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Theses and Dissertations

Spring 2017

Two canoes: a case study in organizational change

failure and the implications for future population
health initiatives
Bryson Kruthoff
University of Iowa

Copyright © 2017 Bryson Kruthoff

This thesis is available at Iowa Research Online: https://ir.uiowa.edu/etd/5541

Recommended Citation
Kruthoff, Bryson. "Two canoes: a case study in organizational change failure and the implications for future population health
initiatives." MS (Master of Science) thesis, University of Iowa, 2017.
https://doi.org/10.17077/etd.fj8g2cl7

Follow this and additional works at: https://ir.uiowa.edu/etd

Part of the Health Services Administration Commons

TWO CANOES: A CASE STUDY IN ORGANIZATIONAL CHANGE FAILURE AND THE
IMPLICATIONS FOR FUTURE POPULATION HEALTH INITIATIVES

by

Bryson Kruthoff

A thesis submitted in partial fulfillment

of the requirements for the Master of Science
degree in Health Policy in the
Graduate College of
The University of Iowa

May 2017

Thesis Supervisor: Associate Professor Brian Kaskie

 Graduate College
The University of Iowa
Iowa City, Iowa

CERTIFICATE OF APPROVAL

____________________________

MASTER'S THESIS

_________________

This is to certify that the Master's thesis of

Bryson Kruthoff

has been approved by the Examining Committee for

the thesis requirement for the Master of Science degree
in Health Policy at the May 2017 graduation.

Thesis Committee: ____________________________________________

Brian Kaskie, Thesis Supervisor

____________________________________________
Xi Zhu

____________________________________________
Linda Lee
 ABSTRACT

Organizational change is undeniably difficult, and change efforts often fail to overcome

the status quo processes and routines. By threatening these structures, change becomes an

existential danger to organizations, who often respond with significant resistance. Organizations

will look to their experiences with past change efforts to inform future changes, limiting the

ability of change actors who seek to implement change beyond this narrow scope.

The “Heart Failure Lite” model was a change effort that exceeded the scope of previous

changes at an organization with deeply embedded routines and processes. This model threatened

the traditional revenue streams that had benefited the organization for years. The resistance

exhibited by the organization when presented with the change was consistent with the underlying

theory.

Although change failure is common, proactive efforts on the part of change actors can

help break down the organizational barriers. Conceptual models like PARiHS can be utilized to

identify the evidence supporting the change, the contextual environment in which the change will

be introduced, and the facilitation efforts needed to guide the project to a successful conclusion.

The “Heart Failure Lite” team failed to survey the organizational landscape and tailor the project

accordingly. Therefore, the change effort failed.

Shifting clinical practices toward a population health model presents a unique opportunity

for healthcare organizations. A concerted effort from all stakeholders to find common ground

will allow change agents to overcome the traditional barriers, and will help organizations to truly

transform the delivery of healthcare services.

ii
 PUBLIC ABSTRACT

Organizational change is undeniably difficult, and change efforts often fail to overcome

the status quo processes and routines. By threatening these structures, change becomes an

existential danger to organizations, who often respond with significant resistance. Organizations

will look to their experiences with past change efforts to inform future changes, limiting the

ability of change actors who seek to implement change beyond this narrow scope.

The “Heart Failure Lite” model was a change effort that exceeded the scope of previous

changes at an organization with deeply embedded routines and processes. This model threatened

the traditional revenue streams that had benefited the organization for years. The resistance

exhibited by the organization when presented with the change was consistent with the underlying

theory.

Although change failure is common, proactive efforts on the part of change actors can

help break down the organizational barriers. Conceptual models like PARiHS can be utilized to

identify the evidence supporting the change, the contextual environment in which the change will

be introduced, and the facilitation efforts needed to guide the project to a successful conclusion.

The “Heart Failure Lite” team failed to survey the organizational landscape and tailor the project

accordingly. Therefore, the change effort failed.

Shifting clinical practices toward a population health model presents a unique opportunity

for healthcare organizations. A concerted effort from all stakeholders to find common ground

will allow change agents to overcome the traditional barriers, and will help organizations to truly

transform the delivery of healthcare services.

iii
 TABLE OF CONTENTS

LIST OF TABLES .......................................................................................................................... v

LIST OF FIGURES ....................................................................................................................... vi
CHAPTER 1 PREVALENCE AND ADVERSE CONSEQUENCES
OF CARDIOVASCULAR DISEASE IN THE UNITED STATES............................................... 1
CHAPTER 2 EFFORTS TO REDUCE THE BURDEN
OF CARDIOVASCULAR DISEASE .......................................................................................... 10
External Environment: Alternative Payment and Delivery Reform ......................................... 10
“Sickness Model”: Previous Method of Treating Heart Failure and Other CVD Patients ....... 12
New Model: Prevention through Patient Engagement and Self-Management ......................... 16
Patient Education Intervention .............................................................................................. 19
Patient Activation and Self-Management .............................................................................. 22
CMMI Million Hearts®: Cardiovascular Disease Risk Reduction Model ............................... 24
CHAPTER 3 ASSESSMENT OF CHANGE FAILURE USING
ORGANIZATIONAL CHANGE THEORY ............................................................................... 30
Change Theory: Existential Resistance and Structural Inertia .................................................. 30
A Framework to Assist the Implementation of Evidence-Based Practices ............................... 33
Evidence, Context, and Facilitation: Definitions Updated .................................................... 37
Evidence: Proactive Questions to Guide and Evaluate Change Process ................................... 38
Context: Proactive Questions to Guide and Evaluate Change Process ..................................... 44
Facilitation: Proactive Questions to Guide and Evaluate Change Process ............................... 48
CHAPTER 4 HEALTHCARE MANAGEMENT AND POLICY IMPLICATIONS
FOR FUTURE POPULATION HEALTH CHANGES ............................................................... 54
Change Reborn: The Genesis of “Population Health Lite”....................................................... 54
Informing Future Population Health Change Initiatives:
Healthcare Management Perspective ........................................................................................ 55
Informing Future Population Health Change Initiatives:
Health Policy Perspective.......................................................................................................... 59
Conclusion................................................................................................................................. 64
REFERENCES ............................................................................................................................. 67

iv
 LIST OF TABLES

Table 1. Prevalence of Cardiovascular Diseases in Adults in the United States ............................ 2

Table 2. Estimated Inpatient CVD Procedures and Mean Hospital Charges - 2010 ...................... 3

Table 3. Mortality Percentages for Cardiovascular Disease in Adults in the United States ........... 6

Table 4. Total Volume of Cardiovascular Services - UIHC ......................................................... 13

Table 5. Risk Calculation Variables ............................................................................................. 25

Table 6. Cash Flow Models .......................................................................................................... 27

Table 7. Stetler, et al. PARiHS Update ......................................................................................... 38

v
 LIST OF FIGURES

Figure 1. Referral into the HVC ................................................................................................... 14

Figure 2. General Cardiology Treatment Pathway ....................................................................... 14

Figure 3. Sub-Specialty Pathway and Care Management Program .............................................. 15

Figure 4. Prevention Pathway ....................................................................................................... 18

Figure 5. Proposed "Heart Failure Lite" Model ............................................................................ 20

Figure 6. Example of Education Module ...................................................................................... 22

Figure 7. Scale for Measuring High/Low Evidence: Clinical Experience Sub-Element .............. 34

Figure 8. PARiHS 3D Matrix ....................................................................................................... 35

vi
 CHAPTER 1

PREVALENCE AND ADVERSE CONSEQUENCES OF CARDIOVASCULAR DISEASE IN

THE UNITED STATES

Living a life filled with alcoholic beverages, unhealthy meal selections, cigarette

smoking, and no exercise led James Young II down a precarious path. Weight gain, swollen legs,

and labored breathing became the norm. Young chose to forego treatment, not understanding the

danger these warning signs presented. When Young finally sought medical advice, he was

diagnosed with hypertension, Type 2 diabetes, pneumonia, and kidney disease. Further

monitoring from his physician revealed Young’s heart was functioning at 30 percent of normal.

Shortly thereafter, Young’s heart function dropped to 20 percent. Young was admitted to

hospital where he was informed had he waited much longer to seek treatment, he would have

died.

This brush with death was all the motivation Young needed to make the necessary

changes in his life. Alcohol, smoking, and fast food turned into health greens, protein, and

exercise. Though the process was long and laborious, Young was able to build his stamina to the

point he could run or walk on the track up to 11 miles.

His experience with heart failure exemplifies how easy it is for individuals to exhibit

risky behaviors that endanger their well-being. Young’s success in overcoming his illness

highlights the possibility of altering these behaviors, and the benefit that can be derived from this

transformation. Providers, payers, and patients can work together to develop a system of care

that helps individuals struggling to make the necessary alterations to their risky behaviors to

improve health outcomes and create a healthy population.

1
Cardiovascular Disease in the United States

As of the 2017 Update from the American Heart Association, 92.1 million American

adults have one or more cardiovascular diseases (CVD). (Benjamin, et al., 2017); (Centers for

Disease Control and Prevention, 2016). The diseases and diagnoses included in the total CVD

count—as determined by the American Heart Association—include, but are not limited to, high

blood pressure, coronary heart disease, myocardial infarction, chest pain, heart failure, and stroke

(Benjamin, et al., 2017); (Centers for Disease Control and Prevention, 2016).

Table 1. Prevalence of Cardiovascular Diseases in

Adults in the United States

High Blood Pressure 85.7 million

Coronary Heart Disease 16.5 million

Chest Pain 8.7 million
Myocardial Infarction 7.9 million

Stroke 7.2 million

Heart Failure 6.5 million

With CVD expenditures equating to roughly 17% of all healthcare related expenditures in

the US, treating and managing these diseases and their associated complications places a

significant economic burden on the non-provider stakeholders who maintain the responsiblity for

financing the care (Ojeifo & Berkowitz, 2015). Data from the Medical Expenditure Panel Survey

(MEPS) calculates the total economic impact—direct and indirect costs—at nearly $316.1 billion

(Benjamin, et al., 2017). Direct costs equate to $189.7 billion, with the largest percentage of that

total being attributed to inpatient stays at $88.3 billion (Benjamin, et al., 2017). Visits to an

ambulatory clinic for CVD-related issues totaled $41.5 billion, and prescription medication costs

2
were $32.4 billion (Benjamin, et al., 2017). Indirect costs attributed to lost productivity equaled

$126.4 billion (Benjamin, et al., 2017). The American Heart Association projects increases in

these costs over the next decade. By 2030, projections indicate the direct medical cost of CVD

will reach $918 billion, and the indirect costs will reach $290 billion (Benjamin, et al., 2017). In

each scenario, the high costs placed upon patients, payers, and other non-provider stakeholders

translates into significant revenue for hospitals, physicians, and other practitioners.

A large portion of these high costs can be attributed to the volume of services and

procedures used to treat CVD, which has grown significantly over time. From 1979 to 2003,

inpatient procedures for CVD-related illnesses increased 470% (Mensah & Brown, 2007). From

2000 to 2010, the number of inpatient procedures for CVD-related illnesses rose from an

estimated 5,939,000 to an estimated 7,588,000, a 28% increase (Benjamin, et al., 2017). The

charges for these procedures have increased in a similar fashion, and are often financial drivers

for many healthcare institutions (Table 2) (Mensah & Brown, 2007).

Table 2. Estimated Inpatient CVD Procedures and

Mean Hospital Charges - 2010
Mean Hospital
Procedure Total
Charges
Valves 106,000 $192,703.00

Angioplasty 955,000 N/A

PCI 500,000 $79,354.00

Cardiac Revascularization 397,000 $160,477.00

Cardiac Catheterization 1,029,000 $54,489.00

Pacemakers 370,000 $79,616.00

Implantable Defibrillator 97,000 $159,283.00

3
Table 2. cont.
Endarterectomy 100,000 $41,873.00

Heart Transplantation 2,804 $758,847.00

Total 7,588,000 $84,691.00

The high costs associated with cardiovascular diseases can be attributed to the complexity

and inherent variability associated with these illnesses, leading to significant downstream

utilization of care. For example, data from the Agency for Healthcare Research and Quality

(AHRQ) shows three different CVD diagnoses—congestive heart failure, cardiac dysrhythmias,

and acute myocardial infarction—within the top ten conditions related to all-cause, 30-day

readmissions (Hines, Barrett, Jiang, & Steiner, 2014). Further studies support this propensity for

high utilization rates among diagnosed patients. One study that included nearly 40,000 patients

who were admitted to the hospital with a heart failure diagnosis showed a 24% readmission rate

among these patients within 30 days (McHugh & Ma, 2013). Similarly, results from the same

study showed a 20% 30-day readmission rate among nearly 12,000 patients admitted to the

hospital with acute myocardial infarction (McHugh & Ma, 2013). Other studies that include data

for all Medicare fee-for-service beneficiaries found the 30-day readmission rates for acute

myocardial infarction and heart failure was 19.9% and 24.4%, respectively (Krumholz, et al.,

2009). Beyond the standard 30-day measurement, researchers have found that 45% of patients

discharged with a heart failure diagnosis were readmitted to the hospital within six months

(Ross, et al., 2009).

