Implementing Change
in Hospitals
The Technical Assistance & Mentoring Program
(TAM)
Rivka Gordon, PA-C, MHS
Senior Consultant, Technical Assistance and Mentoring Program
Learning Objectives:

Describe the organizational cultural change
model for implementing service-delivery
change.

List the components of the mentoring process.

Apply components of the mentoring process to
case examples and home settings.
What is TAM?
Cultural change model
 Provide sustainable technical
assistance and mentoring
 Result in service delivery change
 Influence standards around
management of early pregnancy loss

Primary Areas of Work
Training &
Resource
Development
Data Collection
& Analysis
Equipping
Primary Areas of Work
Training and Resource
Data Collection and
Development
Analysis
Prioritize geographic areas
Develop “master mentors”
Develop and implement
curriculum and training tools
Disseminate model to partners
Equipping
Identify research questions related Support and implement systems
to incidence, trends and
in hospitals to incorporate MVA
management of Early Pregnancy
Assist provider systems with
Loss (EPL)
group purchasing and product
Develop sound outcomes targets
development
Collect program data
Update market analyses
Publish and disseminate
quantitative and qualitative data
Develop educational and
marketing materials for health
systems and consumers
History of TAM: 2002

January: NARAL Pro-choice New York advocacy led to
Mayor Bloomberg mandate that residents in public
hospitals be trained in provision of abortion care.

March: Ipas visits 5 NYC hospitals

May: Ipas and partners lobby NY
City Council for funding, resulting in
$2.1 million for construction of
Women’s Options Center at Kings
County Hospital
History of TAM: 2003

January: HHC system-wide Grand Rounds;
Improvements in Family Planning and Abortion
Care at Jacobi Hospital

March: Lincoln Medical and Mental
Health Center – Grand Rounds
Practicum and Clinical Training
History of TAM: 2004

January: Queens Hospital Center – Grand
Rounds, Practicum, Clinical Training

September: Dedication Women’s Options
Center at Kings County Hospital

November: Kings County Hospital –
Grand Rounds, Practicum, Clinical
Training

December: Coeytaux & Wells
Report completed
History of TAM: 2005

January: Service Delivery Handbook and Toolkit
for Management of Pregnancy Loss and Abortion
developed
 February: Elmhurst Hospital – Grand
Rounds, Practicum, Clinical Training

March/April: APGO meeting & NAF
meeting → requests for Ipas
mentors

January - May: TAM Project
Planning
History of TAM: 2005, cont.
May 15 – 17, 2005:
Technical Assistance and
Mentoring Project
Training
8 clinicians participated
(OB/Gyn, Family Practice, Pediatrics, CNM, PA)
Training vs. Mentoring

Mentoring and training strategies complement
one another for service delivery change
Training
Mentoring
-Brief and finite
period of time
-Sustained process
-Outcomes relate to
knowledge and skills
-Outcomes relate to
relationship building
and support
A Combined Strategy
Mentoring clinicians and health systems
through service delivery change
 Training clinicians to safely and effectively
perform outpatient uterine evacuation
 Developing and disseminating tools and
resources to assist in service delivery
change
 Advocating for improved standards and
guidelines

Four Predictable
Stages of
Mentoring
Preparation
Explore motivation, skill level and learning needs
Negotiation
Participation
Create an agreement and a work plan
Practice, build competency and confidence levels
Closure
Transition on-going responsibilities to
continue at institution
Criteria for Selecting
Mentors




Involvement in successful integration of
MVA into ambulatory settings
Current MVA trainer
Ability and willingness to complete scope of
work
Personal characteristics

Listening, flexibility, devotion to high quality
care, ability transfer passion, ability to
appreciate and affirm personal /
organizational diversity
Criteria for Selecting
Change Agents



Participation in Ipas hospital assessment
and/or request for Ipas technical assistance
Current engagement in effect staff
relationships
Willingness to meet expected level of
commitment:



Weekly listserve participation
Coordinated telephone communication with
Ipas mentors
Coordinated site visit with Ipas mentors
Criteria for Selecting
Participating Institutions
Completion of site assessment
 Geographic priority areas
 Opportunity windows:

Committed change agent
 Clear institutional goals
 Commitment to training residents in all
technologies
 Committed leadership
 Appropriate facilities

TAM: The Pilot Year
May 2005 – June 2006
Pilot Year: Results
Performed interventions at 25
institutions, 22 of whom are engaged
in ongoing work with TAM
 Approximately 450 clinicians and staff
participated in TAM activities
 More than 20 active Change Agents
work together and with Mentors to
influence service delivery change

