2007 Innovation Learning Network Toolkit

Innovation Learning Network 2006

Innovation Learning Network: Insights and Lessons Learned February 2007

Innovation Learning Network 2006 TABLE OF CONTENTS 1 Introduction Origins and Initial Goals

2

First Meeting: April 2006 • Open Space • Subcommittee on Diffusion and Spread

3 3 4

Building the Network • Relationship Building • Social Network Mapping • Social Network Metrics • EPIC Subcommittee • Collaboration within Kaiser

5 5 6 7 8 8

Virtual Collaboration • Virtual Fridays • Virtual Infrastructure

9 9 10

Second Meeting: October 2006 • Panel Discussion • Open Space and Collaborative Projects • Follow Up

12 12 13 14

Lessons Learned

15

Going Forward

17

For more information about the Innovation Learning Network, contact: • Chris McCarthy, Director, Innovation Learning Network, [email protected] • Linda DeWolf, President, VHA Health Foundation, [email protected] • Steve DeMello, Director of Research and Forecasting, Health Technology Center, [email protected]

Innovation Learning Network 2006 INTRODUCTION If ever there was an industry that was closed-minded and steeped in its own importance and tradition, and resistant to major change…it’s health care. I’ve never seen an industry that is so siloed and focused on itself without looking outside of itself. George Burgess, MD, Vice President of Technology and Innovation, Franciscan Missionaries of Our Lady Health System How do you institutionalize the practice of innovation? Isn’t regimented creativity an oxymoron? How do you allow for creativity and risk-taking in health care? Doesn’t that sound like a bad idea?

Intentional, disciplined innovating – with methodologies and theories behind it – has been neglected, from local settings all the way up to the global arena. As a result, the need is so big and so pervasive it’s numbing… it’s been obvious for so long and yet, where do we start? Keith McCandless, Consultant, Social Invention Group

Ten nationally recognized health care organizations have been jointly pursuing the answers to these and other questions associated with innovation. Breaking away from typical practices in health care, scores of senior managers agreed to let go of control so that something exciting could emerge. The results have been interesting, surprising, and offer useful guidance to other health care organizations and leaders seeking to affect change earlier, more rapidly, and better than before. The network that emerged to answer these questions became an innovation itself. This is the story of the Innovation Learning Network (ILN): what was done, what has been successful, and what the future holds. The ILN hopes that this narrative will serve as an example to other groups planning to build collaborative networks, and will accomplish the following purposes: To describe the development and activities of the ILN To enumerate the specific tools and practices used by the ILN To comment on the relative effectiveness of the activities Groups wishing to replicate the tools and practices used by the ILN should consult the associated “Resources and Tools” document. Our thanks to all the members of ILN, project staff, consultants and the VHA Health Foundation for taking risks, trying something different, and participating in the adventure as it unfolds.

Page 1

Innovation Learning Network 2006 We made it really clear from the onset that this was going to be a member-led organization. Chris McCarthy, Director, Innovation Learning Network I think we’ve done very well with… helping the ILN members to create a forum for them that works… soliciting what it is that the members would need and having it drive. Marilyn Chow, RN, DNSc, FAAN - Vice President of Nursing/Patient Care Services, Kaiser Permanente What organization structures are being used for innovation?

What is the role of project work in innovation?

ORIGINS AND INITIAL GOALS The ILN was conceived in the summer of 2005 as a joint venture between Kaiser Permanente and the VHA Health Foundation (VHAHF). VHAHF hoped to bring together a network of organizations that could create innovations, then share and prototype them throughout each of their respective systems. The initial ILN charter called for the group of organizations to “evaluate best practices related to the selection of innovation and technology, the implementation process, and the outcomes of these endeavors.” Everybody didn’t need to be working on technology to be part of an innovators’ network – they could be working on anything. The more important thing would be the attitude they bring. Together they could come up with what were the most meaningful things to work on. The principles for innovation are the principles of innovation, and it doesn’t matter whether you’re working on technology or communication strategy…there are things to share and learn. Linda DeWolf, President, VHA Health Foundation

Projects

Structures

Diffusion What vehicles are being used among members for diffusion of innovations?

