EVALUATING TEAMS WORKING IN NEW MODELS OF CARE [NCMs] Author and co-presenter:

Dr Catherine B Matheson-Monnet c.b.matheson@soton.ac.uk

Co-presenter: Philippa Darnton philippa.darnton@wessexahsn.net

Which of the following QI projects is most likely to fail?

A. No shared understanding of purpose and outcomes

B. People not open to work in new ways/not legitimate part of work

C. Work not assigned to those with required skills/insufficient training provided

D. People cannot modify how they work as a result of feedback

E. OtherNo sh

ared understanding o

f...

People not open to

work in

...

Work

not assi

gned

to th

ose ...

People cannot m

odify how ...

Other

0% 0% 0%0%0%

The least important factor for a successful QI project?

A. How it differs from usual ways of working

B. Key people drive it forward and get others involved

C. Can easily be integrated into existing work

D. People agree that it is worthwhile

E. OtherHow it

differs

from usu

al wa..

Key people

drive i

t forw

ard ...

Can ea

sily be i

ntegrat

ed into...

People agree t

hat it i

s wort.

..Other

0% 0% 0%0%0%

The most important factor for a successful QI project?

A. How it is conceptualised and understood

B. How team members decide to engage and actually engage

C. How the work is organised and activities structured and constrained

D. How it is appraised and the effects of appraisal

E. OtherHow it

is conce

ptualised

and...

How team

members

decide .

.

How the w

ork is o

rganise

d a..

How it is a

ppraised and th

e e...Other

0% 0% 0%0%0%

LEARNING OUTCOMES 1. To explain what NPT is and how it can

be used in evaluating New Care Models

2. To describe how NPT was used in Farnham Integrated Care Team and the Enhanced Recovery at Home Team

Which of the following statements applies best to you?

A. No idea what NPT is about

B. Have heard of NPT, but not sure what it is

C. Know what NPT is, but I have not used it

D. Know about NPT and have used it No id

ea what

NPT is about

Have heard

of NPT,

but not ..

.

Know what N

PT is,

but I hav

...

Know about N

PT and hav

e us..

0% 0%0%0%

1To explain what NPT is and how it can be used in evaluating New Care Models and new teams

NPT – NORMALISATION PROCESS THEORY(May and Finch 2009; May et al, 2007, 2009, 2010; Finch et al 2013, 2015)

A validated sociological instrument widely used to evaluate the implementation of QI interventions in Healthcare

Evaluates the contribution of individuals and teams focussing on factors that promote and inhibit implementation

Explains how QI interventions become embedded in routine every day practice

Within certain limits NPT has predictive potential and this diagnostic dimension can help address early problems and remedy them

NPT PRINCIPLES AND ASSUMPTIONS(May and Finch, 2009)

Either QI interventions become routinely embedded in every day work or not

Implement, embed and sustain is operationalised through 4 domains: 1) coherence; 2)cognitive participation; 3) collective action; 4) reflexive monitoring

Activities in all 4 domains may occur concurrently

Sustainability requires continuous and on-going investment through collective action

1/COHERENCE DifferentiationMobilisation

How it is conceptualised and held together in action

2/COGNITIVE PARTICIPATION

InitiationParticipation

How team members decide to engage and actually engage

3/COLLECTIVE ACTION

Interactional workabilityEnacting

How work is organised and activities structured and constrained

4/REFLEXIVE MONITORING

SystematisationAppraisal

How it is appraised and effects of appraisal i.e. how it is ‘understood’

NPT 4 DOMAINS

What is the most important factor for a successful QI project?

1. How it is conceptualised and understood: coherence

2. How team members decide to engage and actually engage: cognitive participation

3. How the work is organised and activities structured and constrained: collective action

4. How it is appraised and the effects of appraisal: reflexive monitoring

NPT CAN BE USED BEFORE, DURING AND AFTER QI INTERVENTIONS

BEFORE• views of the team about how they think the NCM will impact on their work • expectations of the team about whether the NCM could become a routine

part of their work • suggestions of the team for routine embedding of the NCM

DURING (at various time points)• to ascertain the extent to which perceptions have changed • identify areas (within the 4 key domains) that might require additional work

to enable embedding

AFTER • to assess the extent to which routine embedding has achieved sustainability

NPT CAN BE USED WITH ANY STUDY DESIGN

NPT is compatible with quantitative and qualitative data collection and all research designs

Constructs and components can be translated into simple statements for managers, clinicians, researchers to help them think through and work through implementation problems.

