1. Describe the organizational and/or delivery system environment in which your intervention will take place.
The organizational environment that my 2 phase project targets will be primary care clinics at UCSF and Kaiser Permanente. Phase 1 aims to gather information about primary care providers practicing within clinics in these two organizations and phase 2 eventually will involve rolling out the use of a screening measure for suicidal ideation and depression as well as referral pathway for follow-up care for patients who screen positive. Since the systems I'm hoping to roll the intervention out in are very large and complex, I would begin in one clinic across both systems and eventually include additional clinics. To do this, I will have to gain a better understanding of the organizational structure of each clinic.
2. Based on Shortell’s 4 domains of organizational change, identify organizational barriers that could potentially impede successful implementation of your proposed intervention.
I anticipate that all four domains (structure, culture, governance, and environment) all serve as barriers. Since the goal is to train all primary care providers in suicide detection and risk prevention, the structure of each clinic will differ in regards to who does what. This may lead to the issue of who needs to be trained and who needs to be involved in follow-up care. Also, a thorough understanding of the current structure for carrying out similar processes will need to be acquired.
Culture will be a main barrier. Current culture in primary care clinics is that providers work to be efficient and this often involves going through things quickly. Providers may not feel they have enough resources to support them and also need to get through things quickly. Furthermore, the culture of each clinic will be different and may not be able to be defined in words. This will serve as a barrier.
Governance and power is also a barrier because in able to gather data on the current situation, reaching out to people at the top of the hierarchy and gaining approval is key. Much of my efforts in conducting a short survey to gather information has involved spending time figuring out who I need to approach and how to make a "pitch".
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.
For the first phase of my project, the best way to address the organizational barriers including culture and governance/power has been to identify existing or upcoming initiatives within the system and then to attach my intervention (in this case survey project). For example, I learned that Kaiser is rolling out a zero suicide initiative and has been trying for the past year to get providers to use the PHQ-9. In my pitch to the chief medical officer and administration, I tied the project to the initiative and communicated that the project would ultimately strengthen the culture of "zero suicide" within Kaiser.
In order to roll out phase 2 into clinics, it will be important to identify existing cultural barriers to engage providers and this will include providing education about about the current status of the situation and why it is important and implement it in a way that is consistent with current practice and does not cause undue burden on anyone.