1. Describe the organizational and/or delivery system environment in which your intervention will take place.
The intervention (not yet defined) is likely to have two different environments in which to take place: UCSF subspecialty clinic (Pediatric Rheumatology) and/or Primary Care Pediatric clinics (varies throughout the community). Based on this past weeks lecture, it seems that an intervention in Pediatric Rheumatology clinic would be more feasible and impactful, based on the fact that the patients on teratogenic medications are concentrated here (and we prescribe the medications) and it is one system, as opposed to trying to implement an intervention across many, hetergenous organizations with different Structures, Cultures, Governance/Power and Organizational Environments.
Organizational Environment of UCSF Pediatric Rheumatology clinic:
Players: patients and their families, front desk staff, LVN's for vitals and rooming patients, pediatric rheumatologists and fellows, rotating residents and students. Room space, computers to chart, space for LVN's, MD and front staff to work. Sufficient time to see patients. Insurance companies. Social workers, NP's, interpreters.
Critical rules: We must see enough patients to generate enough revenue to survive. We should see patients in a timely manner to ensure there is some degree of patient satisfaction. We must work efficiently, in the time and space that we are given by the larger organization (UCSF).
UCSF has a fair amount of influence over the key parts of it's environment, with the exception of patients and their families, time providers takes to see patients (though they do have some control over this) and insurance companies.
2. Based on Shortell’s 4 domains of organizational change, identify organizational barriers that could potentially impede successful implementation of your proposed intervention.
Clinical Quality Performance: If a clinical intervention to provide reproductive health care to our patients displaces other health promotion practices and evidence based management processes of rheumatic diseases, this could be problematic - as there are may already for patients with lupus, for example: wearing SPF 50 sunscreen, having eye exam every 6-12 months especially if on plaquenil, every 3 month labs, no live vaccines if immunosuppressed, medication monitoring for immunosuppression, low salt diet if on prednisone, flu vaccine yearly, etc. Organizational barriers include physician/patient time and space for this intervention to occur.
Patient Satisfaction: Patients overall I think will be more satisfied by the information provided, quality of care and overall experience. If intervention increases wait times, this has to potential to negatively affect patient satisfaction. It could be argued that parents may not appreciate the information provided and assess to care as we would be discussing confidential reproductive healthcare with their child/teen.
Organizational Learning: Knowledge of teratogenic medications may not be easily transparent to providers. An intervention that would require communication across subspecialists and primary care providers may be difficult given how many different medical systems there are Cerner, Apex, Meditech, Paper, etc.
Financial performance: Extra time needed for an intervention in pediatric rheumatology clinic may decrease RVU's for a given Attending provider, which effects profitability and productivity.
3. Using the same 4 domain model, describe how your intervention plan can take advantage of organizational strengths OR propose practical methods for addressing these barriers within your program.
CQP: Clinical quality performance should improve with implementation of an intervention that increases provision of reproductive health care for adolescents taking teratogenic medications. Perhaps the meaningful checklist could be added for patients that are female, marked to be post menarchal and on a teratogenic medication to track clinical quality performance.
Patient Satisfaction: Patients are likely to appreciate more information and preventative care, as they are a particularly vulnerable population. Most teens appreciate the extra time spent talking and addressing these issues. This may build patient rapport with providers and improve adherence to care plans, thus improving patient outcomes (not sure how measurable this would be)
Organizational Learning: Teratogenic medications should be marked on medication lists for providers (at least category X) to improve provider understanding of risk (as a reminder). At UCSF, we do have EMR and we also have Care-everywhere, which has improved exchange of information across institutions. Perhaps an extension of that, something like universal messaging to providers that have EMR's (like apex messaging between providers at UCSF) may improve communication and the exchange of patient information that is needed for interdisciplinary providers to provide reproductive health care for adolescents on teratogenic medcations.
Financial performance: If an intervention is provider by another subspecialty (for example adolescent medicine) this may increase revenue for the organization (not sure if it will outweigh costs needed for that provider) or if there was a way to bill for extra services (provision of reproductive health care) that is worth a small increase in the time it takes a provider to provide this care.