affect implementation not included

Study Limitations

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For Health Services Research

• Clinical staff may play key role in quality improvement
• Implementation science frameworks may need to consider idea creativity

For Organizational Research

• Health care studies may provide new insights for creativity research
• Greater need to study staff dynamics associated with successful creative idea

implementation

For Health Care Managers

• Value in promoting staff creativity to improve quality improvement
• Need to dedicate effort to foster and facilitate creativity

Implications

This research contributes to our understanding of why creativity matters, and why it should matter to health care

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Thank you!

yuna.lee@yale.edu / ysl2118@cumc.columbia.edu

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• In the last 6 months, when this provider ordered a blood test, x-ray or other

test for you, how often would someone from this provider’s office follow up to give you these results?

• In the last 6 months, did you get the help you needed from this provider’s
• ffice to manage these different providers and services?
• In the last 6 months, how often did the provider named in question 1 seem

informed and up to date about the care you got from specialists?

• In the last 6 months how often did you and anyone in this provider’s office

talk about all the prescription medicines you were taking?

Care Coordination Items

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

• 1. Care Coordination
• 2. Provider Rating

0.43**

• 3. Percentage of

high-creativity ideas 0.18** 0.09**

• 4. Percentage of

high-creativity, implemented ideas 0.23** 0.09** 0.85**

• 5. Length of

relationship 0.12** 0.15** 0.10** 0.04

• 6. Number of office

visits

• 0.04*

0.04*

• 0.05**

0.03

• 0.01

7 Rating of overall health 0.11** 0.14*

• 0.13**
• 0.01

0.01 0.13

• 8. Rating of mental

health 0.04 0.12

• 0.11**

0.01

• 0.03

0.12* 0.53*

• 9. Age

0.04 0.04 0.01 0.05* 0.08*

• 0.06*

0.14* 0.10*

• 10. Gender
• 0.03

0.02

• 0.05*
• 0.02

0.01 0.08* 0.02 0.02

• 0.10*

11 Education

• 0.01

0.03 0.04

• 0.03

0.05*

• 0.03*
• 0.01

0.02 0.02 0.06*

• 12. Race
• 0.05
• 0.06
• 0.04

0.03

• 0.03*
• 0.01

0.12* 0.17* 0.15* 0.01 0.23*

• 13. Percent patients

white

• 0.10*

*

• 0.06**
• 0.02
• 0.52*

0.09

• 0.06

0.01

• 0.01

0.17* 0.02 0.12*

• 0.06*
• 14. Percent patients

uninsured 0.04 0.02 0.07** 0.19**

• 0.02

0.06

• 0.07*
• 0.02
• 0.01

0.03 0.02

• 0.03
• 0.08*

`15. Number of visits per FTE 0.14**

• 0.05
• 0.04

0.22**

• 0.03

0.03 0.003

• 0.04
• 0.03*

0.01 0.01

• 0.05*
• 0.02*

0.28*

• 16. Number of ideas

per center 0.03* 0.02 0.02 0.15**

• 0.04

0.04

• 0.03

0.01

• 0.01

0.05

• 0.08

0.01

• 0.63*

0.43* 0.03*

• 17. Psychological

Safety 0.13** 0.03 0.40** 0.60 ** 0.01

• 0.02
• 0.01

0.03 0.03 0.03 0.02 0.01 0.20

• 0.02

0.01 0.1**

Correlations: Patient Care Analyses

*p<0.05, **p<0.01

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Dependent Variable: Care Coordination Dependent Variable: Provider Rating Model 1

• del 1

Model 2

• del 2

Model 3

• del 3

Model 4

• del 4

Independent Variables β (SE) β (SE) β (SE) β (SE) Proportion of high-creativity ideas per center 0.61 (0.42) * 1.08 (0.47) ** Proportion of high-creativity, implemented ideas per center