…science of innovation, the science of chaos, the science of complexity. When I first heard about that in the late 80s, early 90s, and I thought, “what? That’s weird.” But in fact, quantum mechanics has had some breakthroughs that Newtonian physics just didn’t cut. It’s the same thing with our thinking. David Tew, Vice President and COO, Bergan Mercy Medical Center

During the last months of 2005 and the early months of 2006, Kaiser and VHAHF worked to recruit health care organizations and the sponsors and champions that would serve as primary contacts for the network. The group agreed to participate in two in-person meetings and monthly conference calls. A fundamental premise of ILN organizers was that members should determine the process and content of the group. Project leaders focused on creating an environment that was capable of identifying compelling interests and allowing participants to act on those interests. The approach was primarily experimental, and not prescriptive. One need members recognized early was for all to learn about the practice of innovation itself – the science and the methodology behind it. Three primary elements emerged – diffusion (spread), structures, and projects – and formed the core of the ILN’s work and learning about innovation. The fundamental purpose of the ILN has remained consistent throughout the group’s lifespan: the group would facilitate the spread of knowledge from one health care organization to another. Yet what resulted was even larger than what was originally planned. In addition to finding great ideas within each organization’s existing operations, the group found an effective infrastructure for innovation: the network that they themselves had created. Page 2

Innovation Learning Network 2006 FIRST MEETING: APRIL 2006

Structures

Open Space

Projects

Diffusion

Open Space increases responsibility and freedom for participants. To be sure, what emerges is only a guess. And to even do it, you have to accept uncertainty and work with it – trusting that people will organize themselves in a better way than you could have anticipated or controlled or planned. Keith McCandless

In April, the group met in person for the first time at CIMIT (Center for Integration of Medicine and Innovative Technology), an affiliate of Partners HealthCare in Boston. The meeting structure contained two essential components: the use of Open Space Technology meeting design (Open Space), and an explicit focus on building relationships among participants. Open Space. Chris McCarthy, the Director of the ILN, Maggie Hentschel, Project Analyst for the ILN, and Keith McCandless of Social Invention Group had chosen to use Open Space for the group’s first session in order to facilitate the development of a member-driven network. According to one expert, Open Space is “a self-organizing practice of individual discipline and collective activity that releases the inherent 1 creativity and leadership in people.” At the beginning of the day, all participants are invited to announce a topic of their choice to discuss at some point during the day, and post that topic on the wall-size agenda. Participants are free to join the discussions they find compelling, and to move in between discussions as they see fit – the only rule is to follow your passion. The principles of Open Space are simple and direct: Whoever comes are the right people Whatever happens is the only thing that could have When it starts, it starts When it is over, it’s over These principles are supported by the “Law of Two Feet”: participants must go to where they are learning or contributing, and are responsible for ensuring that their own needs are met.

It also established, I think, by the methods used, that the organization itself was highly flexible and open to new ideas… Maybe to all of us. We were kind of scratching our heads saying, “what on earth are we doing here?” But by the time it was finished, I knew I had a much better idea of what we were doing and why.

At the end of each discussion, a designated Recorder enters a report-out into a website that all participants can later access. The day closes with an hour-long discussion where participants can share highlights, “ahas,” and key learnings.

George Burgess 1

Anne Stadler, [email protected] Page 3

Innovation Learning Network 2006 The initial ambiguity of the meeting structure allowed all the participants to express their passions and talk about the areas of interest that really mattered to them. This facilitated both the development of relationships between members with common interests and a general awareness building of the variety of issues that were now open for exploration.

Lessons learned Let the members choose the direction.

The ILN staff had hoped that the discussions held in April would lead to further collaboration – that participants would utilize the website as a gathering place for further conversation and eventually, collaborative project work. A handful of the topics resulted in additional discussions, meetings or activities. Notes from the diffusion surveys “[One innovation] started to spread natural[ly] and then leadership acknowledged it as a best practice and mandated it for everyone to do.” “Implementation can drive innovation which in turn accelerates implementation….as the ‘inventors’ are the users.” “Implementation is the responsibility of those who created the project and asked the question. The design team considers implementation throughout the process by maintaining a primary focus on the human aspect of the desired/intended change.”

Structures

Diffusion survey

Diffusion

An Example: Subcommittee on Diffusion and Spread One of the discussions during the April meeting focused on two topics: teaching styles that can accelerate the implementation of an innovation, and the process of diffusion. A smaller group of members continued to converse and explore the topics further over the summer. The group had several conference calls, in which they discussed methods to capture lessons from ILN members on best practices of implementation and diffusion. They eventually settled on a survey, in which members could interview another individual within their organization about an innovation success story. The group’s activities slowed a bit over the summer, but moved back into action as the second in-person meeting in October neared. After the meeting, in which members mentioned the work they had done so far and encouraged other ILN participants to contribute to the survey, the group began to gather results. The lessons learned through the survey will certainly apply to other ILN activities going forward. Although there may be no further activity among this particular group, the knowledge gained through their work will become part of the dataset held by the network that will affect future projects.

