What happens when communication policies hit the ground?

Sue Stableford, MPH, MSB, DirectorUniversity of New England Health Institute

September 2013

The Diffusion of Innovation meetsComplex Adaptive Systems

Assumptions

• Communication focus: Terms and 2 major strategies

• Moving strategies into practice = CHANGE • Core issue for better health and public health

outcomes

What’s Ahead

1. The challenge of change2. Context: Policy and history3. What happens when policy

hits the ground?4. How change happens:

Interweaving theories5. Opportunities to improve practice

The Challenge of Change

[Atul Gawande. Slow Ideas. New Yorker, July 29, 2013]

• Adopted quickly: Anesthesia– Ether introduced 1846 and universal in 7 years

• Adopted slowly: Antiseptic techniques– Lister report 1867: Carbolic acid– Generation(s) passed; still challenges

• Public health example: Limes on British ships

Relationship to plain language and teachback?

Context: Policies, Guidelines, Standards, Tools

Triple Aim

More Policies, Guidelines, Standards, Tools

Context of Change: History in 1 Slide

2013

1985 Doaks and Root publish “Teaching Patients With Low Literacy Skills”

All major national policy and accreditation bodies recommend/require clear health communication

1999 AMA ‘White Paper’

2003 2nd National Assessment of Adult Literacy (NAAL)

1992 1st National Adult Literacy Survey (NALS)

Policy hits the ground

Healthcare and public health:Stormy environments

• Complex• Many players• Multiple stakeholders• Limited resources• Competing agendas

Competing for Attention

• External forces– Finances– Politics– Regulations– Safety & quality

• Internal agendas

Time pressures acute

Impact on improving communication?

More like this Than this

Results

How can we get to better communication practice?

• Not easily!• Change theories converge– Public Health: Diffusion of Innovation– Medicine: IHI Model for Improvement– Business: Kotter’s 8 step action model– Popular press: Switch

Tipping Point

Core Concepts of Change

• Establish need– Engage head and heart

(data and stories)• Engage trusted leaders• Show the way/Start small• Clear obstacles• Measure and celebrate• Spread, build, and anchor

What promotes broad-scale change?

• Relative advantage• Compatibility• Simplicity• Trialability• Observability

(visibility)

“Diffusion of Innovation” (Everett Rogers)

Lacks 4 of 5 key elements of easy diffusion • Visibility• Simplicity• Relative advantage• Compatibility with

‘usual care’

Barriers to Communication Change

Another Framework for Understanding Change

– Nonlinear– Self organizing– Emergent– Dynamic– Adaptive

Healthcare and public health as Complex Adaptive Systems (CAS)

The CAS framework and communication practice change

“Health care providers, patients, officials and the many other stakeholders in a health system interact with each other through a web of complicated relationships, influenced by communities of practice, neighborhoods, and social networks. Scaling up health services involves intervening in these networks and engaging in dynamic, health system relationships.”

Paina L & Peters D. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy and Planning, 2012: 27.

Diffusion of Ideas and Behaviors

Core Concepts of

Change

Complex Systems inComplex

Environments

Common theme: Social Relationships

Policies, Guidelines,Standards, Tools

Showing the way: Models of Success

• IOM Health Literacy Roundtable, April 2013– Focused on organizational change– Care systems using change frameworks

and systems thinking to integrate plain language and teachback

• Public health: ecological paradigm

So, what does it take to change communication practices?

1. Core concepts– Prioritize, Invest, Measure

2. Diffusion of Innovation– Compatibility and

simplicity– Emphasize advantage

3. Systems & social theory– Flexibility and creativity– Points of leverage

Support for Improved Communication Practice

• ACA payment reforms• Links to high-profile issues

e.g. Cultural Competence• Accreditation requirements• Academic changes• Links to proven programs

e.g. TeamSteps and Choosing Wisely

What about technology solutions?

• Technology: A supporting player, not the star• Change– A social process– Person to person

• Gawande: “People talking to people is still how the world’s standards change.”

Will it make a difference?

Yes! Evidence on communication impact:• Patients• Providers and care systems• Public health

Finale

Atul Gwande referencing Everett Rogers:

“Every change requires effort, and the decision to make that effort is a social process.”

Selected Additional References• Foster-Fishman P, Nowell B, Yang H. Putting the system back into systems

change: a framework for understanding and changing organizational and community systems. Am J Community Psychol, 2007. 39:197-215.

• Hawe P, Shiell A, Riley T. Theorising Interventions as Events in Systems. Am J Community Psychol, 2009. 43:267-276.

• Hibbard JH and Greene J. What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs. Health Affairs, 2013. 32(2):207-214.

• Langley GJ et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Francisco: Jossey-Bass, 2009.

• Meadows D. Thinking in Systems. Vermont: Chelsea Green Publishing, 2008.• Patton MQ. Developmental Evaluation: Applying Complexity Concepts to

Enhance Innovation and Use. New York: The Guilford Press, 2011.• Rogers E. The Diffusion of Innovation. New York: Simon & Schuster, 1962.• Sterman JD. Learning from Evidence in a Complex World. Am J Public Health,

2006. 96(3):505-514.• Trickett EJ et al. Advancing the Science of Community-Level Interventions.

Am J Public Health, 2011. 101(8):1410-1419.