• 1.31 (0.61) **
• 1.94 (0.84) **

Length of relationship Year

• 0.43 (0.08) **
• 0.43 (0.09) **

1.21 (0.17) ** 1.23 (0.24) ** Three

• 0.38 (0.10)**
• 0.38 (0.10) **

1.39 (0.19) ** 1.43 (0.28) ** Five

• 0.33 (0.09) **
• 0.34 (0.09) **

1.36 (0.19) ** 1.18 (0.27) ** Number of office visits Two

• 0.55 (0.08) **
• 0.56 (0.08) **

0.20 (0.16) 0.14 (0.23) Three

• 0.63 (0.08) **
• 0.63 (0.08) **

0.26 (0.24) 0.28 (0.24) Four

• 0.57 (0.09) **
• 0.57 (0.09) **

0.10 (0.26) 0.10 (0.26) Five

• 0.54 (0.08) **
• 0.55 (0.08) **
• 0.02 (0.23)
• 0.02 (0.23)

Ten

• 0.67 (0.09) **
• 0.67 (0.09) **
• 0.25 (0.29)
• 0.25 (0.29)

Rating of overall health 0.07 (0.02) ** 0.06 (0.02) ** 0.20 (0.07) ** 0.20 (0.07) ** Rating of overall mental or emotional health 0.003 (0.02) 0.003 (0.02) 0.10 (0.06) 0.10 (0.06) Age 25 to 34

• 0.04 (0.20)
• 0.04 (0.20)

0.02 (0.50) 0.02 (0.50) 35 to 44 0.16 (0.20) 0.16 (0.20) 0.23 (0.65) 0.23 (0.65) 45 to 54 0.20 (0.19) 0.21 (0.19) 0.22 (0.48) 0.22 (0.48) 55 to 64 0.25 (0.19) 0.26 (0.19)

• 0.13 (0.48)
• 0.13 (0.48)

65 to 74 0.20 (0.20) 0.20 (0.20) 0.22 (0.50) 0.22 (0.50) 75 or older 0.45 (0.22) ** 0.45 (0.22) ** 0.49 (0.59) 0.49 (0.59) Gender (1=female) 0.03 (0.05) 0.03 (0.05) 0.30 (0.14) ** 0.30 (0.14) ** Education Some high school, but did not graduate 0.02 (0.08) 0.02 (0.08)

• 0.15 (0.27)
• 0.15 (0.27)

High school graduate or GED

• 0.03 (0.08)
• 0.03 (0.08)

0.03 (0.26) 0.03 (0.26) Some college or 2-year degree

• 0.03 (0.08)
• 0.03 (0.08)

0.05 (0.26) 0.05 (0.26) 4-year college graduate

• 0.22 (0.12)
• 0.22 (0.12)

0.20 (0.37) 0.20 (0.37) More than 4-year college graduate 0.08 (0.17) 0.08 (0.17) 0.47 (0.51) 0.47 (0.51) Race Black or African American 0.02 (0.07) 0.02 (0.07)

• 0.198 (0.22)
• 0.198 (0.22)

Hispanic

• 0.06 (0.06)
• 0.06 (0.06)
• 0.39 (0.18) **
• 0.39 (0.18) **

Asian 0.25 (0.14) 0.25 (0.14) 0.53 (0.42) 0.53 (0.42) Native Hawaiian or Other Pacific Islander

• 0.30 (0.17)
• 0.30 (0.17)

0.47 (0.27) 0.47 (0.27) American Indian or Alaskan Native

• 0.02 (0.10)
• 0.02 (0.10)

0.25 (0.27) 0.25 (0.27) Percentage patients White 0.43 (0.67) 0.42 (0.60) 0.65 (1.10) 0.65 (1.10) Percentage patients Uninsured

• 1.43 (1.32)
• 1.53 (1.32)

3.31 (2.44) 3.31 (2.44) Number of visits per FTE

• 0.01 (0.02)
• 0.01 (0.02)
• 0.03 (0.01) **
• 0.03 (0.01) **

Number of ideas per center 0.02 (0.02) 0.03 (0.02)

• 0.01 (0.03)
• 0.01 (0.04)