Regarding emergency department visits, CVD-related heart conditions—non-specific

chest pain, congestive heart failure, cardiac dysrhythmias—were among the primary reasons for

4
ED visits resulting in hospital admissions for individuals age 45-85+ (Weiss, Wier, Stocks, &

Blanchard, 2014). Emergency department visits for CVD-related complications resulted in $9.2

billion in direct medical costs (Benjamin, et al., 2017). Patients with a heart failure diagnosis

present to the emergency department an average of 958,167 times each year (Storrow, et al.,

2014). After presenting to the emergency department, 83.7% of these patients are admitted to the

hospital (Storrow, et al., 2014). Substantial regional variation exists in the treatment of these

patients meaning heart failure may have significantly different experiences in care depending on

which part of the country they reside (Storrow, et al., 2014). These variations impact each

patient’s health status, and also carry financial implications for the patient through elevated

costs, and for the provider organizations through increased revenue. Efforts can be made to help

patients avoid unnecessary emergency care. Researchers in Germany found that almost 20% of

all emergency department visits are preventable, and of that number nearly half of the

preventable visits were for angina, heart failure, and hypertension (Mockel, 2016). Reducing

unnecessary utilization of these services will have significant financial implications, and patients

will experience an improved health status.

Death is a common result of the presence of these diseases. For the past 116 years—

excluding 1918—CVD has been the leading cause of death in the United States for both men and

women (Benjamin, et al., 2017). The latest data indicates CVD accounts for more than 800,000

deaths per year, or one out of every three deaths (Table 3) (Benjamin, et al., 2017). Table 3

details the mortality percentages for the diseases and diagnoses included in the total CVD count.

Statistics indicate improvements in CVD mortality. From 2004-2014, the death rate per

100,000 from CVD declined almost 25.3%, while the number of actual deaths decreased nearly

6% (Benjamin, et al., 2017). This decrease follows a similar trend that began in the 1960s when

5
CVD death rates were at their highest (Luepker, 2016). Debate continues about the causality

behind this decrease with many researchers arguing in favor of primary preventive techniques,

and others arguing in favor of secondary prevention efforts (Luepker, 2016). Regardless of the

cause of the decline, if all cases of CVD were eliminated, life expectancy would increase by

nearly seven years (Benjamin, et al., 2017). For comparison purposes, if all cancer cases were

eliminated, the increase in life expectancy would increase roughly three years (Benjamin, et al.,

2017).

Table 3. Mortality Percentages for Cardiovascular

Disease in Adults in the United States

Coronary Heart Disease 46.2%

Stroke 16.1%
High Blood Pressure 9.0%
Heart Failure 8.1%

Diseases of the Arteries 3.2%

Other 17.4%

Although the decline in mortality rates indicates movement in a positive direction, the

incidence and prevalence of CVD continues to rise (Benjamin, et al., 2017). Given the adverse

nature of CVD—both in terms of health outcomes and in terms of its economic burden—the

federal government and private payers have begun experimenting with alternative payment and

delivery arrangements to address the clinical and financial issues associated with these diseases

with an emphasis on rewarding institutions that can prevent the onset of chronic illnesses like

CVD (Centers for Medicare and Medicaid Services, 2017). In response, healthcare provider

organizations have been working to develop innovative treatment pathways to better manage the

6
prevalence of CVD in their communities, and to assist in reducing the economic burden

associated with these illnesses.

Because the economic burden of CVD is so large on patients and payers, payment and

delivery experimentation must begin to explore solutions that will significantly reduce costs in

the long-term. One of these methods is a preventive approach to CVD. Successful prevention of

CVD across significant portions of the population would result in a noticeable reduction total

healthcare expenditures, meaning fewer costs being passed on to any individual, employer, or

government entity responsible for paying for insurance coverage. A statistical analysis from the

AHRQ using data from the MEPS 2009 Full Year Consolidated Data File found that the average

cost of a patient receiving care for CVD was $4,279 (Uberoi & Cohen, 2012). Other studies

indicate even higher annual direct medical costs. A study from 2010 that included expenditure

data for 12,278 patients on the Kaiser Permanente Northwest CVD registry found the average

annual direct medical cost for CVD to be $18,953 (Nichols, Bell, Pedula, & O'Keeffe-Rosetti,

2010). Looking at more specific CVD diagnoses, a study from 2011 observed the lifetime costs

of heart failure in one county in Minnesota over the span of 19 years. Results from the study

indicate that after a heart failure diagnosis the average lifetime medical costs were $109,541

(Dunlay, et al., 2011). Lifetime costs were measured from the initial diagnosis until the patient

died or no longer sought treatment for heart failure.

In any scenario, successful prevention efforts will have noticeable economic effects, and

as the federal government continues to emphasize prevention efforts—one recent effort is

striving to prevent one million heart attacks and strokes by 2017—relevant stakeholders have an

opportunity to take advantage of the situation to improve the well-being of their populations, and

the financial performance of their organizations (Centers for Medicare and Medicaid Services,

7
2017). A basic simulation using the cost data from the study of Minnesota residents—~$110,000

lifetime average cost for heart failure patient with an average lifetime with the disease of 4.5

years equates to ~$24,400 annual cost per patient to treat heart failure—indicates the potential

benefit for payers and providers alike in pursuing prevention efforts. If an organization treats

2,300 heart failure patients each year, the total payment to the providers and cost to the insurance

company and employer/government is $56,120,000. If that same organization prevented 5% of

those heart failure diagnoses, and subsequently reduced the average cost of each prevented

patient to $10,000 per year, the cost savings would be nearly $1.7 million.

From the perspective of the patient, avoiding a costly and dangerous heart failure

diagnosis is a positive and desired outcome. From the perspective of the payer (insurance,

employer, government, etc.), $1.7 million likely represents significant savings and improved

financial performance and stability. From the perspective of the provider, as more and more

payers continue to tie reimbursement to cost, quality, and outcomes, this $1.7 million result

represents strong performance in a contemporary service delivery environment. To facilitate this

prevention effort, all involved parties must collaborate to develop mutual incentives that result in

desired outcomes for the patient, and positive financial performance for payer and provider

organizations.

The literature regarding general preventive techniques is inconclusive, and debate

continues as to it long-term effectiveness. However, studies with a more specific focus on CVD

prevention indicate the potential for cost-effective approaches, particularly interventions

surrounding smoking cessation and the use of statins, and can be used as the basis of a

prevention initiative (Franco, Kinderen, De Laet, Peeters, & Bonneux, 2007); (Cohen, Neumann,

& Weinstein, 2008); (Ward, et al., 2007). Using this shift toward—and potential benefit of—the

8
prevention of chronic illnesses like CVD, the following chapters will outline the clinical redesign

efforts of one cardiology outpatient clinic at the University of Iowa Hospitals and Clinics

(UIHC). The redesign focused on transitioning away from the traditional fee-for-service delivery

model that rewarded organizations for treating individuals after they were diagnosed, to a

population health model that emphasized the prevention of these illnesses. The new model was

predicated on enhanced risk identification practices, and worked to empower patients to become

active members in the maintenance of their care. Although the change effort ultimately failed,

this case study will highlight the efforts made by the multidisciplinary team, identify the

variables that led to the demise of the project, and how a subsequent projects that focus on

population health management can experience more success in facilitating change.

9
 CHAPTER 2

EFFORTS TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE

External Environment: Alternative Payment and Delivery Reform

With the passage and implementation of the Patient Protection and Affordable Care Act

(ACA) came a wave of experimentation with alternative payment and delivery methodologies.

Created through Section 3021 of the ACA, the Center for Medicare and Medicaid Innovation

(CMMI) was developed to pilot these innovative payment and delivery models in an effort to

identify viable alternatives to the long-standing system of fee-for-service delivery. Some of the

more prominent programs developed by CMMI include the Medicare Shared Savings Program

and Accountable Care Organizations (ACO), Bundled Payments for Care Improvement

Initiative, and the Comprehensive Primary Care Plus program, among others.

Beyond developing these new payment and delivery models, CMMI conducts yearly

evaluations of all models, determining their impact on cost and quality. Given the results, CMMI

has the authority to collaborate with other stakeholders throughout the country to further develop

these models and establish them as the primary method of payment and delivery of particular

health care services—see: mandatory bundled payments for orthopedic and cardiac conditions

and procedures. Further, a combination of positive results from these demonstrations and

provider organizations learning how to operate effectively in these environments has led to a

proliferation of payment reforms in the private sector. Regarding ACOs, in 2011 only 64 existed

across the entire country. In the first quarter of 2016, that number had increased to 838 across

public and private payers (Muhlestein & McClellan, 2016). For bundled payments, a tracking

tool from The Advisory Board Company indicates many provider organizations are participating

10
in some type of bundled payment arrangement for a variety of conditions and procedures. These

organizations are either contracting with a private payer, or are contracting directly with large

employers like Wal-Mart or Lowe’s (The Advisory Board Company). As momentum continues

to build for these alternative payment models, lagging organizations who have yet to operate in a

non-fee-for-service environment must consider how this lack of experience may affect their

future financial stability and position within the market.

At the University of Iowa Hospitals and Clinics (UIHC) the focus has been on the

organization’s inclusion in the University of Iowa Health Alliance (UIHA) ACO. The ACO is

comprised of four provider organizations in the region, and is participating in the Medicare

Shared Savings Program (MSSP) Track 1. Absent from the Track 1 arrangement is the threat of a

financial penalty due to poor performance relative to an established spending benchmark set by

Medicare. Other arrangements such as the MSSP Track 3 and NextGen programs include

downside risk, and are growing in popularity (Muhlestein & McClellan, 2016). The existence of

these voluntary programs that include downside risk indicates a desire on the part of the federal

government to shift to that type of arrangement on a larger scale in the future to transform the

delivery of healthcare services into a system based on the foundation of health and well-being.

Maintaining the health of the population and preventing chronic illnesses will be essential under

this type of system, and having little to no experience operating in an environment where

enhanced population health management practices will be the key to success potentially places

UIHC in a precarious position moving forward.

Additionally, succeeding in these arrangements requires the proper identification of risk

factors that would result in an individual requiring expensive hospitalizations and complex

procedures (Colbert, et al., 2014). Risk identification is complex and expensive, and different

11
strategies may work better depending on the characteristics of an organization (Colbert, et al.,

2014). Organizations can put themselves in an advantageous position by identifying which

strategy is best situated for their organization before downside risk arrangements become more

prevalent.

CMS has begun to promote risk stratification and risk reduction with one of its more

recent demonstrations from CMMI. The Million Hearts®: Cardiovascular Disease Risk

Reduction Model was developed as a preventive approach to CVD diagnoses. This program is a

five-year demonstration with the primary goal of reducing the 10-year CVD risk within the

patient population of participating organizations, and the diffusion of the best practices used to

achieve those reductions across the industry. UIHC was selected to participate in this

demonstration that began January 1, 2017. The pursuit of a preventive approach to CVD is a

deviation from the normal fee-for-service delivery structures that are present at many

organizations, including UIHC (Table 3). Economic incentives under the traditional model

rewarded providers for delivering a higher volume of services with little regard for the

maintenance of the health and well-being of the population. Participation in this type of program

indicates a progression toward a more focused approach toward population health, and a

movement away from the approach that UIHC had become accustomed to over many years.