Projects

Some of the other discussions that began in April never resumed; some re-emerged at the meeting in October or in subsequent conference calls. By building a network with many interpersonal and inter-organizational relationships, the ILN created for themselves an ability to tap into the collective knowledge, interests and experiences of the group, at a time when it is right for each individual member’s particular situation.

Page 4

Innovation Learning Network 2006 That’s why I think to some degree it is important to have the in-person contact. You know, you can talk over the phone but it’s so easy to then, once you get off that hour phone call, to get sucked back into your daily organization and life. And when you see each other and you spend some time together, you actually say, “OK, what are we going to do to really make this happen, really make this come together?” Donna Deckard, Vice President of Implementation/ Optimization - KP HealthConnect, Kaiser Permanente

BUILDING THE NETWORK The group soon learned that collaborating on innovations was not something that could happen in a productive manner immediately. Group members needed time to get to know each other and understand each other’s strengths and interests, so they could determine who to collaborate with on what projects. Relationship building turned out to be the central principle of a successful collaborative network. Relationship Building. One of the difficulties of creating a successful network is a function of time – finding the time to create personal connections outside of each member’s Lessons learned existing duties and official job descriptions. Developing meaningful connections between Work hard to build organizations and individuals required a personal personal relationships. investment on the part of the participants. Make it fun! Additionally, participants needed to feel trust before they were willing to collaborate. The in-person meetings were thus designed with a trust-building component in order to truly cement the relationships between the participants. In addition to the formal piece of the meeting in April, the group also gathered for dinner, where participants were able to get to know each other personally, as well as professionally. In the April meeting we had this great dinner. And next thing you know, everyone’s putting on these leopard robes and having this really great moment together where they really bonded and were laughing and sharing. That one moment carried them through to the October meeting. Chris McCarthy

I thought the Boston hotel was fabulous. I’d never been in a hotel with robes that were leopard-skinned, leopard colored. That really made that first meeting, that hotel, I think was such a great contributor to that. I know that’s strange sounding. It broke what would be an ordinary meeting into an innovative meeting that was not the same as every other one. George Burgess, MD

The special nature of the meeting – the platform for members to be candid, the social activities, and the lack of structured expectations – led the members to develop a different kind of bond with each other than they would at a typical conference or other meeting. After the two days in Boston, members reported that they felt freer to contact each other with questions about each other’s projects and work on collaborative efforts. Chris and Maggie worked to connect ILN members with common interests and challenges, and made sure to include social activities in the October meeting, further cementing the developing bonds. As those relationships developed, the network became more distinct – a creative and adaptive organism of its own.

Page 5

Innovation Learning Network 2006 Social Network Mapping. At the end of the April meeting, Keith McCandless had asked the ILN members to put one hand on the shoulder of another ILN member with whom they wanted to work in the coming year. The results were several different weblike formations that allowed the ILN members to visually recognize the potential value of the connections they had made. After several months had passed and the network had further developed, the ILN staff hoped to recapture this visualization in a more robust, quantifiable way. Keith brought forward the concept of social network mapping – an emerging technology-based method used for defining personal interactions and building relationships.

Before ILN

Keith introduced ILN project leadership to June Holley, an expert in building networks, who educated the group on the concepts of social network mapping. June also demonstrated a visual software tool that tracks the ties between members of a network. ILN leadership agreed to pursue developing metrics about network composition and changes over time using the tools. In September, the group participated in a survey that asked a series of questions about the connections made within the network: 1. Prior to the start of the ILN, who did you work with or exchange information on a project, topic or shared interest? 2. Since the ILN started, with whom have you shared ideas or worked on projects that were catalyzed by your ILN interactions 3. Who has inspired you or given you new ideas since the ILN began? 4. Who would you like to work with over the coming year on an ILN-inspired project or topic? The results came in several network maps, which show the blossoming of the network over time. The maps contain many individual stories of collaboration and connections made. The process was repeated following the October meeting, and maps updated.