TAM: Institutional Picture
TAM Institutions
N=22
Private
36%
Private Institutions
Public
64%
Unknown
For Profit
Non- Profit
0
2
4
6
Participation in TAM Activities
Residents
Attending physicians
2%
8%
7%
7%
2%
8%
33%
33%
Advanced-Practice
Clinicians
Nurses
20%
20%
7%
7%
23%
23%
Other (Admin, Central
processing)
Medical Students
Not Reported
o
Interventions reached attendings, residents,
advanced-practice clinicians and nurses
o
Between 12 and 74 participants were reported at
varying sites
Equipping TAM Participating
Institutions
Equipping hospitals where the TAM worked 2005-2006
current as of the end of FY 2006
Location of the Institution
FY 2005 Sales
New York City: Multiple Hospitals
FY 2006 Sales
$5179
$13,666
$853
$5135
Pennsylvania: 2 Hospitals
$0
$892
Colorado: 1 Hospital
$0
$2,384
Illinois: 2 Hospitals
$0
$6038
California: 2 Hospitals
$0
$30
$6,032
$28145
Texas: 2 Hospitals
TOTAL
New York (HHC)
Colorado
1 hospital
California
2 hospitals,
including one ED;
1 large, multi-center
network
Illinois
3 hospitals, including 1
Family Medicine
department, and
another OB/Gyn
department
Texas
2 hospitals, including 1
University-based centers
Where TAM Has Worked
Multiple hospitals that are
part of a public, urban
system
Pennsylvania
3 hospitals, including 2
University-based centers
New York: Objectives



Improve quality of abortion and miscarriage
services delivered by public hospitals that serve
poor and marginalized women in NYC
Increase the number of clinicians trained to
provide abortion services in the US by
institutionalizing abortion training in teaching
hospitals in NYC
Document Ipas’s service delivery improvement
model of dissemination and replication in other
areas of the US
New York: Precursors to
Success
NARAL Pro-choice New York research and
advocacy
 2002 Mayor Michael Bloomberg mandates
Women’s Options Initiative
 Ipas role established through

Partnerships
 Communication
 Technical assistance
 Mentoring

New York: Outcomes to
Build Upon

Developed a basic outline for orientation
and training
Initial discussions and site assessment
 Initial onsite visit
 Overview presentation, Grand Rounds
didactic and practicum components
 Administrative support
 Ongoing mentoring relationship

Chicago
An example of the potential for
change in service delivery due to
concentrated mentoring efforts
 Mentors and Change Agents worked
deliberately through the four
predictable stages
 Change Agents at different
institutions collaborated and
supported one another

Chicago: An Institutional
Picture

One OB/GYN department


One Family Medicine department


Goal: improve elective abortion care
Goal: provide miscarriage
management
Two strong change agents
Collaborated effectively
 Strong institutional support

Chicago: Mentoring and
Training Activities
Pre-intervention visits
 Grand Rounds on miscarriage
management
 MVA in-service
 MVA pelvic model practicum
 MVA clinical training
 Journal club

California: New Frontiers






Taking TAM to larger systems
Leveraging built-in monitoring systems
Piloting a model for Emergency
Departments
Collaborating to influence professional
guidelines
Leveraging built-in monitoring systems
Broad, diverse geographic reach
California: Collaborations

Collaborating with partners to expand:
Reach
 Potential for service delivery change
 Opportunities to foster additional
Mentors

California: Reaching New
Systems of Care

Geographically diverse, multi-facility HMO


Member of large national organization






More than 3.2 members in region
8.4 members enrolled nationally
Provides care in 30 medical centers
8 Residency Programs
431 offices
11,000 physicians
Capacity for internal data collection and
documentation
Based on 2005 data
Success Stories
“ Tension at our site was lowered because
we spent so much time together – multiple
interactions solidified trust and by the time
we were really working on MVA, we were
already ‘in’. It was good to talk with people
who we perceive to be barriers to change
even if working with them won’t bear any
fruit – they are glad to be included as part
of the team intervention now, and could be
bigger barriers in the future if not included.”
-Change Agent, Chicago
Success Stories
“ After Ipas’s work with us, we now care for
all our women ‘the Ipas way.’ We are using
much less anesthesia, providing them with
all options, and making sure they have birth
control immediately after their procedures.
We have seen a dramatic change.”
Chief of OB/GYN, Large urban public hospital
Success Stories
“ Two days ago, in OB triage, I had an Hispanic,
non-documented patient with no financial support,
missed abortion and no resources, desperate for
help that I felt so lucky to be able to use my MVA
since OR and L&D were booming and we could
not utilize the OR even if we wanted to. It worked
great, and I got to train one of the other 2nd year
residents on it. It’s great. She was so appreciative
and her family was so grateful. She almost had no
pain. When I told her we were done, she could not
believe it.”
-
Change Agent, 3rd year OB/GYN resident, Texas hospital
The Future of TAM
Moving toward a new system of
care for Early Pregnancy Loss
Institutional Change
Sustain and improve mentoring
process
 Continue to work in priority regions
 Focus on systems of care, to
influence more settings
 Monitor and evaluate changes
 Collect and disseminate findings

Monitoring and Evaluation
Build capacity of TAM Research
Core
 Develop map of priority research
questions
 Collect baseline data and ongoing
data at intervention sites
 Disseminate findings

Influence Professional
Guidelines
Work with partners
 Utilize data from intervention sites
 Collect and synthesize evidencebased standards of care
 Present findings to institutions
responsible for setting professional
guidelines

TAM Cultural Change Model
Monitor &
Evaluate
High Quality
EPL Services
throughout
the US
Disseminate
findings
Foster
relationships
with partners
Mentoring
Ongoing
assistance