“Sickness Model”: Previous Method of Treating Heart Failure and Other CVD Patients

Given that the overwhelming majority of cardiovascular services delivered by UIHC are

reimbursed on a traditional fee-for-service basis, the focus has remained on generating volume

and offering the most advanced surgical procedures for the treatment of CVD. Table 4 displays

the total volume of these procedures and interventions for FY 2015-2017.

12
Table 4. Total Volume of Cardiovascular Services - UIHC
2015 2016 2017 (projected)
Heart and Vascular Center 10,850 13,106 12,721
Electrophysiology 8,702 9,561 8,918

To drive this volume, multiple pathways existed for patients to be referred into the

various clinics within the Heart and Vascular Center (HVC). First, the patient had to be referred

through a primary care provider. The most common referral pathway was to general cardiology,

but patients could also be directly referred into the multiple sub-specialty clinics within the HVC

(Figure 1). If a patient was referred to the general cardiology clinic—the most common referral

pathway—the cardiologist performed an assessment and determined the proper course of action

which usually involved a “watch and wait” strategy, or required a referral to a sub-specialty

provider (Figure 2). As is common in a fee-for-service environment, the incentives to properly

manage associated CVD risk factors before and after the onset of a diagnosis are not present. In

this type of environment, the treatment pathway often does not begin until the onset of a CVD

diagnosis, and the post-treatment or post-procedural routines are often less robust than is

necessary to ensure proper post-discharge and rehabilitative care.

Understanding that this environment is conducive to increases in unplanned utilization of

care—through readmissions or emergency department usage—the ACA created the Hospital

Readmissions Reduction Program (HRRP) in an effort to change organizational behavior to one

that focuses on adequate and proper post-discharge care. This program penalizes hospitals that

experience excessive readmissions through reductions in their Medicare reimbursements.

Understanding the benefit they could provide to their patients while simultaneously avoiding any

penalties, UIHC began a care management program within the HVC to monitor patients after

13
they had received treatment for a CVD diagnosis. Once a patient had been referred to the sub-

specialty provider, and once they had received treatment for their condition, they were referred

into the care management program associated with each sub-specialty (Figure 3).

Figure 1. Referral into the HVC

Figure 2. General Cardiology Treatment Pathway

14
Figure 3. Sub-Specialty Pathway and Care Management Program

Despite the best efforts of the care managers, the care management programs were

becoming overwhelmed by the volume of patients who required their services. For example, in

November, 2015, the heart failure care management program was at capacity with 750 patients.

At the same time, nearly 2,300 more patients that received care in the heart failure clinic who

were inhibited from those services because of capacity issues. Statements from nurse

management indicated that nearly all of these patients would have benefited from the care

management services. As was noted above, the threat of unintended readmissions and emergency

department utilization is significantly increased for CVD patients, and the limited capacity of the

care management programs only compounds the issues faced by individuals following CVD

treatments and procedures. Efforts can be made before and after the diagnosis and treatment of

CVD to both assist in preventing the onset of these diseases, and to ensure patients receive

adequate post-discharge care to mitigate the threat of adverse outcomes.

The traditional modalities of care delivery under the “sickness model” directly

contradicted the preventive nature of the Million Hearts® demonstration, and limited the ability

of the organization to succeed within the program, both clinically and financially. To better

15
operate within the parameters set by the demonstration, UIHC was forced to develop a new

delivery model that would align the practice patterns of the participating providers with the

desired outcome of the program. The change process associated with this new delivery model

was a unique opportunity to examine the dynamics involved with organizational change, and the

amount of effort required to overcome deeply institutionalized behaviors and attitudes associated

with healthcare delivery at UIHC.

New Model: Prevention through Patient Engagement and Self-Management

In February, 2015, it was announced that UIHC had acquired a local cardiology practice,

and in May of the same year the four cardiologists and two nurse practitioners associated with

that practice began seeing patients at their new location. Shortly after the acquisition, the lead

physician of this practice approached members of the College of Public Health about assisting in

the development of population health principles within the outpatient cardiology clinic. A small

multi-disciplinary team comprised of the lead physician, three nurses, an administrator, and two

public health researchers was developed to explore the best opportunities for the clinic and for

UIHC. After brainstorming possible interventions, the team decided to focus its efforts on the

prevention of heart failure with an emphasis on risk identification, patient self-management, and

enhanced care management.

Affecting nearly 6 million adults in the United States each year, heart failure is an

expensive and dangerous diagnosis. Nearly half of the individuals who develop heart failure in a

given year will die within five years of that diagnosis, and data from the American Heart

Association indicates that heart failure was listed a contributor in the cause of death for 1 in 8

deaths (Benjamin, et al., 2017) (Centers for Disease Control and Prevention, 2016). Heart failure

has a significant financial impact on the healthcare industry due to the increase in the utilization

16
of services, the expensive medications required, and the amount of work an individual must

miss. Estimates put the total cost of heart failure at almost $40 billion per year (Centers for

Disease Control and Prevention, 2016). Understanding the burden that capacity issues placed on

the heart failure care management program at UIHC, the project team believed targeting heart

failure would help alleviate this strain. Further, because the risk factors for heart failure are

similar to those of other CVD illnesses, by successfully modifying those risk factors through

prevention efforts, not only would the prevalence of heart failure be reduced in the population,

but reductions in the prevalence of other CVD-related illnesses would also be realized (American

Heart Association, 2016).

Recalling the pathways depicted in Figure 2 and Figure 3, patients were primarily

funneled through the general cardiology clinic where they followed two pathways, either wait

and monitor any concerns, or they were referred to high cost sub-specialty clinics like the heart

failure clinic. The project team proposed a pathway that would allow for a diversion from the

traditional heart failure pathway (Figure 4). This pathway would be utilized by individuals who

had not yet been diagnosed with heart failure or any other form of CVD, but exhibited certain

risk factors that indicated a likelihood of disease progression in the near future. Preventive

interventions within this pathway included an enhanced patient education platform and also

included wearable technology, allowing for patient engagement outside of the clinic. By

providing the infrastructure and resources, the project team hoped to develop an understanding of

heart failure at the individual level. Using this knowledge as a foundation, the goal was to instill

enough confidence in each patient that if they were confronted with any complications (e.g.

weight gain, swelling, dyspnea, etc.) they would be able to manage the symptoms without

provider intervention.

17
Figure 4. Prevention Pathway

To further alleviate the burden placed on care managers under the previous “sickness

model,” we proposed an enhanced care management pathway. This pathway would improve the

care management already being delivered, and would also provide a pathway for those

individuals with a moderate risk profile who had not yet been diagnosed with heart failure, but

were also not likely to succeed in the patient education and self-management pathway. This

enhanced care management strategy would include the services of a pharmacist and social

worker in addition to traditional cardiology services to ensure all of the patient’s biopsychosocial

needs were being met.

With these developments, the final “Heart Failure Lite” proposed model was comprised

of four distinct pathways that would be utilized by different patients depending on their risk

profile and other individual characteristics (Figure 5). The first pathway was for individuals who

exhibited very few risk factors, but still had enough concerns that they sought the care of a

18
cardiologist. Clinicians on the team often referred to these patients as the “worried well.” The

second and third pathways were the previously described patient self-management and care

management programs. The final pathway was for individuals who exhibited too many risk

factors and were likely beyond the scope of our preventive approach, and would likely need

treatment for a diagnosis in the near future. Risk calculation used for pathway selection was

derived from the American College of Cardiology and American Heart Association Heart Risk

Calculator which played a central role in the aforementioned Million Hearts® demonstration.

Using historical patient data on roughly 1,600 patients, the project team was able to

conduct an initial risk assessment to develop a better understanding of the breakdown of pathway

utilization. This initial assessment indicated that 5% and 22% of patients would be directed into

the first and fourth pathways, respectively. For the low-to-moderate risk pathway and the

moderate-high risk pathway, 41% and 32% of patients would be funneled into those respective

services. Considering these two pathways were the primary focus of our project, and a significant

deviation from the traditional delivery methods, these high percentages were a strong indication

of the potential effect our interventions may have if successful.

Patient Education Intervention

When considering how UIHC could best inhibit the onset of heart failure and other heart

diseases, the project team believed emphasis should be placed on modifiable risk factors. In

addition to clinical risk factors, non-clinical factors like socio-economic status—more

specifically education level and health literacy—play a critical role in the development of these

illnesses (Lee, Paultre, & Mosca, 2005). Evidence shows that individuals with lower health

literacy capabilities face greater difficulties related to their general physical and mental function

(Wolf, Gazmararian, & Baker, 2005). This decrease in general health and well-being has

19
downstream effects on higher acuity diseases and diagnoses. A lower education level and poor

health literacy not only leads to a higher prevalence of heart disease, but it also inhibits

preventive efforts like the ones proposed in the “Heart Failure Lite” model (Zavertnik, 2014)

(Bennett, Chen, Soroui, & White, 2009). Health literacy has been defined as a basic level of skill

and ability that a person needs to function within the environment of care (Berkman, Sheridan,

Donahue, Halpern, & Crotty, 2011). Further, the applicable skills and abilities include, but are

not limited to, reading comprehension, quantitative understanding, and medication adherence

(Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011). An important aspect of the proposed

preventive approach is the adherence to a medication regimen. As some studies have shown,

individuals with lower health literacy scores are more likely to exhibit poor behaviors related to

medication adherence (Macabasco-O'Connell, DeWalt, Broucksou, & Hawk, 2011)

(Gazmararian, Williams, Peel, & Baker, 2003).

Figure 5. Proposed "Heart Failure Lite" Model

20
 To address these issues associated with lower education levels and poor health literacy,

the project team partnered with a local patient education organization to develop a well-defined

patient education product that went beyond a typical informational brochure or other handouts.

The goal was to build upon the company’s existing heart failure products (Figure 6) to create

something that aligned with the focus of prevention. One aspect the project team wanted to add

to the existing modules was an interactive quiz/testing application. This application would ensure

that the patient was fully focused on the educational module, and would also allow the care team

to assess how well each patient was understanding the materials. If a patient was not completing

the modules or was not successfully passing the quizzes, steps could be taken by the care team to

remedy any issues or concerns. The education program was comprised of multiple modules that

were completed in succession. This longitudinal focus would create a stronger learning

environment and would improve the chances of the patient truly understanding heart failure as an

illness and what they could do to prevent a future diagnosis.

To ensure that the patient understood how to properly access and utilize the education

modules, they would complete the first module in the clinic with nurse supervision. Subsequent

modules would then be completed by the patient outside of the clinic at their convenience. The

modules could be accessed through any multimedia platform so long as the patient had access to

the internet. Notice of completion and the results from the embedded quizzes would be self-

reported by the patient through the patient portal. Patients without internet access would be

excluded from the patient education pathway. The ideal result from this educational program

would be to provide the patient with enough information and knowledge that if they were

confronted with a heart issue they would have the capacity to manage the situation on their own

without the need for provider intervention.

21
Figure 6. Example of Education Module

Patient Activation and Self-Management

The primary focus of self-management programs is to enhance the ability of the patient to

identify the symptoms related to their condition, and to provide the knowledge and protocol as to

how to respond to those symptoms. Self-management programs have been implemented for a

variety of illnesses including diabetes, asthma, and COPD, but many programs have also been

developed to manage heart failure (Barnason, Zimmerman, & Young, 2011). Studies have shown

the positive impact—both economically and at the individual level—self-management programs

have for coping with heart failure, including reduced utilization and improved quality of life

(Moser, Dickson, Jaarsma, & Lee, 2012); (Riegel, et al., 2009); (Dickson, et al., 2014). In

addition to improved health literacy, self-management programs can be enhanced through patient

activation where the patient plays a critical and active role in the care process.

Patient activation is a relatively new concept developed by Judith Hibbard and her

colleagues. Hibbard and her team were responsible for the development of the Patient Activation

Measure, which is a tool designed to capture a patient’s “knowledge, skill, and confidence

related to managing his or her health and health care” (Hibbard, Mahoney, Stockard, & Tusler,

2004); (Green, Hibbard, Sacks, Overton, & Parrotta, 2015). The growing body of literature

22
indicates a strong relationship between activation and healthy behaviors (Rask, et al., 2009);

(Hibbard & Greene, 2013). A study in 2012 from Hibbard and Jessica Greene measured the

effect of patient activation on 13 outcomes across four domains—prevention, healthy behaviors,

clinical measures, and expensive utilization. The results showed that in 12 of the 13 outcomes,

activation was related in the expected direction (Hibbard & Greene, 2012).