Anytime you want to do something that has more impact, that usually means there’s more risk involved. June Holley, Smart Networks Weaver

The group realized that the maps could prove a great tool to determine where connections could be made both within and between organizations. As a service to the member organizations, the ILN contracted with June Holley to learn about how to create network maps for individual organizations and “weave the network” – a technique used by community development organizations to make better connections between organizations and individuals – using data from the maps.

Page 6

Innovation Learning Network 2006 September 2006

Social Network Metrics. The network maps on pages 6 and 7 present obvious visual differences – notice the increased size and density of each succeeding version. June Holley also introduced some specific metrics that quantify the nature of three critical dimensions of the network: • • •

2007

Integration: Who are network leaders? How healthy is the network? Are we “in the thick of things?” Awareness: How likely is it that you know what is going on far from the core? Connector: To what degree are the “clusters” (in this case, the institutional groups) connected to each other

Measures of integration, awareness and connector were calculated for the pre-ILN, September 2006 and 2007 time periods. In addition, a determination of “potential” could be made – the likely maximum level that could be achieved with the existing network. The results were very encouraging: Metric Integration Awareness Connector

Pre-ILN 184 16 138

Sept 2006 492 29 355

2007 761 37 1099

Potential 810 40 1454

The level of integration – the fundamental index of network health – has nearly quadrupled from pre- ILN levels. As importantly, the incumbents have even greater upside -- the potential of the network is approximately 50 points higher. With awareness, more significant growth occurred in the early months of the network, with slower growth as members were added at the second group meeting. In contrast, connector metrics – the measure of relationships between the member organizations – grew dramatically after the second meeting, and shows significant potential for continued growth. The maps also reveal details about how well Lessons learned the ILN has penetrated within each participant organization. As each organization Sponsors and is represented by a different color, it is champions need to play immediately apparent which organizations active roles. have been successful at inviting more individuals to participate. In order to successfully diffuse innovations further into organizations, individual sponsors and champions will need to work to build connections between other ILN members and staff within their own organizations. Page 7

Innovation Learning Network 2006 I wish you could solve for ways I could stay even better connected. Marilyn Chow

An Example: The EPIC Subcommittee. Woven into the network maps is the story of three organizations who shared experiences with implementing an electronic health record. Evanston Northwestern Healthcare, the Cleveland Clinic and Kaiser Permanente had all recently begun implementing the same information system. At the first in-person meeting in April, Bobbi Schramek of Evanston, Mary Partin of the Cleveland Clinic, and Donna Deckard of Kaiser connected about their experiences with the implementation, and decided to stay in contact over the course of the year to continue to share challenges and lessons learned. Although the group initially had difficulty finding time to connect, they have since held two conference calls to discuss areas of common interest, including some challenges all three had encountered. They hope to help each other wade through the thorny issues of configuring the applications, avoiding common pitfalls, and sharing best practices. The group has also discussed possible engagement in conversation with the vendor, utilizing their combined market share to pressure the vendor to make necessary changes.

Structures

Social Network Mapping

Projects

People are writing a list of questions that they’re sending to Bobbi, that whole team is going to be on the phone, the implementation managers are going to be on the phone. I think it’s going to be really rich, what’s going to come of it. Donna Deckard

Diffusion

An Example: Collaboration within Kaiser. The maps also capture increasing integration that occurred within individual organizations. Several of the ILN member organizations are very large entities with hundreds or thousands of employees, many of whom may never meet or collaborate. The forums for information sharing that the ILN promoted brought many of these individuals together for the first time. Jing Wang of Kaiser reports that she connected with Sean Chai and Scott Heisler, two Kaiser employees in different areas, for the first time to work on mobile sensors. Jing writes that she found “effective knowledge sharing through [the] social network.”

Page 8

Innovation Learning Network 2006 People were actually really excited to share their projects. It seemed like people were proud to be able to report out on the different types of things they were doing. Maggie Hentschel, Project Analyst, Innovation Learning Network

Structures

Virtual Fridays

VIRTUAL COLLABORATION Maintaining connections between ILN meetings became a high priority of the project team. They developed two primary vehicles: Virtual Fridays and a Virtual Infrastructure for collaboration. Virtual Fridays. In April, after the conclusion of the Open Space portion of the inperson meeting, CIMIT staff had given ILN members a tour of the Center along with several presentations about the group’s current initiatives. These presentations piqued the interest of many ILN members, who requested a forum for learning about innovations at other organizations. The ILN staff thus came up with a web-based solution.