Psychological Safety 0..02 (0.11) 0/01(0.02) 0.04 (0.16) 0.13(0.18)

Multivariate Mixed Models on Idea Creativity and Patient Care Experiences (N=2,201)

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Variable Mean (S.D.) 1 2 3 4 5 6 7 8 9

• 1. Idea

Implementation 0.64 (0.48)

• 2. Idea Creativity 2.47 (1.65)
• 0.57 **
• 3. Collaboration 0.58 (0.49)

0.71 **

• 0.46**
• 4. Org. Tenure 4.02 (1.14)

0.10 *

• 0.23**

0.10

• 5. Network

Centrality 0.17 (0.19)

• 0.16 *
• 0.05
• 0.12

0.04

• 6. Center 4.57 (2.54)

0.01

• 0.32*

0.20** 0.09 0.27**

• 7. Gender 0.80 (0.40)

0.04 0.10

• 0.03

0.26**

• 0.21**
• 0.09
• 8. Behavioral

Health Provider 0.13 (0.33) 0.11

• 0.07

0.06

• 0.03

0.03

• 0.04
• 0.06
• 9. Medical

Assistant 0.21 (0.41)

• 0.16**

0.01

• 0.10

0.09 0.03 0.09

• 0.02
• 0.19**
• 10. Provider 0.23 (0.43)

0.30**

• 0.11

0.18**

• 0.04
• 0.11
• 0.05

0.03

• 0.20**
• 0.28**

Correlations: Idea Creativity and Implementation

*p<0.05, **p<0.01

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Dependent variable = Idea Implementation Model 1: Idea Creativity and Idea Implementation (H2) Model 2: Idea Creativity and Implementation plus Collaboration (H3) Model 3: Idea Creativity and Implementation plus Organizational Tenure (H4) Model 4: Idea Creativity and Implementation plus Network Centrality (H5) Hazard Ratio (CI) Hazard Ratio (CI) Hazard Ratio (CI) Hazard Ratio (CI) Independent ndependent Var ariables iables Idea Creativity 0.40 (0.28-0.55) ** 0.20 (0.09-0.44) ** 0.22 (0.14-0.33) ** 0.36 (0.25-0.52)** Collaboration (ref=no collaboration) 1.39 (0.84-2.28) Creativity X Collaboration 3.09 (1.26-7.60) ** Organizational Tenure 6 or more months 1.40 (0.50-4.08) 1 or more years 1.38 (0.47-4.05) 2 or more years 0.28 (0.11-0.71)** 5 or more years 0.24 (0.09 – 0.68)** 10 or more years 0.02 (0.03-0.14)** Creativity x Org. Tenure 6 or more months 1.98 (1.09-2.98)** 1 or more years 2.06 (1.19-3.56) ** 2 or more years 3.89 (2.50-6.08) ** 5 or more years 3.31 (1.92-5.71)** 10 or more years 32.36 (8.35-52.69)** Network Centrality 0.91 (0.65-1.27) Creativity x Network Centrality 2.31 (1.56-3.18)** Covar variat iates – individual es – individual Gender (1=male) 0.80 (0.54-1.20) 0.86 (0.57-1.28) 0.58 (0.38-0.91) ** 0.79 (0.53-1.18) Professional Role Behavioral Health Provider 1.07 (0.74-1.54) 0.98 (0.69-1.39) 1.04 (0.71-1.54) 1.06 (0.73-1.53) Medical Assistant 0.84 (0.55-1.28) 0.94 (0.63-1.40) 0.88 (0.58-1.33) 0.84 (0.55-1.28) Provider 1.02 (0.71-1.45) 0.98 (0.68-1.40) 1.04 (0.74-1.47) 1.02 (0.72-1.45) Center 0.93 (0.89-0.99) ** 0.91 (0.86-0.96) ** 0.91 (0.86-0.97) ** 0.93 (0.88-0.98) ** AIC (smaller is better) 1243.33 1240.14 1217.79 1241.09

Cox Proportional Hazards Model of Idea Creativity and Implementation (N=220 ideas)

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