Critical to the conceptual framework of the “Heart Failure Lite” proposal is the relation

of activation to self-management and the pursuit of healthy behaviors to prevent/delay a

particular illness. First, a study from 2007 indicates that the Patient Activation Measure provides

a more accurate representation of how patients will respond under a self-management program,

and has been shown to be an effective tool in making determinations about self-management

(Mosen, et al., 2007). Second, a study from Hibbard and her colleagues measured the effect of

health literacy and activation on healthy behaviors and self-management behaviors. The findings

from this study show a positive relationship between literacy and the behavioral outcomes

(Greene, Hibbard, & Tusler, 2005). This study then went one step further and found that patient

activation is a strong predictor of healthy behaviors and proper self-management capabilities

(Greene, Hibbard, & Tusler, 2005). Building off this research, the project team at UIHC

proposed tracking activation levels and measuring the impact different activation levels would

have on self-management capabilities.

Despite the scientific evidence supporting the development of this alternative delivery

model, the initial request for financial support to fund the project and build the necessary

infrastructure was not made available when the project was initially proposed. Heart failure is a

valuable revenue stream and its associated treatments and procedures provide great financial

benefit to the organization. The “Heart Failure Lite” model stood in direct contrast to the

23
traditional delivery model, and therefore presented a restriction on the valuable heart failure

revenue stream. Verbal support was given to further develop this delivery model, but the project

team was forced to seek external resources to build the final product. The Million Hearts®

demonstration put forth by CMS both aligned with the goal of preventing the onset of CVD, and

provided the financial resources to assist the operations of the new delivery model at UIHC.

CMMI Million Hearts®: Cardiovascular Disease Risk Reduction Model

First announced in the summer of 2015, the Million Hearts® initiative is a randomized

controlled trial where healthcare providers are encouraged to develop population health

strategies to combat the issues associated with CVD. Participating organizations utilize risk

stratification and predictive modelling techniques to better understand the total risk within their

patient population, and to identify those individuals who are most at risk of developing a serious

illness. The program targets all Medicare fee-for-service beneficiaries who are 40-79 years of

age, with limited exclusion criteria. CMMI received 762 applications, and after the review

process, 516 organizations were selected to participate. After randomization, the organizations

were split 260 to 256 for the intervention and control groups, respectively (Centers for Medicare

and Medicaid Services, 2017). In total, CMMI expects nearly 3.3 million individuals to be

included in the trial that will last until December 2022 (Centers for Medicare and Medicaid

Services, 2017).

The model uses a risk calculator developed by the American College of Cardiology and

the American Heart Association as the primary risk identification tool. The calculator includes

ten different variables to determine each patient’s 10-year CVD risk score (Table 5). The

algorithm used in calculating the risk score was originally published in the 2013 ACC/AHA

Guideline on the Assessment of Cardiovascular Disease Risk (Goff, et al., 2013). Participating

24
organizations in the intervention group receive a one-time $10 payment for every eligible

beneficiary who receives a risk calculation. In year one, CMMI will make monthly $10 payments

per beneficiary for the management of the highest risk patients (30% chance of developing CVD

in 10 years). In years 2-5, the payment fluctuates based on how much the aggregate risk score for

the population decreases. If the aggregate score decrease is greater than 10%, the organization

receives $10 per beneficiary. If the score decreases 2%-10%, the organization receives $5 per

beneficiary. Anything less than a 2% reduction, the organization receives no payment.

Table 5. Risk Calculation Variables

1) Age 6) Use of Statin Therapy

2) Race 7) Antihypertensive Medication

3) Total and High-Density Lipoprotein (HDL) 8) Use of Aspirin Therapy

Cholesterol Levels

4) Low-Density Lipoprotein (LDL) Cholesterol 9) Smoking Status

Levels

5) Systolic Blood Pressure 10) Diabetes Status

UIHC submitted the application to participate in the trial in September 2015, received the

notice of acceptance into the program in early 2016, and was randomized into the intervention

group shortly after. The participating providers included 9 cardiologists and nurse practitioners,

and an initial assessment indicated that this group would expect to see roughly 2,100 eligible

beneficiaries. This assessment also provided an estimate of the expected cash flows for the

various scenarios (Table 6). These cash flow models were used to try and convince the

leadership of UIHC to lend resources and support to the project. Although these numbers were

derived from historical data, and were predicated on the hypothetical success of the new model,
25
the project team believed the potential financial value presented by this initiative was

meaningful.

A key variable in promoting organizational change is effective communication of the

purpose and objectives of the proposed change. Meetings, presentations, electronic

communications, and other form of personal interaction need to be leveraged as opportunities to

promote the desired goal and how the new change will help the organization arrive at that goal

(Armenakis, Harris, & Mossholder, 1993). The project team for the Million Hearts®

demonstration was effective in arranging meetings with multiple members of the leadership team

as well as departmental administrators and other interested stakeholders. Department-level

meetings included social work, legal, nurse management, care management, eHealth &

eNovation, and pharmacy, among others. Many of the meetings involved presentations outlining

the inadequacies of the current process, the future changes as established by the ACA, and the

potential gains for the patient and the organization that would accompany the successful

implementation of the Million Hearts® demonstration.

Similar presentations were made to the administrative and clinical leadership of the HVC

and of the organization at-large in an attempt to draw down necessary resources. These

individuals believed the elements of this project were a step in the right direction regarding

population health practices. The project team was instructed to construct a project charter and

budget detailing the steps needed to develop the program as well as the financial requirements

needed to fund the team and build the infrastructure. These documents were distributed to

members of the leadership team, and updates were made to the document as steps were

completed. As the project team progressed through the development process, the need for

financial support grew increasingly more apparent, yet no money had been made available from

26
the organization, and the earliest any payment would be received from CMS related to the

Million Hearts® demonstration was more than a year-and-a-half away. The project team

continued working to ensure adequate levels of infrastructure development, workflow processes,

and data management capabilities were in place by the projected start date.

Table 6. Cash Flow Models

Million Hearts Financial Models
Participating Providers 9
Eligible Beneficiaries September and August 821
Estimated Annual Eligible Beneficiaries 4,926
% of High Risk Beneficiaries 10%
High Risk Beneficiaries 493
Risk Assessment Payment $ 20.00
Intervention 2-10% aggregate absolute risk reduction for high risk $5
Intervention >10% aggregate absolute risk reduction for high risk $10
% of NEW Patients seen each year 43%
Weighted Average Cost of Capital 10.2%

NPV Intervention Group 2-10% $221,104.47

NPV Intervention Group >10% NPV $297,919.41

Intervention Group Cash Flows 2-10% 2016 2017 2018 2019 2020 2021
Cardiovascular Disease Risk Stratification Payment $49,260 $21,181.80 $21,181.80 $21,181.80 $21,181.80
Year 1 high-risk participant $59,112
Per Member/Per Month (years 2-5) $29,556 $29,556 $29,556 $29,556
Expense
Net Cash Flow $0 $108,372 $50,738 $50,738 $50,738 $50,738

Intervention Group Cash Flows >10% 2016 2017 2018 2019 2020 2021
Cardiovascular Disease Risk Stratification Payment $49,260 $21,181.80 $21,181.80 $21,181.80 $21,181.80
Year 1 high-risk participant $59,112
Per Member/Per Month (years 2-5) $59,112 $59,112 $59,112 $59,112
Expense
Net Cash Flow $0 $108,372 $80,294 $80,294 $80,294 $80,294

Late in the project schedule, unexpected obstacles related to data aggregation and risk

calculation began to manifest. In November 2016, roughly six weeks before the Million Hearts®

demonstration was set to go-live, data analysis was conducted over a two week period on a set of

patients to trial the data capturing capabilities within the clinic. Results of the analysis indicated

a major problem with the ability to collect all necessary data points needed for the risk

27
calculation. Data for 79% of the patients each week was missing, and therefore a risk calculation

could not be completed. Because of the rural nature of the state of Iowa, many of the patients

seen in the cardiology clinic had traveled significant distances for this specialty care. Many of

these patients receive primary care closer to their place of residence, and often have their lab

tests performed in these settings, not at UIHC. Therefore, their cholesterol data had not been

entered into UIHC’s electronic health record system. One response to this issue was to draw labs

for every patient included in the trial while they are being seen in the clinic. However, Medicare

payment policy stipulates they will only pay for one lab draw per year, and any costs incurred for

subsequent tests will fall directly on the patient.

Not wanting to commit to this expense, the project team sought another solution to this

issue, the addition of a part-time nurse who would be solely responsible for collecting missing

data. A time analysis conducted by the clinical members of the project team indicated that the

workload for this individual to collect all missing data was equivalent to a .6 FTE. Placing this

additional responsibility on the existing clinical staff would create an undue burden. An offer

was made to have an available graduate student with nursing certification fulfill these services as

a graduate assistantship, but the offer was never acknowledged. A request was placed with

members of the leadership team for additional personnel, but the hiring practices at the

organization were a significant obstacle. These practices require permission and approval at

multiple levels of the organization with the chief executive officer making the final

determination of every hire. The request for additional personnel was summarily denied.

The inability to collect the necessary information and the failure to obtain additional

support greatly affected the number of patients that the providers would be able to include in the

demonstration, significantly deflating the initial cash flow projections. Further, as more

28
information became available from CMS about the clinical requirements and financial payments,

concerns arose from members of the leadership about how this demonstration would affect the

spending threshold for the ACO. The charges associated with the clinic visits that would be

necessary to collect the requisite data would be used against the benchmark, and the payment

received for successfully reducing the aggregate risk was also believed to be counted against the

benchmark. The ACO was of much greater stature and importance within the organization, and

any threat to its success was cause for concern for members of the leadership team. These issues

created a perfect storm that led to the eventual demise of the Million Hearts® demonstration, and

a complete scrapping of the “Heart Failure Lite” model.

Although the “Heart Failure Lite” model was developed using sound scientific evidence,

the contextual environment was unfavorable toward this type of change from the outset.

Organizational change theory states that contextual environments that present obstacles to

progressive population health changes can be overcome with strategic planning and guidance

through the change process. Individuals leading change efforts must proactively survey the

environment in which the change will be functioning to frame the manner in which it will be

introduced to all stakeholders to increase their chances of successfully implementing their

initiative.

29
 CHAPTER 3

ASSESSMENT OF CHANGE FAILURE USING ORGANIZATIONAL CHANGE THEORY

To fully assess why this initiative did not succeed, the failure must be viewed through the

lens of organizational change theory and implementation science. From the outset, the change

process faced strong organizational resistance in that it challenged the long-standing institutional

structures and processes. The change presented a direct threat to the organization and the service

delivery structures that had proven profitable over time. Successfully implementing the new

delivery model would have require a detailed diagnostic evaluation of the evidence on which the

model was predicated, the contextual environment in which it was introduced, and the

individuals charged with shepherding the program through the process. A detailed

implementation framework can be utilized to retrospectively assess each of these elements to

determine the strengths and weaknesses associated with this change process. Ultimately, the

“Heart Failure Lite” model was unable to leverage its scientific base to overcome the complex

and interwoven institutional structures, and would have benefited from more refined facilitation

practices.

Change Theory: Existential Resistance and Structural Inertia

When organizing a change effort, the project team must take critical steps to overcome

the natural tendencies that cause organizations to resist change. These natural tendencies are

derived from the idea that the day-to-day operations of an organization persist—and therefore the

organization persists—because of the routinization of processes and protocols (Hannan &

Freeman, 1984) (Amburgey, Kelly, & Barnett, 1993). Consumers prefer the reliability that

results from this routinization, and any disruptions in the stability of these routines presents the

30
possibility of consumers being disrupted. Therefore, changes or disruptions are direct threats to

the existence of the organization (Hannan & Freeman, 1984) (Amburgey, Kelly, & Barnett,

1993).