Projects

Chris had come up with this idea that we have people present out on Fridays for a quick forty-five minutes the specific projects they are working on. It’s not mandatory to attend. These would be recorded and posted, and so people in the network could access the presentations at a later time.

Diffusion

Maggie Hentschel, Project Analyst, Innovation Learning Network

Some of the connections resulting from Virtual Fridays: • Guy Chicoine (Kaiser) connected Anna-Lisa Silvestre (Kaiser) to Ginger Price (Veterans Affairs) on the use of online services • Ann Hendrich (Ascension Health) and Jeff Norton (CHI) connected with Chris McCarthy (Kaiser) about Nurse Knowledge Exchange • Jim Noga (Partners) and Christi Zuber (Kaiser) connected about green facility design • Eric Cleveland (Mayo Clinic) connected with Andrea Werner (Bellin Health, a non-ILN participant) on prioritization models • Oyweda Moorer (Veterans Affairs) connected with Marilyn Chow (Kaiser) and Ann Hendrich (Ascension Health) about nurses’ work environments

The presentations became known as “Virtual Fridays” – conference calls that included a web-based component for presenters to share PowerPoint presentations and other interactive components. The Virtual Fridays rapidly showcase a specific topic in detail in a way that keeps the audience interested and engaged, maintaining a personal feel. These interactions helped the members to maintain the relationships they had begun to develop in April. The Virtual Fridays also proved an easy way to introduce the group to the variety of innovations at each organization and float many ideas and interests to the surface. By fostering the development of trust and professional credibility throughout the network, the Virtual Fridays resulted in many connections and collaborations between individual ILN members and their organizations.

Lessons learned Create an idea pipeline.

The Virtual Friday archive also allows organizations to access helpful information at the right time. After Chris McCarthy presented the first Virtual Friday on Nurse

Page 9

Innovation Learning Network 2006 We need to allow us to sample and to look at the menu, rather than having to order the entrée to taste it. David Tew

Structures

Wiki Website List-serve

Diffusion

Projects

Knowledge Exchange, an innovative process to improve nurses’ exchange of information during shift changes, Ann Hendrich from Ascension Health contacted Chris immediately to find out more. Individuals at the Mayo Clinic and CIMIT also expressed interest in the topic, but at a much later time; Chris was able to direct those individuals to the archive for the complete presentation. The archive thus enables the ILN members to access information when a particular issue has an immediate need, and does not require every innovation to be applicable at the very moment in order to diffuse from one organization to another. Virtual Fridays were the most successful collaborative tool used over the course of the ILN; some members have expressed interest in hosting Virtual Fridays for their own organizations’ staff. Virtual Infrastructure. A number of ILN members have emphasized the importance of having an active virtual infrastructure to allow not only for connecting with other members, but also as a host space for joint project management. The ILN staff tested several different virtual collaborative spaces as a means of keeping the network connected, including: an email list-serve, a conventional website, and a wiki – a collaborative website that allows all members to post and edit content. The wiki has certainly been used by the members on a far more regular basis than the previous website, yet still has not taken hold as a consistent tool for members. This reflects both the relative inexperience of members with this form of collaboration, and the early stage of most of the group’s collaborative projects.

Lessons learned Have an active virtual infrastructure.

The list-serve has been utilized relatively frequently, and presents the advantage of allowing members to push information out as well as pull information in from the other members. ILN staff expect that traffic will increase significantly as the network grows. The ILN is changing from a network based on disjointed, one-time encounters to a group that engages in a continuous stream of contact. Over the next year, the ILN faces the challenge of finding or creating a virtual collaboration tool that will facilitate both relationship-building and content generation, without excessive contact.

