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ALLINA HOSPITALS & CLINICS ALLINA HOSPITALS & CLINICS Adaptive Health Practice Adaptive Health Practice N. Marcus Thygeson, MD N. Marcus Thygeson, MD [email protected] [email protected] om om 612-262-4945 612-262-4945

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Page 1: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

ALLINA HOSPITALS & ALLINA HOSPITALS & CLINICSCLINICS

Adaptive Health PracticeAdaptive Health Practice

N. Marcus Thygeson, MDN. Marcus Thygeson, [email protected]@allina.

comcom612-262-4945612-262-4945

Page 2: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

What is AHP?• Application of Ron Heifetz’s

Adaptive Leadership model to clinical practice

• Three key “simple rules” changes:– Patient must and can do their own

adaptive health work; we can’t do it for them

– But we can help them do it by upgrading our skills and using Adaptive Leadership principles.

– Technology (drugs, procedures, etc.) has limited utility and significant potential for harm—use sparingly and judiciously

Page 3: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Fundamentals of Adaptive Leadership• Complex systems face adaptive

and technical challenges.• Adaptive challenges require

learning and behavior change—adaptive work.

• Technical challenges can be addressed with technical solutions and expertise.

• Technical work will not solve adaptive challenges, and often make the problem worse.

• AL consists of knowing this, and how to help people and organizations do adaptive work.

Page 4: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Page 5: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Example: GERD and PPIs• Heartburn mostly related to

lifestyle: diet, obesity, tobacco, alcohol.

• Treatment for GERD now: PPIs• Feedback loops: hypergastrinemia

and failure to address lifestyle factors

• Long-term use of PPIs (> 2 months) causes GERD sxs in normal people

• PPIs cause dependency and are addictive

• Prevalence of GERD has doubled in US since PPIs introduced

Page 6: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Adaptive Work Avoidance• Failure to adopt healthy

lifestyles (patient)• Failure to address unhealthy

lifestyles (MD)• Terminal chemotherapy

instead of hospice• Spinal fusion instead of active

rehab for disc DJD• Drugs in lieu of exercise, light,

talk therapy, etc. for depression

Page 7: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Page 8: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Implications• We and our patients are both

avoiding the challenge of doing the adaptive work required to be healthy and cope with suffering.

• We collaborate in this by inappropriately applying technical solutions in lieu of adaptive interventions, and by remaining unskilled in adaptive leadership.

• This causes a lot of harm and inefficiency (waste), and damages the doctor-patient relationship.

Page 9: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Why is this happening?• Adaptive work is hard and

often avoided (by patients and providers).

• We aren’t incented to practice adaptively.

• We don’t know how to do it.

Page 10: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

What should we do?Support patient adaptive work by doing the

adaptive work to change our• Philosophy of practice

– Explicitly identify adaptive challenges and interventions, to ourselves and our patients

– Recognize the limitations of our technical expertise

– Use technology sparingly and judiciously– Adopt a socio-ecological, whole-systems

approach to health– Build our skills as adaptive leaders to help

patients do adaptive health work• System

– Financial incentives– Blind faith in technology– Inputs (staffing, resources, culture)

Page 11: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Facilitating adaptive work:• Diagnose the system, and the

problem• Establish a “holding

environment”• Identify the “ripe” issues• Think about your framing• Regulate the “heat”• See yourself as part of the

system• Hold steady• Keep the work at the center of

people’s attention

Page 12: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

The proper use of technology?• Facilitate adaptive work (e.g.,

exer-gaming, mobile health apps, analgesics to facilitate PT, etc.)

• Relieve suffering that overwhelms patient coping

• Manage risk factors until adaptive work is effective

• Treat disease not amenable to adaptive work

• Avoid technology with long-term negative feedback loops on health

Page 13: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Implementation Issues• What does AHP look like

behaviorally, for both patients and doctors?

• For which patients will this work? What to do for patients who respond negatively?

• How do we do the adaptive work to change our system and philosophy of care?

Page 14: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Basic AHP• Staff trained on adaptive

leadership• New patients are introduced

to the practice’s philosophy of care

• SOAP approach modified to address both adaptive and technical components

• Measurement reflects both adaptive and technical components

Page 15: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATIONSOAP—New and Old

Traditional AHP

S

Standard history Add health beliefs, social support and network, family and work systems, patient complexity, detailed lifestyle inventory, etc.

OStandard physical and diagnostic testing, (PHQ-9 in MN)

Measures of resilience, adaptive capacity, learning orientation, etc. Social network survey?

ADiagnosis, prognosis Distinguish adaptive and technical

challenges explicitly.

P

Treatment, referrals, testing, etc. Distinguish adaptive and technical work. Develop plan for supporting adaptive work, including social and psychological interventions. Avoid technical interventions that reduce adaptive capacity/work.

Page 16: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Paths to AHP• Incremental: train staff on

organizational Adaptive Leadership; then support them in generalizing to patient care.

• Transformational: train them directly on applying AL to patient care, and hope the culture accepts it.

• For full development, does this need to be managed as a separate company?

Page 17: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Next Steps• Design it

• Pilot and refine it

• Controlled trial? Or just spread it?

Page 18: ALLINA HOSPITALS & CLINICS Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com612-262-4945

CENTER FOR HEALTHCARE INNOVATION

CENTER FOR HEALTHCARE INNOVATION

Suggested References• The Practice of Adaptive

Leadership, by Heifetz, Grashow, and Linsky

• How Clients Make Therapy Work, by Bohart and Tallman

• “Adaptive Leadership and the Practice of Medicine” by Thygeson, Morrissey and Ulstad, JECP 2010