As routines become more institutionalized over longer periods of time, the organization

has a greater chance of achieving the reliability that is preferred by consumers that allows

organizations to sustain their existence. When an organization maintains its existence over these

long periods of time, its routines and processes become embedded to the extent that a change

becomes more hazardous than it would to a younger organization with less developed routines

(Amburgey, Kelly, & Barnett, 1993). This is demonstrated in the formalized routines and clinical

processes within UIHC which have provided the organization significant levels of financial

success. Regarding the clinical redesign project, the “Heart Failure Lite” model presented a

significant disruption to the standard delivery methods that have proven fruitful over long

periods of time. Further, proposing a delivery model that would ultimately shift the focus to

prevention and population health would not only affect internal processes, but it would also

significantly alter the external relationships, routines, and processes UIHC has maintained with

the various healthcare insurance providers, creating a multiplicative disruptive effect. By

maintaining the status quo, both internal and external processes remain stable, the participating

organizations are reaffirmed in their ability to operate reliably within the current structures, and

the likelihood of a similar proactive change continues to diminish.

Though change presents an existential threat to organizations, examples of change are

plentiful, and new ideas for change can often benefit from previous examples where the

organization experienced successful implementation. The behaviors, experiences, and processes

associated with that successful change are formalized by the organization, and are likely to

31
resurface in future changes (Amburgey, Kelly, & Barnett, 1993). Implementation scientists have

labeled this formalization process as “modification routine,” and use it to demonstrate the idea

that organizations learn to change through previous changes, and those previous changes foster

similar changes in the future (Nelson & Winter, 1982); (Amburgey, Kelly, & Barnett, 1993).

When proposing the “Heart Failure Lite” model, the project team was working without a

previous change of a similar kind to use as a model or guide. In the absence of similar change

precedence, the project team was unable to offer previous experiences that could be used as

change guideposts. As a consequence, because the implementation of the “Heart Failure Lite”

model failed, its impact on individuals and teams within the organization who seek similar

changes will be limited, and therefore similar change efforts in the future will have a greater

chance of experiencing similar failures. This death spiral of proactive and alternative change

efforts further exacerbates the persistence of structural inertia and the status quo.

Recognizing the dynamics and nuances associated with these inherent survival

mechanisms is important for the project team in overcoming these forces associated with

structural inertia. Previous organizational change theory demonstrated the need for a change

agent to help drive change and to lead the effort against structural inertia. This individual is

responsible for proactively building support and enthusiasm for a potential change by influencing

the long-standing attitudes, principles, and behaviors of the organization that led to the

formalization of the status quo processes (Armenakis, Harris, & Mossholder, 1993). For the

“Heart Failure Lite” model, the change agent was the lead cardiologist of the newly acquired

practice. In addition to leading the development of the clinical operations within the model, this

individual was responsible for communicating the message and purpose of our change. Beyond

the identification of change agents, more recent developments in implementation science have

32
provided more robust frameworks for project teams to organize and pursue change processes,

particularly when the change is supported by scientific research.

A Framework to Assist the Implementation of Evidence-Based Practices

Developed in 1998 by Kitson and colleagues, the Promoting Action on Research in

Health Services (PARiHS) framework sought to identify the structures present in the

implementation of scientific research (Kitson, Harvey, & McCormack, 1998). The dynamic

forces between three primary elements—Evidence, Context, and Facilitation—will lead to either

successful or unsuccessful implementation of evidence-based practices. Evidence is the quality

and validity of the research and evidence being presented, and was broadly defined under the

original framework as the summation of scientific or non-scientific research, clinical experience,

and patient preferences (Kitson, Harvey, & McCormack, 1998). Context describes the

organizational setting in which the evidence is to be introduced, and was originally defined as,

“the environment or setting in which the proposed change is to be implemented” (Kitson,

Harvey, & McCormack, 1998). Finally, facilitation is the procedural steps taken to enable

successful implementation, and was originally defined as “a technique by which one person

makes things easier for others” (Kitson, Harvey, & McCormack, 1998). Facilitators are different

from local opinion leaders or primary change agents in that opinion leaders often occupy that

position because of their title or status within the organization, whereas facilitators rely more on

enhanced communication skills to help drive individual and group effort and performance.

Evidence suggests that opinion leaders often hold significant levels of influence within their own

unit, but that influence does not necessarily translate across other units (Kitson, Harvey, &

McCormack, 1998).

33
 The authors argue that prior to the development of this conceptual model, the prevailing

belief was that the thoroughness and veracity of the evidence was the most important element to

consider, and that the presence of such evidence would be the primary driver of change. Similar

to the failure of the “Heart Failure Lite” model, change efforts supported by scientific evidence

often fail because stakeholders in the change process are unable to translate the complexities of

the content into practice (Kitson, Harvey, & McCormack, 1998). Thus, at the conceptual level,

the PARiHS model assumes all three elements maintain equal influence on the change process

(Kitson, Harvey, & McCormack, 1998). The primary function of the framework is for informing

the change process and allowing change agents to identify the necessary steps needed to achieve

successful implementation.

Based on the original conceptual model, the Evidence, Context, and Facilitation elements

are broken down into three sub-elements to further refine the definition of each, and to further

inform the process that change agents must pursue when implementing action on research

(Kitson, Harvey, & McCormack, 1998). These sub-elements are measured using a horizontal

axis with higher levels of the given sub-element falling on the right, and the lower levels of a

given sub-element falling on the left. One example is the “Clinical Experience” sub-element

within the Evidence element (Figure 7). In this sub-element, when professional opinion on a

given matter is relatively aligned, evidence would be considered high, and when opinion is

splintered across different groups, evidence is considered low (Kitson, Harvey, & McCormack,

1998).

Figure 7. Scale for Measuring High/Low Evidence: Clinical Experience Sub-Element

34
 The authors developed a 3D matrix to help change agents better understand the dynamics

involved with a given change (Figure 8). The position of that change is based on the

measurements of each sub-element. Assuming an organization will not pursue a particular

change if possesses low levels of evidence, the figure below only depicts situations in the upper

half of the matrix.

Since its inception in 1998, the PARiHS framework has been used as a method of driving

change, and the scientific literature is beginning to develop a better understanding of the

functionality of the framework. Examinations of each element reveal that strong evidence and

scientific consensus were a necessary component for successful implementation (Rycroft-

Malone, et al., 2013). However, this level of evidence was not sufficient for change, and change

actors are forced to implement their change within the parameters of the greater organizational

environment (Rycroft-Malone, et al., 2013).

Figure 8. PARiHS 3D Matrix

35
 Additional studies have revealed some of the strengths of the framework (Helfrich, et al.,

2010) (Ullrich, Sahay, & Stetler, 2014). Users of the PARiHS framework praised the efficacy of

the model in diagnosing the Evidence and Context elements, and its ability to be applied in a

myriad of settings was viewed positively (Helfrich, et al., 2010). The framework is easy for users

to understand and utilize, and users state that it works well in conjunction with other

implementation models or strategies (Ullrich, Sahay, & Stetler, 2014).

Regarding some of the weaknesses of the framework, though many users believed the

elements and sub-elements were adequate in describing the change process, the need for a

clearer, more refined conceptual design was needed due to the evidence of overlap among the

sub-elements (Helfrich, et al., 2010). Additionally, the primary limitation of the research thus far

is the scarcity of prospective applications of this framework. The original framework called for

the prospective diagnostic evaluation of the elements to examine the parameters within which the

change would be introduced, yet most of the scientific literature have been retrospective analyses

through the lens of the framework (Helfrich, et al., 2010).

In response to the lack of conceptual clarity, other implementation scientists have built

upon the existing PARiHS framework to further delineate the role of each element in the change

process, and to provide a more comprehensive tool to help inform and guide implementation

(Stetler, Damschroder, Helfrich, & Hagedorn, 2011) (Rycroft-Malone, et al., 2002). One of the

more thorough revisions to the original framework was conducted by Stetler and colleagues in

2011. This update was an attempt to enhance the effectiveness of the framework and increase the

chances of a successful change implementation. The more robust sub-elements and newly

developed reference tools within this updated framework will increase the capacity of change

agents to develop an adequate implementation plan.

36
Evidence, Context, and Facilitation: Definitions Updated

Published in 2011, the update from Stetler made adjustments to all of these elements and

sub-elements to provide a more focused understanding of what should be included within

Evidence, Context, and Facilitation (Table 7). In addition to the increased conceptual clarity,

Stetler and colleagues developed reference tools for each element that detail the updated

conceptual definitions, provide commentary for each updated element and sub-element. More

importantly, the updated framework provides a menu of questions associated with each new

element and sub-elements that can be proactively answered by the project team to guide the

evaluation and processes (Kitson, Harvey, & McCormack, 1998). Like the original concept from

Kitson, Harvey, & McCormack, organizations can select various questions from the menu of

each element and sub-element to diagnose and evaluate the organizational landscape, and

develop a change process that aligns with the results of that evaluation.

Prior to the development of the “Heart Failure Lite” model, no prospective analysis was

conducted to understand the change environment as originally intended under the framework.

Therefore the project team had to navigate the change process without a complete understanding

of the situation. Because no there was no prospective evaluation conducted using any of the

available implementation frameworks, a retrospective analysis must be conducted to determine

the root cause(s) of the failure using the revised PARiHS framework from Stetler, et al.

37
Table 7. Stetler, et al. PARiHS Update
Elements Sub-elements Originial Sub-Elements
E: Evidence and EBP Characteristics • Research and published guidelines • Research
• Clinical experiences and perceptions • Clinical experience
• Patient experiences and perceptions • Patient preferences
• Local practice information
• Characteristics of the targeted EBP:
• Relative advantage
• Observability
• Compatibility
• Complexity
• Trialability
• Design, quality, and packaging
• Costs
C: Contextual Readiness for Targeted • Leadership • Culture
EBP Implementation • Culture • Leadership
• Evaluation capabilities • Measurement
• Receptivity to the targeted change
F: Facilitator Role of Facilitator • Characteristics
• Purpose, external and/or internal • Role
• Expectations and activities • Style
• Skills and attributes of facilitator

Evidence: Proactive Questions to Guide and Evaluate Change Process

The foundation for every piece of the “Heart Failure Lite” model was rooted in scientific

research and evidence-based practices. This scientific evidence was critical in building support

for a delivery model that subverted the traditional clinical processes. Responses to the questions

derived from the Stetler, et al. revised PARiHS model indicate high levels of evidence

supporting this change.

EQ1) To what extent are stakeholders aware or knowledgeable regarding this evidence?

The multidisciplinary structure of the project team allowed for a diverse understanding of

the multiple variables that reside in the “Heart Failure Lite” model. The cardiologists, nurses and

other clinicians were knowledgeable about all clinical matters related to the project. The risk

calculator that was central to the risk stratification process within the CMMI model had already

38
been in use by some cardiologists within the clinic. Their support and advocacy of the efficacy of

the risk calculator lent credence to the project. Members of the team with a greater understanding

of public health provided the knowledge base for the non-clinical variables like self-management

and education, and were able to incorporate previous research of their own to support the

viability of this project. Further, the organization responsible for developing the patient

education materials had been providing these valuable to resources to similar healthcare

organizations around the world for more than 20 years.

This diversity of knowledge allowed for stronger presentations where project team

members could speak to their areas of expertise and connect with other stakeholders receiving

the presentation (i.e. clinicians connect with other clinicians, non-clinicians with other non-

clinicians). Because this type of delivery model was unique and unprecedented within the

organization, the understanding of the science and research was not at an ideal level when trying

to overcome institutional barriers and formalized attitudes. Establishing connections with similar

individuals who were not part of the project team was critical in helping those less-informed

individuals build an understanding of the nuances and intricacies of the “Heart Failure Lite”

model, and how a successful implementation could mutually benefit the patient and the

organization. Whether these stakeholders were receptive to the research and evidence as it

compared to the traditional processes and beliefs of the institution was an additional

consideration.

EQ2) To what extent do key stakeholders value research vs local knowledge/opinion?

The approach to treating heart failure and other CVD diagnoses mirrored the approach of

all other service lines within the organization in that care was delivered after the onset of a

particular illness or diagnosis with little to no regard for what occurred prior to treatment. This

39
method had proven to be financially advantageous for the organization, and allowed for the

sustainability of long-term growth. Because payers had not presented any economic signals or

incentives for the organization to deviate from this approach, the care processes and the attitudes

toward care delivery had become deeply rooted in a fee-for-service paradigm.