Page 10

Innovation Learning Network 2006 SECOND MEETING: OCTOBER 2006 In October, the group met in person for a second time, at the Sidney H. Garfield Health Care Innovation Center, Kaiser Permanente’s recently opened innovation laboratory in San Leandro, California. Three elements drove the meeting: the opening of the session with a panel discussion; the continuation of Open Space; and a sharpened focus on collaborative projects.

craigslist ILN asked the panelists: what should health care work on? Robin: My mom has a variety of illnesses and I took her through the hospital. Whenever I had a question, my mom felt it wasn’t our place to ask. I would like her doctors to help her to be a more informed consumer. Be more interactive, want your patients to ask questions. Joy: When I was in the hospital, I wanted to know what was happening and when and why – what is the task flow? I want to make sure I’m on track and okay. I want unbiased advice but don’t ask me to be intelligent while I’m in the hospital because I’m not feeling well. Make it simple for me to understand, with pictures. Ron: My kids are 20, 16, 3 and 1. I want an opportunity for them to get information they can use throughout their lives – an educational process that’s built into experience of going to the doctor. Jim: Push the needle from curative to preventive. Open the system up to user reviews. The American medical system is screwed up in terms of incentives - why can’t we talk about national health care? We can lean on IT trends to push improvement. Sarah: Reduce my barriers to entry. I can’t overemphasize the need for accessibility. I’d also like to be able to give feedback to my dad’s doctor from far away. Balance optimism with reality.

Panel Discussion. Activities began with a panel discussion of innovators from industries outside health care. The idea for this panel had initially emerged in the April meeting during a group discussion on “Human-Centered Design.” Members of this group recognized that there were many lessons to be learned from other industries, and hoped to enlist innovative leaders from other fields to learn specifically about their practices of engaging with their customers. The discussion featured five panelists: • • • • •

Robin Boyar, Senior Director of Research, Electronic Arts Jim Buckmaster, CEO, Craigslist Joy Mountford, Distinguished Scientist and Senior Director in User and Experience and Design – Yahoo! Communications, Communities and Front Doors business areas Sarah Snudden, Consumer Packaged Goods, Clorox Ron Volpe, Customer Vice President – Supply Chain, Kraft Foods

The panel discussed how each of their organizations view and practice innovation, along with how they have handled the barriers that prevent innovation. The group also spoke at length about how they incorporated customer feedback and opinions into the design of new products and processes. Joy Mountford of Yahoo! emphasized the importance of storytelling when bringing innovations to life, a subject that members often reiterated throughout the two days of discussions. Several other themes discussed during the panel would emerge throughout the next two days. By exposing the ILN members to perspectives from outside their industry, the panel helped the group to think outside of healthcare’s usual norms, kicking off two days of creativity and excitement.

Page 11

Innovation Learning Network 2006 Open Space and Collaborative Projects. Attendance at the October meeting included large cohorts of returning and new members, requiring a balance of consolidating the group and advancing specific agendas. The members perceived themselves as more focused – many came to the meeting with the question in their mind: “What are we going to do this time that will lead to some specific action?” The content that had started to emerge in April and had developed through the Virtual Fridays began to coalesce into common areas of interest with specific related projects. The first day resembled the April meeting very closely in set-up: after an initial tour of the Garfield Center, participants were asked to choose topics that they wanted to discuss. The second day, however, had a more distinct action-oriented component. Keith McCandless, who facilitated the meeting, asked the group to select a few topics that had enough momentum during the discussions to move forward and become group projects. Lessons learned Four groups emerged. Using a template The real value will come provided by Keith, they created concrete game from collaborative plans for next steps, with goals, timelines and projects. leaders. These included: •

Personal Health Records - a group led by David Tew of Alegent Health Care that aims to make personal, portable, electronic health records nationally available within two years

•

Virtual Simulations - a group led by Christi Zuber of Kaiser Permanente that seeks to use virtual simulations to support collaboration and innovation between and among providers and patients

•

Innovation Labs - a group led by Jennifer Ruzek of Kaiser Permanente that plans to share the resources of their innovation laboratories and workshops

•

ILN 2007 - a group led by Chris McCarthy that began planning the work of the ILN over the next year

It is living… really is a living network. Marilyn Chow

Page 12

Innovation Learning Network 2006

Structures

Virtual Simulations Projects Innovation Labs Personal Health Records Diffusion

Personal Health Records survey

Follow Up. Since the meeting in October, each of the projects has progressed. With the term of the VHAHF grant coming to a close, the ILN members have taken steps to keep the network financial sustainable. By November, eight of the ten original organizations had committed to supporting the ILN for the next year, a testament to both the potential that participants saw in the collaborative work and the value that they had already received from having access to each other. The personal health record group has continued to hold regular conference calls. After an initial investigation revealed a wealth of existing available products, the group decided to compile a review of the current major offerings. The group assembled a list of available products, and created a tool to evaluate these according to the standards they had developed during the October meeting. In a Virtual Friday, the group updated the ILN on their progress and enlisted members’ help to evaluate products. The group hopes to publish these results soon, and leverage their findings to engage in discussions with other stakeholders, such as employer groups, to make Personal Health Records more widely available. The virtual simulations group agreed to evaluate the Second Life website as a potential platform for development. Since the October meeting, the group has held two virtual meetings within the Second Life platform to begin investigating the potential applications of this avatar-based environment. One of the committee members has instigated discussions with an executive of Second Life; the group hopes to learn from her how other health care organizations have used Second Life.

