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									              Implementing Change
              in Hospitals
      The Technical Assistance & Mentoring Program

Rivka Gordon, PA-C, MHS
Senior Consultant, Technical Assistance and Mentoring Program
Learning Objectives:

   Describe the organizational cultural change
    model for implementing service-delivery

   List the components of the mentoring process.

   Apply components of the mentoring process to
    case examples and home settings.
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
Primary Areas of Work

            Training &

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

Prioritize geographic areas     Identify research questions related Support and implement systems
                                to incidence, trends and            in hospitals to incorporate MVA
Develop “master mentors”
                                management of Early Pregnancy
                                                                    Assist provider systems with
Develop and implement           Loss (EPL)
                                                                    group purchasing and product
curriculum and training tools
                                Develop sound outcomes targets      development
Disseminate model to partners
                                Collect program data                Update market analyses
                                Publish and disseminate             Develop educational and
                                quantitative and qualitative data   marketing materials for health
                                                                    systems and consumers
         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
        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
        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
                            December: Coeytaux & Wells
                             Report completed
        History of TAM: 2005
   January: Service Delivery Handbook and Toolkit
    for Management of Pregnancy Loss and Abortion
          February: Elmhurst Hospital – Grand
           Rounds, Practicum, Clinical Training
                   March/April: APGO meeting & NAF
                    meeting → requests for Ipas
                          January - May: TAM Project
History of TAM: 2005, cont.

May 15 – 17, 2005:
Technical Assistance and
 Mentoring Project
8 clinicians participated
  (OB/Gyn, Family Practice, Pediatrics, CNM, PA)
          Training vs. Mentoring

   Mentoring and training strategies complement
    one another for service delivery change

    Training                 Mentoring
    -Brief and finite        -Sustained process
    period of time
                             -Outcomes relate to
    -Outcomes relate to      relationship building
    knowledge and skills     and support
      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
 Advocating for improved standards and
                    Four Predictable
                       Stages of

Preparation       Explore motivation, skill level and learning needs

                Negotiation      Create an agreement and a work plan

Participation     Practice, build competency and confidence levels

                   Closure         Transition on-going responsibilities to
                                   continue at institution
Criteria for Selecting
   Involvement in successful integration of
    MVA into ambulatory settings
   Current MVA trainer
   Ability and willingness to complete scope of
   Personal characteristics
       Listening, flexibility, devotion to high quality
        care, ability transfer passion, ability to
        appreciate and affirm personal /
        organizational diversity
Criteria for Selecting
Change Agents
   Participation in Ipas hospital assessment
    and/or request for Ipas technical assistance
   Current engagement in effect staff
   Willingness to meet expected level of
       Weekly listserve participation
       Coordinated telephone communication with
        Ipas mentors
       Coordinated site visit with Ipas mentors
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
     Committed leadership
     Appropriate facilities
TAM: The Pilot Year

May 2005 – June 2006
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
TAM: Institutional Picture
 TAM Institutions

                  36%                        Private Institutions



                            For Profit

                           Non- Profit

                                         0   2        4        6
        Participation in TAM Activities

                                                Attending physicians
                 7%      8%
            2%          7%    8%          33%   Advanced-Practice
                      2%                 33%    Clinicians
      20%        20%
                                                Other (Admin, Central
                  7%    7%         23%          processing)
                                                Medical Students

                                                Not Reported

o   Interventions reached attendings, residents,
    advanced-practice clinicians and nurses
o   Between 12 and 74 participants were reported at
    varying sites
          Equipping TAM Participating
              Equipping hospitals where the TAM worked 2005-2006
                         current as of the end of FY 2006
Location of the Institution                   FY 2005 Sales        FY 2006 Sales
New York City: Multiple Hospitals                      $5179              $13,666
Texas: 2 Hospitals                                      $853               $5135
Pennsylvania: 2 Hospitals                                     $0             $892
Colorado: 1 Hospital                                          $0           $2,384
Illinois: 2 Hospitals                                         $0           $6038
California: 2 Hospitals                                       $0              $30
                                     TOTAL            $6,032              $28145
                                                          New York (HHC)
                                                          Multiple hospitals that are
             Colorado                                     part of a public, urban
                               Illinois                   system
             1 hospital
                               3 hospitals, including 1
                               Family Medicine            Pennsylvania
                               department, and
California                                                3 hospitals, including 2
                               another OB/Gyn
                                                          University-based centers
2 hospitals,                   department
including one ED;
1 large, multi-center     Texas
network                   2 hospitals, including 1
                          University-based centers

Where TAM Has Worked
        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
        New York: Precursors to
 NARAL Pro-choice New York research and
 2002 Mayor Michael Bloomberg mandates
  Women’s Options Initiative
 Ipas role established through
     Partnerships
     Communication
     Technical assistance
     Mentoring
        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

 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
    Chicago: An Institutional
   One OB/GYN department
       Goal: improve elective abortion care
   One Family Medicine department
       Goal: provide miscarriage
   Two strong change agents
     Collaborated effectively
     Strong institutional support
    Chicago: Mentoring and
    Training Activities
 Pre-intervention visits
 Grand Rounds on miscarriage
 MVA in-service

 MVA pelvic model practicum

 MVA clinical training

 Journal club
California: New Frontiers

   Taking TAM to larger systems
   Leveraging built-in monitoring systems
   Piloting a model for Emergency
   Collaborating to influence professional
   Leveraging built-in monitoring systems
   Broad, diverse geographic reach
California: Collaborations

   Collaborating with partners to expand:
     Reach
     Potential for service delivery change
     Opportunities to foster additional
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
                                       Based on 2005 data
     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
     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
      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
   The Future of TAM

Moving toward a new system of
care for Early Pregnancy Loss
Institutional Change

 Sustain and improve mentoring
 Continue to work in priority regions

 Focus on systems of care, to
  influence more settings
 Monitor and evaluate changes

 Collect and disseminate findings
Monitoring and Evaluation

 Build capacity of TAM Research
 Develop map of priority research
 Collect baseline data and ongoing
  data at intervention sites
 Disseminate findings
Influence Professional
 Work with partners
 Utilize data from intervention sites

 Collect and synthesize evidence-
  based standards of care
 Present findings to institutions
  responsible for setting professional
      TAM Cultural Change Model
              High Quality     findings
Monitor &     EPL Services
 Evaluate     throughout
              the US

  Mentoring                    with partners


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