# Presentation: 502876

## Rigor AND Relevance 

- Kurt C. Stange, MD, PhD
- Editor, *Annals of Family Medicine*
- Gertrude Donnelly Hess, MD Professor of Oncology Research
- Professor of Family Medicine, Epidemiology & Biostatistics, Sociology and Oncology
- Case Western Reserve University

## Overview

- Reflections on Ornstein & Ruhe presentations
- The problem
- An integrative epistemology
- A transdisciplinary whole systems approach
- QI “laboratories” - PBRNs
- Participatory approaches to both R & D
- Mixed methods – quantitative & qualitative
- A complexity science underpinning
- Putting it together

## Reflections on Presentations by Ornstein & Ruhe

- Responding to common stimuli
- Intervention approaches
- Evaluation Methods

## Responding to Common Stimuli

- Real-world primary care
- Incompatible reimbursement/business model
- Competing demands / opportunities
- PBRNs
- Diversity
- Undesirable (low rates of effective practices)
- Desirable  (local adaptation)
- Melding research & quality improvement
- Resistance to randomization
- Peer review / categorical funding

## Intervention Approaches

- Multifaceted
- Multiple processes, tools & outcomes
- Moving toward multilevel Chronic Care Model
- Individualization of shared best practices
- Outside facilitation / consultation
- Shared learning
- Complexity science principles

## Evaluation Approaches

- Mixed methods designs
- Group RCT → pre/post design
- Concurrent qualitative process evaluation
- Tailoring of intervention
- Measures
- Quantitative process & outcome
- Inductive approach
- Observation, interviews
- Discovery of what works locally

## The Problem

- Rigor vs. relevance
- Internal vs. external validity
- Isolation of a phenomenon from context (so that it can be more rigorously studied) when context matters
- Our methods, theories, world view don’t match the problems or apparent solutions

##  4 Ways of Knowing 

- Adapted from:
- Wilber, K.  *Sex, Ecology, Spirituality*.  1995/2000, Boston: Shambhala Publications, Inc.
- Wilber, K.  *A Brief History of Everything*. 1996, Boston: Shambhala Publications, Inc.

- Inner Reality

- Outer Reality

- Individual

- “I”

- “It”

- Collective

- “We”

- “It”

## 4 Ways of Knowing About Health & Health Care

- Adapted from:
- Stange KC, Miller WL, McWhinney I.  Developing the knowledge base of family practice.  *Fam Med*.  2001; 33(4):286-297.

## 4 Ways of Knowing About Health & Health Care

_**Borders**_** **
- 1-2   Relationship
- 2-3   Justice
- 3-4   Prioritization
- 4-1   Information
-         mastery
- 1-3   Collaboration
- 2-4   Illness

## Multiple Ways of Knowing

_**SYNTHESIS of ways of knowing**_
- The craft of policy & general practice is the integration and application of knowledge of biomedicine, health care systems, individuals, families, communities & self.

- 1-2   Relationship
- 2-3   Justice
- 3-4   Prioritization
- 4-1   Information
-         mastery
- 1-3   Collaboration
- 2-4   Illness

_**BORDERS among ways of knowing**_

## Multiple Ways of Knowing

## Honoring Different Ways of Knowing

- Acknowledging different perspectives
- In planning studies
- In interpreting findings
- Multiple groups working separately but communicating
- Paying attention to (or at least considering) other ways of knowing, even if only working on one.

## Integrating Different Ways of Knowing

- Sequential studies
- Simultaneous studies
- Multiple viewpoints
- Multiple methods
- Studies of the border regions
- Studies of the integrative function

## Transdisciplinary, Whole Systems Collaboration

- can create abundance by sharing scarcity.

- Crabtree BF, Miller WL, Adison RB, Gilchrist VJ, Kuzel A. *Exploring Collaborative Research in Primary Care*.  Thousand Oaks, California: Sage Publications; 1994.

## Leadership for Collaborative Research, Development and Quality Improvement

- Whole system
- Top down
- Bottom-up

- Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks for research in primary health care. *BMJ*. 2001;322:588-590.
- Thomas P.  *Integrative Primary Health Care: Leading, Managing, Facilitation*.  London: Radcliff Press, 2006.

## A Typology of Collaboration

- Multidisciplinary
- Interdisciplinary
- Transdisciplinary

- Crabtree BF, Miller WL, Adison RB, Gilchrist VJ, Kuzel A. *Exploring Collaborative Research in Primary Care*.  Thousand Oaks, California: Sage Publications; 1994.