Second Life screenshot

The innovation labs group hopes to utilize each other’s facilities to discover innovative solutions regarding medication reconciliation. The group is still coalescing and has yet to determine how that plan will unfold; first steps have included meetings between CIMIT and Garfield Center staff in Boston.

Page 13

Innovation Learning Network 2006 This is about diffusion, and the water will seek its own level on the one hand. On the other hand, a rising tide does not lift all boats. The boats that it lifts are the boats that are seaworthy. David Tew I think that innovation is really a science of quality. It’s a process in which rich discovery and self-discovery and all sorts of spin-off innovations are occurring as you’re trying to get to this deliverable. And most of that is an invisible thing to the senior leaders that hold the purse strings or whoever originally started this thing. Keith McCandless

Open Space Network Maps Email & Web Tools

Personal Health Records Virtual Simulations Innovation Labs

Projects

Structures

Diffusion Virtual Fridays Diffusion Survey

LESSONS LEARNED Innovation does not need to occur within a network – it can occur within a single organization. Yet the ILN members found an immense diversity and richness of ideas that they could tap into by being hooked into this network, facilitating the innovative process. Innovation is a dynamic interplay of structures, projects and diffusion – the ILN became a successful innovation because it grew to exhibit all of these. The set structures included Open Space meeting design and Virtual Fridays, from which collaborative projects grew; these subsequently diffused into organizations via the Virtual Fridays and the members’ relationships – the network itself. Several ideas have emerged about how to build a successful network. 1. Requiring the members to decide on the direction and activities of the network themselves will result in a more engaged, participatory group than might arise from a group that has been given a predetermined agenda. The ILN’s initially vague agenda fostered creativity and energy among the members, who used the open space forum to surface the issues they most wanted to address, then expressed an extraordinary willingness to tackle these issues. Participants cannot be given freedom without bounds, however; they must also have responsibility for ensuring the success of their homegrown network. 2. Relationship building is the central principle of a successful network. In order for the members to truly collaborate, they needed to feel like they could trust each other. That perhaps may be why most of the discussion topics that arose at the April meeting failed to take off – the network was not yet mature enough. Many members wished that the second in-person meeting had been held sooner after the initial meeting, in order to reinforce those initial connections made. 3. Make it fun! Every single member of the network had a full workload before they began participating in any of the ILN’s activities. To find time to devote to the ILN, members must truly enjoy the work. From the very first meeting, the ILN staff set a tone that was playful and energetic, and the members responded in kind.

Page 14

Innovation Learning Network 2006 4. Each organization’s sponsors and champions need to actively push information out within their own organization and pull in new people to participate. The social network maps demonstrate how well connections, and subsequently information, spread throughout individual organizations. As the next year of work begins, the ILN will need to clearly define the roles and expectations for sponsors and champions, to ensure that value reaches many areas of each organization. Greater diffusion into the member organizations will also help to make a more compelling case for continuing the ILN’s activities and funding. 5. The discovery of common interests will come from surfacing many initial ideas. Through both the open space meeting discussions and the Virtual Fridays, members were able to learn about the projects being completed at each other’s organizations, along with the challenges that each organization faced. The life of the ILN can be viewed as a narrowing pipeline that highlighted those projects that could develop momentum. 6. In order to build on the momentum around projects, the network needs an active virtual infrastructure to serve both as a means of maintaining relationships and as a tool for managing projects. The wiki and the list-serve have served as a foundation for collaborative activities. In order to maintain engagement, the network will need tools that push information out and serve as consistent reminders of the wealth of content available through the members of the network. 7. The true value of the network will come from collaborative projects. In order to thrive and continue, the ILN will need to significantly and tangibly impact the member organizations. There has been significant small-scale collaboration (groups of two or three members) that has been hard to document; the ILN hopes to further utilize the social networking surveys and maps to capture that work and demonstrate value. The major projects that took root during the October meeting demonstrate promise, and may serve as a litmus test for the organization’s viability moving forward.