The “Heart Failure Lite” model was a subversion of these attitudes and behaviors, but

was backed by peer-reviewed research and evidence from reputable sources. Because UIHC acts

as the primary teaching hospital in the state of Iowa, it is closely associated with the research arm

of the university’s college of medicine. The hospital is supportive of scientific endeavors and

often promotes any groundbreaking advancements or significant findings that take place at the

university. What is unclear is the extent to which these findings affect the actual delivery of care

in the way the “Heart Failure Lite” model intended. The validity of the evidence supporting the

model was never questioned, but because the model directly contradicted the deeply rooted

financial structures, the long-held beliefs about the most effective form of delivery were difficult

to overcome. Research and scientific discovery are held in high esteem at the university, but the

practical application remains difficult when the financial incentives and signals are misaligned.

EQ3) To what extent do opinion leaders in the “unit” support this change/EBP?

The development of the “Heart Failure Lite” model was at the behest of the lead

cardiologist in the clinic who reinforced the importance of population health, and believed

population health initiatives could succeed at the organization. This cardiologist acted as the lead

change agent and was the primary point of contact when interfacing with both the leadership of

the HVC and of the ACO. Having this physician champion helped garner support across all

levels of the clinic. To create greater economic return, a greater number of clinicians were

needed to provide an access point for patients to be included in the demonstration. Individual

40
meetings between the physician champion and the other providers helped build the base needed

to drive the potential economic return. Further, nurses were the most critical part of the “Heart

Failure Lite” model, and having the support of these cardiologists allowed the support and

enthusiasm for the project to permeate throughout the clinic. Despite not being able to overcome

the larger institutional forces, the unit-level support was a major factor in allowing the project to

persist as long as it did.

EQ4) What is the strength and nature for/against the change?

EQ5) To what extent do they see a need?

Organizational theory states that for a change to be successfully implemented change

agents must adequately address the need for change by identifying the areas in which the

organization is failing to achieve a desired goal (Armenakis, Harris, & Mossholder, 1993). In this

instance, the project team argued that UIHC was not prepared to operate effectively in a

population-health environment that was predicated on alternative payment and delivery reforms.

Many of the developments in payment reform were the product of positive results within

previous CMMI demonstrations, and the rollout of the Million Hearts® demonstration indicated

further alterations to payment and delivery standards in the future. In anticipation of these

changes, the project team felt it prudent to experiment with delivering services in an unfamiliar

environment. Because there was no downside risk associated with the Million Hearts®

demonstration, this experimentation would provide a safe environment that would help UIHC

identify its strengths and weaknesses, and would provide adequate time to adjust prior to

widespread changes.

Statements from members of the leadership team indicate a division in the rationale for

pursuing the Million Hearts® demonstration, and the value it would provide the organization.

41
Members of the ACO leadership team stated that they saw no “immediate value” in some of the

clinical requirements of the demonstration (Archer, 2017). They acknowledged that collecting

clinical data—in this case most of the focus was on cholesterol—and finding ways to improve

the risk factors within the patient population was beneficial. However, those benefits would not

be realized by the patient for many years into future, and there may never be a tangible economic

benefit for the organization (Archer, 2017). The lack of immediate return prevented the ability of

the project team to establish and highlight the definite need of the “Heart Failure Lite” model and

Million Hearts® demonstration.

This reluctant behavior toward proactive change, in the face of external evidence that

supports change, aligns with the aforementioned “modification routine” which also includes the

tendency to rely on past behaviors and experiences even if an alternative method may be more

beneficial in the future (Amburgey, Kelly, & Barnett, 1993). Additional research would suggest

that this type of reluctant behavior is indicative of an adaptor rather than an innovator (Kirton,

1980). Adaptors are more receptive to changes that take place in increments, while innovators

are more likely to be receptive to the type of readiness change presented by the Million Hearts®

demonstration (Kirton, 1980).

EQ6) To what extent do members of the targeted audience see congruence between EBP and

previous changes?

Developing a model focused on preventing the onset of a serious illness that also sought

to fully engage the patient through education modules and wearable technology had only been

attempted once at the organization, and that initiative experienced a similar outcome as the

“Heart Failure Lite” model. A basic patient education tool was embedded within the electronic

health record, but that tool did not exhibit the longitudinal and interactive qualities that were

42
present in the “Heart Failure Lite” model. A relatively new division of the organization had been

created to develop eHealth initiatives, but nothing had been put into practice at the organization,

and therefore nothing could be used as a guide in developing eHealth procedures for the “Heart

Failure Lite” model. This lack of congruence with past experiences limited the ability of the team

to display the potential efficacy of the new model.

EQ7) To what extent do key stakeholders believe this change will improve practice/outcomes?
EQ8) To what extent will the results be observable to stakeholders?

Observability of results under the “Heart Failure Lite” model can be considered from

multiple perspectives, with each perspective displaying different outcomes and presenting

different implications for successful change implementation. The first perspective is the clinical

and financial results derived from the Million Hearts® demonstration. Clinical success is

observable within this perspective if the aggregate risk score for the population decreases year

over year, and is significantly lower at the end of the five-year demonstration. If clinically

successful, positive financial results will follow. However, the financial return on clinical

success is not immediate meaning the financial improvement is often not realized for a

significant amount of time. Initial projections showed that with optimal clinical performance the

organization would realize an estimated return of $297,919.41. That total was after five years, a

considerable amount of time for the full potential of a project to come to fruition, and does not

account for the possibility of sub-optimal clinical performance which would result in financial

reductions.

The second perspective was the observability of the central mission of the “Heart Failure

Lite” model, the sustained reduction of heart failure and other CVD diagnoses. This measure

would extend beyond the reductions in aggregate risk score from the Million Hearts®

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demonstration to examine the long-term impact on CVD prevalence within the patient

population. The difficulty with this measure is the impact would not be observable for many

years, well beyond the five-year Million Hearts® demonstration. Further, in the absence of

alternative reimbursement structures, the success of the “Heart Failure Lite” model would mean

a long-term financial decline for the organization. The multiplicative effect of the amount of time

needed to determine success with the financial implications of that success create difficult

conditions when convincing an organization to pursue a shift in care delivery like “Heart Failure

Lite.”

Context: Proactive Questions to Guide and Evaluate Change Process

CQ1) To what extent do leaders show active and visible support for the change?
CQ2) To what extent does the leadership communicate the priority of this change?

At the outset of the project, the administrative and clinical leadership teams of both the

HVC and ACO provided verbal support to pursue the development of an alternative model

focused on population health practices. Beyond verbal support, there were no additional

resources—financial or otherwise—allocated to the development of the model. Operating in the

absence of sufficient resources, the project team was forced to pursue external funding, and

settled on the Million Hearts® demonstration. After presenting the details of the demonstration

and the potential cash flows resulting from successful clinical performance, more enthusiastic

support began to show among members of the various leadership teams. Administrative and

clinical leaders at the department level and in the C-suite voiced their support and offered to

assist in any way they could. However, this support never permeated beyond the walls of the

meeting rooms, and as the project team began to meet with different stakeholders who would

44
need to be involved in the program (e.g. social work, nursing, pharmacy, etc.) nobody was aware

of the project or the apparent support of the leadership.

These issues associated with tentative support were compounded by the physical location

of the project team relative to the members of the leadership who initially voiced their support.

Located primarily at an off-campus outpatient facility, the project team faced difficulties in

maintaining contact and communicating with the leadership. Although informational meetings

were held by members of the team to inform the progress of the project, the separation between

the team and the decision-makers further limited the enthusiasm surrounding this initiative.

CQ3) To what extent are the needed resources committed and provided in a timely manner?
CQ4) To what extent is the leader responsive to requests for support to eliminate barriers?

Beyond the limitation of resources at the outset of the project, subsequent requests for

capital, personnel, or any other form of assistance were met with similar forms of hesitance and

resistance. To develop the patient education infrastructure, monetary expenditures were required

to acquire the software and make the necessary changes to conform to our ideal education

platform. Four different scenarios were presented by the partnering organization responsible for

developing the modules, with prices for these scenarios ranging from $4,158.00 – $56,158.00.

The leadership within the cardiovascular department had been in previous communication with

this company to develop products for another initiative. Despite the commonalities in the

education products, the leadership was unwilling to provide the necessary funding to purchase

and alter the heart failure modules.

Beyond infrastructure development, additional staff support was necessary for this

project to succeed, particularly when confronted with the issues surrounding missing data

elements. In interviews following the demise of the project, issue was taken with lack of
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expediency regarding hiring practices at the organization. The request for a 0.6 FTE to assist in

gathering the missing data points was denied immediately, but if the request were to make its

way through the system it would not have been processed prior to the January 1st start date for

the Million Hearts® demonstration, severely limiting the effectiveness of the model.

CQ5) What are the current organizational priorities? Does this fit?

At the time the “Heart Failure Lite” model was introduced to the HVC and ACO

leadership teams, the organization was in the midst of its cautious approach to population health

management, with the primary focus on the MSSP Track 1. According to a member of the UIHA

ACO leadership, the approach to population health has been more measured and less aggressive

as the organization works to build physician engagement and the necessary infrastructure to

operate in a riskier payment environment (Vermeer, 2017). As these developments progress, the

strategic plan is to “dip the toe” into downside risk arrangements, either with Medicare, or with

private payers in the region (Vermeer, 2017).

Much of this hesitant entry into more progressive population health arrangements can be

viewed through two domains, the organization’s confidence in their ability to succeed, and the

external market factors that drive change. Regarding the first domain, early performance results

from the MSSP Track 1 model indicate the organization has areas of improvement to meet the

shared savings benchmark (Vermeer, 2017). The lack of absolute success in their first population

health endeavor acts as a hindrance to further population health efforts. Regarding the second

domain, the organization feels limited pressure from payers and consumers to switch to a

population health environment. The ACO leadership believes consumers are not aware of

population health efforts within the industry, and therefore are detached and indifferent toward

any initiatives at the organizational level (Vermeer, 2017). Additionally, beyond Medicare

46
experimentation efforts, the private payers in the region have not provided any economic

indication of a move toward population health, allowing organizations like UIHC to continue to

operate in the traditional fee-for-service model (Vermeer, 2017) (Archer, 2017).

Operating in an environment devoid of pressure to transform care delivery means very

few resources have been allocated up front to invest in population health initiatives, and this

limitation inhibits all efforts like the “Heart Failure Lite” model (Vermeer, 2017). By following

the money, one can understand the focus of the organization. In the case of UIHC, the majority

of the scarce resources are being allocated to the daily operations of the ACO (Vermeer, 2017)

(Archer, 2017). In developing a model that was misaligned with the goals of the predominant

population health apparatus in the organization, the “Heart Failure Lite” project team failed to

adequately adjust the proposal to gain acceptance into the organization.

Had the project team conducted a proactive survey of the organizational environment, the

model may have been able to gain more traction and the change might have experienced greater

success. From the outset, the project team should have engaged directly with the UIHA ACO

instead of only with UIHC. The model would have had to been adjusted to align with the short-

term goals of the ACO, but the hesitance toward the model would have been muted in the ACO

compared to the fee-for-service driven world of UIHC.

Moving into the future, an arrangement like the “Heart Failure Lite” model might gain

more traction within the organization. UIHC has recently engaged in a partnership arrangement

with the largest private payer in the state to operate a Medicare Advantage insurance plan. Under

this arrangement, UIHC takes on the full risk of nearly 2,500 members. Further, the leadership

has indicated a strategic vision that includes alternative arrangements for the employees of the

organization, and an effort to contract directly with employers for the care of their employees

47
(Vermeer, 2017). By taking on more risk, preventive efforts similar to the “Heart Failure Lite”

model become financially advantageous for the organization.

Facilitation: Proactive Questions to Guide and Evaluate Change Process

After a complete understanding of the Evidence and Context have been formalized,

facilitation of the proper change processes can commence. The facilitation reference tool

published by Stetler, et al. focuses primarily on the characteristics of an external facilitator. The

limited resources prevented the use of an external facilitator for the “Heart Failure Lite” model,

but the same questions and personal characteristic requirements can be applied to an internal

facilitator.

For the purposes of effective facilitation, it is important to distinguish between local

opinion leaders and the primary facilitator. The lead cardiologist on the team assumed the role of

change agent and local opinion leader, and played a considerable role in the development of the

project. However, it would be misguided to label this individual as the facilitator, and it is

important to distinguish between these two roles. In this instance, the lead cardiologist held full-

time clinical responsibilities. It is unreasonable to add full-time facilitation responsibilities to

these clinical duties. A more effective approach would have been to designate a non-clinical

team member as the primary facilitator. Once that individual has been identified, the team can

develop the necessary process to implement the change.