## Multidisciplinary Research

- Multiple disciplines
- Each contributes their piece to solving a problem
- Like an edited book or separate presentations by multiple experts

## Interdisciplinary Research

- A conversation *between* and *among* disciplines
- Working together on solving a common problem
- Like a collaborative health care team

## Transdisciplinary Research

- A sustained conversation *across* and *beyond* disciplinary boundaries
- Creates a new shared language
- Such as the emergence of family systems medicine

## 6 Stages of Collaboration

- Acceptance / validation
- Shared expectations
- Declaring group process
- Action consensus
- Common space
- Sustained common action

## Barriers to Collaborative Process

- Rhetorical stones
- Power heaping
- Shaming
- Jargon hurling
- Powerful hegemony
- Rationality *vs. / and*
- Wonder, confession gratitude, receptivity to gift and mystery
- Tension between pragmatism and reflection
- Tension between individual & systems focus

## Tactics for Advancing the Process

- Brainstorming
- Humor
- Storytelling
- Silence and time out for play

## The Actual Process

- Non-linear
- Blurring and blending of levels
- Back and forth between levels
- Destabilized by time pressure
- Enhanced by flexibility, tact, patience and persistence

## Dangers of Collaborative Research Relationships

- Sloppiness from training down
- Suppression of individuality
- Cultism
- Political nature of groups
- Minimizing these requires self-reflection and challenging

## 6 Ingredients for Successful Collaborations

- Linkage perspective
- Local context and action
- Problem-focused
- Appropriate methods
- Critical multiplism
- Coordination by a generalist researcher

## Leadership for Collaborative Research

- In the face of change and uncertainty
- Animation
- Provide initial direction
- Encourages updating
- Facilitates respectful interaction - trust, trustworthiness
- Improvisation
- A hunch held lightly is a direction to be followed, not a decision to be defended
- Lightness
- “I don’t know”
- Authentication
- Sensemaking
- Learning

- Weick KE.  Leadership as the legitimation of doubt.  In Bennis W, Spreitzer GM, Cummings TG, (eds).  *The Future of Leadership*.  San Francisco: Jossey-Bass, 2001.

## R &D &QI “Laboratories”

- Whole systems  e.g. HMO Research Network
- NIH Research Center Model e.g. Cancer Centers
- Practice-based research networks  (PBRNs)

## PBRNs

- Affiliated practices devoted to patient care
- Often academic or other partners
- Engage frontlines wisdom to
- Develop or frame questions
- Gather data
- Interpret findings
- Implement findings
- More generalizable patient populations, & theoretically, more transportable research
- 	http://ahrq.gov/research/pbrnfact.htm

## Primary Care PBRNs

- Laboratories for primary care research
- 111 networks in 44 states
- Translate research into practice
- Translate practice into research
- Nutting P, Beasley J, Werner J. Practice-based research networks answer primary care questions. *JAMA*. 1999;281:686-688.
- Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks for research in primary health care. *BMJ*. 2001;322:588-590.
- Lanier D. Primary care practice-based research comes of age in the United States.  Ann Fam Med.  2005; 3(suppl 1):S2-S4.

## Primary Care PBRNs

- Answer important questions
- Challenging current environment
- With support, ready for prime-time
- Answer to the call of the NIH Roadmap
*Contemporary Challenges for Practice-Based Research Networks*. *Ann Fam Med*; 2005; 3 (suppl 1). http://www.annfammed.org/content/vol3/suppl_1/index.shtml
- Nutting PA, Stange KC, eds. *Prescription for Health: Changing Primary Care Practice to Foster Healthy Behaviors. * *Ann Fam Med*; 2005; 3 (suppl 2).       Full text free at: http://annfammed.org/content/vol3/suppl_2/index.shtml
- Green LA, Dovey SM. Practice based primary care research networks. They work and are ready for full development and support. *BMJ.*2001;322:567-568.
- Nutting PA, Beasley J, Werner JJ. Practice-based research networks answer primary care questions. *JAMA. *1999;281:686-688.

## Slide 32

| The Ecology of Medical Care |
| --- |

## Community Participatory Research

- Knowledge, resources, involvement of communities are key to success of research and its transportability & sustainability
- 3 primary features
- Collaboration
- Mutual education
- Acting on results developed from research questions relevant to the community
- Macaulay AC, Commanda LE, Freeman WL, et al. Participatory research maximises community and lay involvement. *BMJ. *1999;319:774-778.

## Facilitation of Participatory Research

- Continuity
- Timeliness
- Flexibility
- Clear and explicit expectations
- Appropriate & instructive accountability
- A vision for participatory research
- Tailored technical assistance
- Enhancing partner collaboration & support
- Mercer SL, MacDonald G, Green LW. Participatory research and evaluation: from best practices for all states to achievable practices within each state in the context of the Master Settlement Agreement. *Health Promot Pract*. 2004;(3 Suppl):167S-178S.