NPT 16 questions [4 for each of the 4 domains] (May and Finch, 2009)

NPT derived NoMAD instrument [20 questions between 4 and 7 for each of the 4 domains (Finch et al, 2013, 2015) SEE NEXT SLIDE

COHERENCE 1. How NCM differs from usual ways of working   2. Shared understanding of purpose of the NCM  3. How NCM affects nature of work   4. Construct potential value for NCM re work COGNITIVE PARTICIPATION

5. Key people drive NCM forward  6. Participating in NCM is legitimate part of role   7. Open to working in new ways  8. Continued support for NCMCOLLECTIVE ACTION

9. NCM can easily be integrated into existing work   10. NCM does not disrupt working relationships   11. Confidence in others’ skills and expertise  12. Work is assigned to those with appropriate skills  13. Sufficient training provided  14. Sufficient resources available to support NCM  15. Management adequately support the NCMREFLEXIVE MONITORING

16. Awareness of information about effects of NCM  17. NCM worthwhile   18. Value effects that NCM has on own work   19. Feedback about NCM can be used to improve it  20. Can modify way of working with NCM

2To describe how NPT was used for ICT and ER@H

Integrating primary care (GP and HCPs) and community/social care to provide a holistic service to those at risk

Service in place for 18 months + weekly MDT meetings to discuss new and follow-up patients

Planning increased GP input to core team and closer working with ambulance service and FPH A&E team.

Data gathering re tracking service impact on unplanned care, analysis of health care utilisation before and after the intervention, patient experience and PROMS, interviews with patients/carers

FARNHAM INTEGRATED CARE TEAM

ICT: Summative evaluation of early implementation

using structured focus groups with survey during one day development meeting [n=9]

Evaluate the impact in respect of the experience of staff involved in the delivery

Identify areas for further development

Merging secondary care provision [FPH FORT] with community-based provision [SHFT RR] to provide an integrated holistic service to those that may benefit

Interim service with 6/18 staff in post. Collaboration, joint training and joint patients visits already in place. Significant period of change for all staff involved.

Preparatory work over approx 9 months to develop a vision for the ER@H service, explore shared values and processes and to foster a common vision in preparation for the launch

Data gathering re tracking service impact on unplanned care and patient experience. Staff experience away surveyed through R-Outcomes at away day in September

FARNHAM ENHANCED RECOVERY AT HOME

ER@H: Formative evaluation of developmental phase using non-

participant observation during staff away day [n=40]

Capture any significant learning from the developmental phase

Identify potential challenges in implementing the intervention before it is properly launched

LEARNING OUTCOMES 1. We explained what NPT was and how

it can be used in evaluating New Care Models

2. We described how NPT was used for understanding the impact of New Care Models on two teams: ICT and ER@H

Are you likely to use NPT in future?

A. YesB. NoC. Not sure

Yes No

Not sure

0% 0%0%

REFERENCES

Finch TL, Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, Steen I and May CR (2013) Improving the normalization of complex interventions: measure development based on normalization process theory [NoMAD]: study protocol, Implementation Science, 8, 1, 43. DOI:10.1186/1748-5908-8-43

Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, Steen IN, McColl EM, Dickinson C, Rapley T (2015) NOMAD: Implementation measure based on the Normalisation Process Theory [Measurement Instrument]. Available at http:www.normalisation process.org [Accessed 7 July 2016]

May CR, and Finch TL (2009) Implementation, embedding and integration: an outline of Normalization Process Theory, Sociology, 43, 3: 535-554. DOI:10.1177/0038038509103208

May CR, Murray E, Finch TL, Mair F, Treweek S, Ballini L, Macfarlane A and Rapley T (2010) Normalization Process Theory On-line Users’ Manual and Toolkit. Available from http://www.normalizationprocess.org http://www.normalizationprocess.org/npt-toolkit/how-to-use-the-npt-toolkit.aspx [Accessed on 25th Sept 2015]

May C, Finch TL, Mair FS, Ballini L, Dowrick C, Eccles M, Gask L, MacFarlane A, Murray E, Rapley T, Rogers A, Treweek S and Wallace P (2007) Understanding the Implementation of Complex Interventions in Health Care: The Normalization Process Model, BMC Health Services Research, 7, 148.

May, CR, Mair F, Finch TL, MacFarlane A, Dowrick C, Treweek S, ,Rapley T, Ballini L, Ong BN, Rogers A, Murray E, Elwyn G, Legare F, Gunn J and Montori VM. (2009) An interdisciplinary theory of implementation, embedding and integration: the development of normalization process theory, Implementation Science, 4, 29, DOI:10.1186/1748-5908-4-29