The primary responsibility of the facilitator as described in the original PARiHS

framework is to “make things easier for others” (Kitson, Harvey, & McCormack, 1998).

Whereas local opinion leaders and change agents leverage their status within the organization to

influence the opinion of others, the facilitator is responsible for informing others about their

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responsibilities as it relates to the change, and detailing the steps needed to complete that change

(Kitson, Harvey, & McCormack, 1998). Successful facilitation is often predicated on the strong

interpersonal skills of the facilitator, and the ability to effectively communicate the needs and

process for change across domains. A lack of proper facilitation can have damning effects on a

particular change, even in the presence of strong evidence and a supportive contextual

environment (Kitson, Harvey, & McCormack, 1998). The updated PARiHS framework expands

upon this original definition to create a more refined understanding of the role of facilitation.

This revision states the importance of identifying the appropriate individual(s) to assume the role

of facilitator based on the diagnostic evaluations of the Evidence and Context elements (Stetler,

Damschroder, Helfrich, & Hagedorn, 2011).

In the case of the “Heart Failure Lite” model, the role of facilitator was never clearly

defined, and this lack of a designated facilitator led to inefficiencies in the implementation

process. One of the key responsibilities of the facilitator is to maintain strong interpersonal

relationships with the individuals and groups included in the change process. During the

development of the “Heart Failure Lite” model, team members would hold separate meetings

with stakeholders throughout. The messaging in these meetings was not cohesive, and the actions

needed from these stakeholders were not properly communicated. Further, the results of these

meetings were often not relayed to other members of the project team. These breakdowns in

communication and the disparate interactions with external stakeholders inhibited the ability of

the team to move in a unified direction, and to ensure the necessary steps in the process were

being completed correctly.

Facilitation does not need to be isolated within the unit where the change is taking place,

and can benefit from the support of the organizational leadership. The updated framework

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acknowledges the value of this support, particularly in maintaining accountability among other

members of the organization (Stetler, Damschroder, Helfrich, & Hagedorn, 2011). This

leadership support was a key missing variable in the “Heart Failure Lite” model. However,

despite the absence of strong institutional support, the PARiHS model states that a facilitation

process that focuses on educating and instructing the most critical stakeholders on a routine basis

can overcome a non-conducive contextual environment (Kitson, Harvey, & McCormack, 1998).

Using the reference tool from the updated PARiHS framework, a retrospective analysis can be

conducted to determine missteps on the part of the “Heart Failure Lite” project team, and the

characteristics of facilitation that would have been more appropriate for this project.

FQ1) Are you targeting awareness, knowledge, motivation, attitudes, engagement, skills,

behavior, processes, etc.?

Representing a paradigmatic shift in care delivery at UIHC, the project team was

targeting all variables related to the entrenched habits and customs within the organization. The

effort needed to overcome these forces, and their entrenched nature within the organization, is

the foundation of the role of the facilitator, and is the lens through which all other questions

related to the facilitator should be viewed and answered.

FQ2) Based on the diagnostic analysis of Evidence & Context, what type of facilitator role is

needed?

Operating in an environment devoid of strong contextual support, the facilitator needed to

be able to effectively craft and communicate the stated purpose and goals of the “Heart Failure

Lite” model to the stakeholders throughout the organization who would be critical to its success.

Communication between the facilitator and the organizational leadership needed to happen on a

50
much more frequent basis than it did during the development process where oftentimes months

would pass between correspondences with the leadership. Updates on the progress and future

needs of the project team needed to be communicated on a weekly basis to ensure the project

remained visible to the leadership.

Much of the technical requirements of the “Heart Failure Lite” model required assistance

from other units within the organization, or from external organizations, and often informational

meetings with these individuals/teams would not be followed up in an expeditious manner. When

informed of the “Heart Failure Lite” project, these stakeholders would often respond positively

and express a willingness to help, yet the lag time between subsequent communication resulted

in diminished enthusiasm. Having a designated facilitator would have allowed for the

development of enhanced interactions and coordination between the project team and these

additional entities whose assistance was required, helping to drive the project forward and gain

traction within the organization.

FQ3) What intensity of Facilitation support appears to be required?

Without significant support structures from the time the project was introduced, the

project team would have benefited from higher intensity facilitation to build support for the

project on its own. Indeed, higher levels of intensity would have increased the visibility of the

program to the leadership, but by increasing the intensity of the facilitation efforts at the lower

level of the organization, support can be built from the bottom and permeate its way to the top.

Additionally, a higher level of intensity can help mitigate the side-effects of structural

inertia that begin to surface during the implementation process. Without a previous change of a

similar nature for stakeholders to use as an example, the facilitator needed to be an effective

51
educator to inform members of the organization about the program, the role they would play, and

how a successful outcome would benefit all stakeholders involved. Without this level of

intensity, stakeholders are likely to turn toward their established routines and processes that stand

in direct contrast to the efforts of the “Heart Failure Lite” model (Amburgey, Kelly, & Barnett,

1993).

FQ4) What skills and characteristics are needed from the facilitator?

Understanding that the “Heart Failure Lite” model included many intricate parts—

cardiologists, nursing, pharmacy, social work, IT, finance, etc.—the facilitator needed to have a

basic level of understanding of each unit to be able to navigate each facet of the change process,

and to build credibility among stakeholders (Stetler, Damschroder, Helfrich, & Hagedorn, 2011).

After establishing the requisite knowledge base, communication becomes the next most

important skill for the facilitator (Stetler, Damschroder, Helfrich, & Hagedorn, 2011).

Communication was necessary between the project team and the leadership to inform members

of the progress and areas of concern. Communication among other stakeholders was important to

consistently inform them of the purpose of the project, their role within the new system, and how

that role will affect the results of the new system. Effective communication skills are the

foundation of an additional skill required of the facilitator, marketing (Stetler, Damschroder,

Helfrich, & Hagedorn, 2011). The project team for the “Heart Failure Lite” often split the role of

primary communicator among different members of the team, leading to the lack of a cohesive

message. Lastly, the facilitator needed to have situational agility and strong problem-solving

skills to adapt to unexpected changes during the implementation process (Stetler, Damschroder,

Helfrich, & Hagedorn, 2011). The facilitator may have the inherent ability to address an

52
unexpected situation themselves, but it may also require them to seek the services of someone

with a more specialized skill-set.

The “Heart Failure Lite” project team displayed inadequate facilitation efforts that

severely limited its ability to overcome the organizational forces that stood as an obstacle from

the outset of the project. The project team failed to communicate properly on a consistent basis,

and it often resulted in fleeting support from other stakeholders. When correspondence did take

place, it was too often conducted separately by different members of the team. Failing to

establish one individual exhibiting the necessary skills and attributes for effective facilitation

prevented the project team from garnering widespread support for the project. The lack of

facilitation also prevented the foresight of future problems and the ability to adapt in an

expeditious manner to maintain the stability and progress of the project.

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 CHAPTER 4

HEALTHCARE MANAGEMENT AND POLICY IMPLICATIONS FOR FUTURE

POPULATION HEALTH CHANGES

Change Reborn: The Genesis of “Population Health Lite”

Although the attempt to shift attitudes toward a more favorable disposition regarding

population health through the “Heart Failure Lite” model ultimately failed, the leadership within

the ACO believed the underlying infrastructure could be repurposed to support a separate project

within cardiology. At the same time the “Heart Failure Lite” model was being eliminated, the UI

ACO was experiencing difficulties with increases in emergency department utilization for non-

emergent conditions that led to a hospital admission. An analysis of this problem indicated the

category most responsible for this high utilization was non-specific chest pain patients who were

recently discharged from the facility. At the time of the analysis, these patients presenting with

non-specific chest pain cost the ACO nearly $4.8 million over the prior 12 months (Archer,

2017). The leadership believed parts of the “Heart Failure Lite” model—specifically the patient

education modules and enhanced care management—could be utilized to manage these patients

and help prevent the utilization of non-emergent care.

Still in its infancy, this project appears to meet the conditions necessary for implementing

successful change initiatives. The strength of the scientific evidence remains the same as

previously described for the “Heart Failure Lite” model. The most significant deviation from the

experiences with the “Heart Failure Lite” model is the contextual environment in which this

change is being developed. The genesis of this project was a top-down directive of the

organization’s leadership. Contrasted with the bottom-up development of the “Heart Failure

54
Lite” model, the project team has less of an inherent resistance to overcome in developing this

change, and does not need to expend as much energy convincing the leadership and other

stakeholders about the necessity of this project. The organizational support has led to greater

acquiescence to the concerns of the project team, and has resulted in the allocation of additional

personnel to support the project, a significant difference of experiences with the “Heart Failure

Lite” project. Further, in contrast with the Million Hearts® demonstration where the overall

benefit of the project would not be realized for at least five years, this project has a much tighter

focus and has goals that are easily measurable.

Lastly, the role of facilitation at the outset of this project was taken on by the medical

director of the ACO. This allowed the project team to focus on infrastructure development and

creating workflow and process maps. However, this facilitation from the leadership member has

begun to fade with time. The project remains a priority, but the day-to-day responsibilities that

resemble elements of facilitation have begun to shift toward the project team. Steps need to be

taken to ensure the facilitation failures of the “Heart Failure Lite” model are not repeated in this

new initiative.

Informing Future Population Health Change Initiatives: Healthcare Management Perspective

For healthcare managers who do not hold executive leadership positions but still want to

pursue changes regarding population health management, possessing a keen understanding

contextual elements within the organization will be a key component to successful change

implementation. Assuming the proposed change is predicated on a sound scientific foundation,

managers must understand where the change resides within the organization, and who the change

will affect the most. In the case of the Million Hearts® demonstration, the goals and financial

incentives did not align with the goals and financial incentives of the UI ACO. This ACO was

55
the centerpiece of the population health efforts at UIHC, and any effort that counteracted the

success of the program was likely to be resisted (Vermeer, 2017). When presented with a similar

obstacle in the future, population health advocates should demonstrate how new changes will

positively impact the more robust structures that possess a greater level of importance within the

organization.

Managers must also understand the operational and financial constraints that may present

issues in the change process. Structural inertia theory states that an alteration to these operational

and financial constraints present an existential threat to the organization (Amburgey, Kelly, &

Barnett, 1993). The “Heart Failure Lite” model challenged many of these structures, and the

leadership responded in a manner consistent with the underlying theory (Archer, 2017).

Commentary from the leadership suggested an apathetic attitude toward making a significant

institutional investment in the absence of a noticeable return, and an inability to step beyond the

business capabilities of the organization to experiment in this system (Archer, 2017).

These comments continue to highlight the fact that the most important variable to

healthcare managers in any change effort is the monetary value derived from the proposed

change, and the immediacy of the return on the investment. Interviews after the project was

eliminated indicated apprehension toward the cost of the program compared to the limited

returns (Archer, 2017) (Vermeer, 2017). The returns were an estimate of the best-case scenario,

and would not be realized until at least five years into the future. As one leader stated, managers

must demonstrate that “the juice is worth the squeeze” (Vermeer, 2017). Managers facilitating

future population health change need to acknowledge the importance of these constraints, and

develop a product that can help move the organization in a positive direction without significant

levels of disruption.

56
 It must also be understood that a poor contextual environment can be overcome with

effective facilitation from those charged with implementing the change. The “Heart Failure Lite”

project team failed to appoint an individual whose responsibility was to shepherd the project

through the change process. The facilitation that did occur did not meet the intensity

requirements needed to overcome the strong institutional forces that were working against the

change initiative. Communication between the project team and other relevant stakeholders was

inconsistent and often spread across multiple team members. First and foremost, future change

efforts must appoint an individual who exhibits the ability to lead the facilitation efforts. This

individual must be aware of the organizational context, and understand the effort needed to

overcome any institutional obstacles. By manipulating the change effort to better align with the

organizational context, and by taking the necessary steps to guide the project through every

change step, managers can increase their chances of succeed in implementing population health

changes.

To assist these mid-level managers and administrators, members of the executive

leadership can take steps to create an environment that is conducive to population health change.