## Multimethod Approaches

- Increasingly accepted
- Efficient for generating new knowledge
- Stange KC, Zyzanski SJ.  Integrating qualitative and quantitative research methods.  *Fam Med*, 1989; 21:448-451.
- Stange KC, Miller WL, Crabtree BF, O’Connor PJ, Zyzanski SJ.  Multimethod research: Approaches for integrating qualitative and quantitative methods.  *J Gen Intern Med*.  1994; 9:278-282.
- Crabtree BF, Miller WL.  *Doing Qualitative Research.  2nd Ed*. Thousand Oaks, California: Sage Publications, 1999.
- Crabtree BF, Miller WL, Stange KC.  Understanding practice from the ground up.  *J Fam Pract*, 2001; 50:881-887.
- Borkan JM. Mixed methods studies: a foundation for primary care research. *Ann Fam Med. *2004;2(1):4-6
- NCI Conference on Mixed Methods Research, July, 2004, Denver, CO.

## Multimethod Research 

-   **Quantitative methods**
- Counting descriptions
- Testing *a priori* hypotheses
- Seek to isolate phenomenon from context
-   **Qualitative methods**
- Rich descriptions
- Discovery; testing evolving hypotheses
- Seek to understand meaning and context
-  **Integrated use**
- Qualitative, then quantitative
- Quantitative, then qualitative
- Simultaneous
- Stange KC, Miller WL, Crabtree BF, O’Connor PJ, Zyzanski SJ.  Multimethod research: Approaches for integrating qualitative and quantitative methods.  *J Gen Intern Med*.  1994; 9:278-282.

## Mixed methods allow you to have your cake and eat it too.

## Additional Theoretical Underpinnings

- Complexity science principles
- Chronic care model
- Re-Aim
- Framework for complex interventions
- Gree nhalgh

## Practices as Complex Adaptive Systems

- Complex behavior emerges from relationships among agents
- Simple rules
- Recurrent patterns
- Co-evolution
- Dependence on initial conditions
- Non-linearity
- Strategies for intervention
- Joining
- Transforming
- Learning
- 	Miller WL, Crabtree BF, McDaniel RA, Stange KC.  Understanding primary care practice: A complexity model of 	change.  *J Fam Pract*, 1998; 46:369-376.
- 	Miller WL, McDaniel RA, Crabtree BF, Stange KC.  Practice Jazz: Understanding variation in family practices using complexity science.  *J Fam Pract*, 2001; 50:872-878.
- 	Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. Using complexity science to inform a reflective practice improvement process.  *Jt Comm J Qual Patient Saf*, 2005; 31:438-446.

## Three Key Insights

- Practices are co-creative participants in dynamic fitness landscapes.
- There are multiple ways to achieve effective health care delivery in practice.
- The best strategies for improving practice pay attention to improving relationships among stakeholders.
- 	McDaniel RA, 2005

## Chronic Care Model

- Community
- Health care system
- Resources, policies & organization
- Self-management support
- Delivery system design
- Decision support
- Clinical information systems
- Interaction
- Informed, activated patient
- Prepared, proactive practice team
- Wagner EH.  Chronic disease management: What will it take to improve care for chronic illness:  *Effective Clinical Practice*.  1998;1:2-4.
- Glasgow RE, Orleans CT, Wagner EH, Curry SJ, Solberg LI. Does the chronic care model serve also as a template for improving prevention? *Millbank Q. *2001;79:579-612.

## Re-Aim

- Reach
- Efficacy/effectiveness
- Adoption
- Implementation
- Maintenance
- www.re-aim.org
- Glasgow RE, McKay HG, Piette JD, Reynolds KD. The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management? *Patient Educ Couns. *2001;44:119-127.
- Glasgow R, Magid D, Beck A, Ritzwoller D, Estabrooks P. Practical clinical trials for translating research to practice: design and measurement recommendations. *Med Care. *2005;43:551-557.

## Design & Evaluation of Complex Interventions

- Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. *BMJ. *2000;321(7262):694-696.

## Next Generation of Diffusion of Health Service Innovations

- Theory-driven
- Process rather than ‘package’ oriented
- Ecological
- Addressed with common definitions, measures, tools
- Collaborative & coordinated
- Multidisciplinary & multimethod
- Meticulously detailed
- Participatory
- Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. *Milbank Q. *2004;82(4):581-629.

## An Incremental Approach

- Work on or pay attention to multiple levels
- Pursue research, development & shared learning
- Develop participatory relationships that transcend single projects
- Integrate qualitative & quantitative methods
- Reconsider enabling the current dysfunctional system versus fostering its transformation