These leaders must find ways to improve communication of organizational population health

goals to ensure all members of the organization understand the purpose and direction of any

population health initiative. Executive leaders must define what “population health” is to the

organization, and establish the parameters in which future population health project should

function. The “Heart Failure Lite” model went beyond the population health parameters at UIHC

where the focus was primarily on the ACO. The stature of the ACO within the organization

meant the short-terms goals of that program would take precedence over the long-term goals of

the “Heart Failure Lite” model (Archer, 2017). Stronger communication techniques at the outset

57
of the project, and throughout the life of the project, could have presented opportunities for

adjustment to the model that better aligned with the goals of the ACO. In the future, members of

the leadership team must communicate more explicitly the population health focus of the

organization to better shape change initiatives.

Employee Wellness Programs

As one of the most integral parts of the healthcare system in the United States, hospitals

and other provider organizations can help facilitate the change to health and wellness by

changing the cultures within their own organizations. Released in January 2011, “A Call to

Action: Creating a Culture of Health” was a report from the American Hospital Association

(AHA) detailing the prevalence and structure of employee health and wellness programs in 876

hospitals. The findings indicated that although most of these organizations had wellness

programs, they typically were only comprised of health risk assessments, and were otherwise

superficial and lacked depth (AHA Long-Range Policy Committee, 2011). Programs that

contained more focused and intensive programs were rare, and that a lack of motivation on the

part of employees to utilize the services presented difficulties for these programs. Hospitals

preferred to use participation incentives compared to completion incentives, and a small minority

utilized negative incentives (AHA Long-Range Policy Committee, 2011). Many of the

participating organizations have experienced difficulties in measuring the return on investment,

but some have been able to show that these programs have been financially beneficial to the

organization (AHA Long-Range Policy Committee, 2011). Based on the findings of their survey

the AHA developed seven recommendations to help hospitals transform their culture and

develop these programs on a broader scale. By successfully shifting the internal culture toward

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health and wellness, these organizations can begin to develop similar services for the patients

they serve to promote health and wellness for the entire population.

Informing Future Population Health Change Initiatives: Health Policy Perspective

Assistance from Insurance Companies and Other Financing Organizations

Population health is an opportunity for insurance companies—and other financing

organizations like employers and state and federal governments—to experience significant cost

savings. The apathetic shift toward population health from providers is an impediment to savings

for these financing organizations. To propel provider organizations into a population health

environment, the financing organizations must alter the economic signals they present. Two

methods can be pursued to alter the economic signals, a mandatory but incremental change

process, or a mandatory full-scale switch to population health financing.

In the first option, financing organizations begin signaling to provider organizations their

desire to shift payments away from the fee-for-service realm. However, because the change takes

place over time, provider organizations are allowed flexibility in developing the proper

infrastructure needed to operate in a new environment. An example of this type of change is the

mandatory bundles for certain orthopedic and cardiac conditions implemented by CMS. Their

experimentation with voluntary bundled payments eventually developed into a system where

certain providers throughout the country are now required to provide care under a bundled

arrangement. This incremental changes has provided organizations adequate time to adjust to the

bundles and maintain financial stability. The next step in the process will be to enforce

mandatory bundles across all physicians and hospitals that provide the designated services.

Based on the results of these programs, new mandatory payment and delivery models can be

59
developed to continue the incremental change process. Private payers and some employers have

taken similar steps to proliferate bundled payments, and can work in conjunction with public

payers to advance the movement toward population health. Bundled payments remain popular

among payers and providers, but the purpose of the programs could be defeated if providers

reduce costs to the extent where bundled operations once again become a highly profitable,

volume-based service. To prevent this situation, payers and policymakers must continue to

develop, pilot, and establish updated payment and delivery arrangements that continue the

movement toward population health.

In the second option, a mandatory full-scale switch to population health financing can be

used as a blunt instrument in forcing provider organizations to change. Full-scale change will

force timid organizations to change immediately. Although this option would be the swiftest in

shifting the system to population health, there are practical concerns that limit the viability of this

option. First, not every provider organization has shown the capability of operating in a

population health environment. Forcing an organization who does not have the capacity to

manage this change could potentially put patients in a dangerous position. Second, this option

would be most efficient if every payer made the switch at the same time, and the requirements

for providers were uniform across all payers. Given the large number of payers, this seems

improbable, and might violate anti-competition laws. Lastly, a full-scale switch without adequate

preparation will undoubtedly result in the failure of some provider organizations. The greater

economic effects of this job loss must be considered with examining this option.

Although some organizations have exhibited proactive behaviors in embracing

population health arrangements, others have remained apprehensive and have restricted the

industry from moving forward in that environment. Insurance companies and other financing

60
organizations have significant leverage to force these reluctant organizations into changing their

approach. Efforts are underway from public and private payers to make this switch, but all

stakeholders must continue to collaborate to develop mutual incentives that create the desired

outcomes for everyone.

Community Wellness Programs

Although a large portion of medicine is focused on the diagnosis and treatment of acute

and chronic illnesses, some organizations are working to develop a more holistic and integrative

approach to both healing and prevention. Four of the most recognizable hospitals and health

systems in the United States—Northwestern Medicine, University of California, San Francisco

(UCSF), Brigham and Women’s Hospital, and Vanderbilt Health—have been designated as

Osher Centers for Integrative Medicine. These organizations are offering a variety of fitness

classes, educational sessions, support groups, and other health and wellness programs to promote

healthy lifestyles and behaviors, and to teach individuals how to maintain these lifestyles. At this

point, these programs require payment from the patient, but the success of these programs can be

used as a catalyst in transforming the industry. Participating organizations can work with payers

and other financing organizations to establish programs where health, wellness, and prevention

are rewarded at a similar level as providing the most complex procedures and treatments.

Hospitals and health systems can begin to partner and collaborate with gyms and workout

facilities in the community to provide proper access to these wellness services for patients. As

stated before, payers and financiers can help propel this transition by transforming the economic

signals they promote. This collaborative shift in healthcare delivery can benefit all organizations

and can have a noticeable positive impact on the lives of patients.

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 One final alternative for policymakers, payers, and financing organizations to consider

would be to take one step beyond the community wellness partnerships between providers and

contract directly with fitness and wellness centers to prevent chronic illness in the population. If

these stakeholders believe prevention is the proper route, and if provider organizations are

unwilling to focus their efforts on that route, then a certain portion of the available funding can

be rerouted to someone who is willing to make prevention work. By seeing valuable resources

being diverted elsewhere, providers may alter their approach and place a greater focus on

prevention. Despite the potential of this model, it would be unwise for policymakers to advocate

for a wholesale switch in this direction at this time. Many questions around facility and provider

accreditation, patient allocation, prospective vs. retrospective payment, electronic health records,

prevention timeline remain unanswered and would need to be explored further. Policymakers

would need to consider the necessity for parity in underserved urban and rural settings. Further,

there is limited evidence supporting this policy idea. Unlike employee wellness programs—

which are supported in some regard by the literature—these programs would not pay patients

directly, but would provide funds to the fitness and wellness centers (Aneni, et al., 2014)

(Rothstein & Harrell, 2011). Given the lack of scientific support, policymakers would be wise to

pilot this type of program through CMMI or some other platform to test the viability and identify

any weaknesses. Similar to the first policy option stated above—incremental but mandatory

policy movement—any successful results from a demonstration could be transitioned into new

policy from CMS and other payers. Until the unanswered questions are resolved and a

demonstration can be developed, this policy option retains limited viability in the current

environment, but could present an opportunity in the future.

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Additional Considerations for Policymakers

Many issues arose from a resistant organizational context and poor facilitation efforts

during the “Heart Failure Lite” implementation process, but incongruences between different

population health demonstrations also affected the chances of successful implementation. The

primary issues arose from UIHC’s participation in the MSSP Track 1 program, which prevented

or limited their participation in other programs and demonstrations. The requirements of the

Million Hearts® demonstration meant that some of the attributed members of the ACO would

need to receive cardiology services. This utilization of care would count against the ACO’s

spending benchmark established by Medicare. Further, any compensation received by the

organization for reducing the aggregate risk score of the population—the central focus of the

demonstration—was believed to also impact the spending benchmark of the ACO. Commentary

from members of the leadership indicates this is not their first encounter with these issues

(Archer, 2017). The organization had also shown interest in pursuing participation in the

Comprehensive Primary Care Plus (CPC+) program. Once again, their participation in the MSSP

Track 1 prevented their participation in this additional demonstration.

Participation in the MSSP Track 1 did not preclude the organization from participating in

the Million Hearts® demonstration, but the misaligned incentives made it difficult for the

organization to pursue both initiatives. More specifically, the MSSP Track 1 rewards

organizations for falling below an established spending threshold within a three-year window,

whereas the Million Hearts® demonstration rewards aggregate risk reduction over five years.

The incongruence between the short-term and long-term rewards made it difficult for the

organization to move in a unified direction on population health. Members of the project team

stated that the value of the Million Hearts® demonstration was not clearly defined (Lee L. ,

63
2017) (Archer, 2017). When comparing this model to the ACO, where the metrics and goals are

clearly stated, the organization was unable to incorporate the Million Hearts® demonstration into

the greater population health strategy in an adequate manner. Per the leadership, the financial

realities within UIHC and the UI ACO did not align with the intent of the Million Hearts®

demonstration (Archer, 2017) (Vermeer, 2017). To increase participation experiments and

demonstrations, and to help continue the shift within the industry toward population health,

policymakers would be wise to correct these disparities.

As policymakers continue to develop experiments and payment structures that incentivize

strong population health management strategies, they must consider the unique characteristics

that allow some healthcare provider organizations to perform at a higher capacity than others in

these types of arrangements. At UIHC, the providers were limited in meeting the clinical

requirements of the Million Hearts® demonstration because the eligible beneficiaries were not

confined to seeing only UIHC physicians, and therefore these providers had difficulty collecting

all necessary data points. Operating within a closed system where patients are restricted to a

defined set of providers—systems like Kaiser Permanente and Geisinger Health—allows for

increased data collection capabilities and improved care management capacity. This dynamic

was not present at UIHC (Lee L. , 2017). Policymakers need to understand the constraints open

networks place on organizations who are trying to manage the health of their populations, and

identify ways to increase the sharing of data across providers who are otherwise not employed or

aligned under the same system.

Conclusion

Organizational change is undeniably difficult, and like the “Heart Failure Lite” model,

change efforts often fail to overcome the status quo processes and routines. By threatening these

64
processes and routines, change efforts present existential danger to organizations, who often

respond with a significant amount of resistance. This resistance becomes more emphatic as

organizations age and their processes and routines become increasingly more institutionalized.

Organizations will look to their experiences with past change efforts to inform future changes,

limiting the ability of change actors who seek to implement change beyond this narrow scope.

The “Heart Failure Lite” model was an example of a change effort that went beyond the

scope of previous changes at a long-standing organization with deeply embedded routines and

processes. The model significantly altered the clinical delivery of care to a system predicated on

population health management techniques to prevent the onset of deadly and expensive illnesses.

Compared to the traditional paradigm of fee-for-service medicine, this model threatened the

traditional revenue streams that had benefited the organization for years. As a result, the

resistance exhibited by the organization when presented with the change was consistent with the

structural inertia theory. The project team associated with the project was unable to overcome

this resistance, and the initiative ultimately failed.

Although change failure is a common result, proactive efforts on the part of change actors

can help break down the organizational barriers and improve the chances of successful

implementation. Conceptual models like PARiHS can be utilized to identify the evidence needed

to support the change, the contextual environment in which the change will be introduced, and

the facilitation efforts needed to guide the project to a successful conclusion. The “Heart Failure

Lite” team failed to adequately survey the organizational landscape and tailor the project in a

manner that would have allowed for greater levels of acceptance amongst the members of the

leadership. Coupled with inadequate facilitation efforts, the project was destined to fail.

65
 Shifting clinical practices toward a population health model presents a unique

opportunity for healthcare organizations to separate themselves from their competitors in the

market. Healthcare leaders, payers and financing organizations, and policymakers must work

together to identify shortcomings with the current efforts, and develop innovative delivery and

payment structures that benefit all stakeholders and healthcare consumers. A concerted effort to

find common ground will allow change agents to overcome the traditional barriers that have

prevented past change efforts, and will help organizations to truly transform the delivery of

healthcare services.

66
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