Page 15

Innovation Learning Network 2006 Well, it gives me hope, and I need it.

GOING FORWARD

I think it’s got extreme potential.

The activities of the ILN thus far establish a pattern for a continuing two-phase cycle: face-to-face meetings with deep dives into particular topics, followed by longer periods of collaborative projects and network building. In 2007, the ILN has plans to initiate new activities such as group consultations and a “borrow an expert” interorganizational exchange program; the in-person meetings will become larger, longer, and more frequent. While the ILN is still building capacity and momentum, it has proven an exemplary model of a rapidly developed network with an enormous amount of potential.

Donna Deckard

As 2007 progresses, the ILN will be the group to watch.

Keith McCandless I’m looking forward to seeing what continues to come out of this. Chris McCarthy

It gives me as a health care consumer a lot of hope. Maggie Hentschel That’s why innovation is so important and why I’m really excited about the ILN. David Tew

Page 16

Innovation Learning Network 2006

Innovation Learning Network: Resources and Tools February 2007

Innovation Learning Network 2006 RESOURCES AND TOOLS First Meeting/Open Space • Principles and Set Up • Meeting Agenda • Summary of Discussion Groups • Diffusion Survey Results o Summary o Surveys o Elements of Successful Spread

A-6 A-7 A-15

Social Network Mapping • Survey • Summary of Results • Presentation of Findings • Article: Building Smart Communities through Network Weaving

B B-1 B-2 B-6 B-7

Virtual Fridays • Process Guide • Topics and Abstracts

C C-1 C-2

Online Collaboration • Site Map – ILN Website • Site Map – ILN WIKI • Screen Shots

D D-1 D-2 D-3

Second Meeting • Panel Discussion o Participants o Summary • Meeting Agenda • Summary of Discussion Groups • Project Game Plans o Game Plan Template

A A-1 A-3 A-4

E E-1 E-3 E-5 E-6 E-9 E-13

Going Forward • Summary of ILN 2007 • RFP for Social Network Mapping and Weaving

F F-1 F-2

Resources • ILN 2006 Members • Other Resources

G G-1 G-2

Innovation Learning Network 2006

Section A: First Meeting/Open Space Principles and Setup of Open Space What is Open Space? It is a self-organizing practice of individual discipline and collective activity that releases the inherent creativity and leadership in people. By inviting people to take responsibility for what they care about, Open Space establishes a marketplace of inquiry, reflection and learning, bringing out the best in both individuals and the whole. It has been used successfully all over the world in many organizations and communities. When to Use It • • • • •

Where the situation is complex Where there is a high degree of diversity Where there is an urgent need to make speedy decisions Where many stakeholders are needed for good decisions to be made Where there are few preconceived notions of what the outcomes should be

Probable Outcomes • • • • • • •

•

Builds energy, commitment and shared leadership Participants accept responsibility for what does or doesn't happen Action plans and recommendations emerge from conversations You create a record of the entire proceedings as you go All of the issues that are MOST important to the participants will be raised All of the issues raised will be addressed by those participants most qualified and capable of getting something done on each of them In two days, all of the most important ideas, discussion, data, recommendations, conclusions, questions for further study, and plans for immediate action will be documented in one comprehensive report -- finished, printed and in the hands of participants when they leave After an event, all of these results can be made available to an entire organization within minutes of the event, so the conversation can invite every stakeholder into implementation -- right now

How It Works The Law of Two Feet means you take responsibility for what you care about -- standing up for that and using your own two feet to move to whatever place you can best contribute and/or learn. Four principles apply to how you navigate in Open Space: •

•

Whoever comes is the right people Whoever is attracted to the same conversation or challenge are the people who can contribute most to that conversation—because they care. So they are exactly the ones -- for the whole group -- who are capable of initiating action. Whatever happens is the only thing that could have We are all limited by our own pasts and expectations. This principle acknowledges we'll all do our best to focus on NOW -- the present time and place-- and not get bogged down in what could've or should've happened.

Page A-1

Innovation Learning Network 2006 • •

When it starts is the right time Creativity cannot be forced or scheduled. Our task is to make our best contribution and enter the flow of creativity when it starts. When it's over, it's over Creativity has its own rhythm. So do groups. Just a reminder to pay attention to the flow of creativity, not the clock. When you think it is over, ask: Is it over? And if it is, go on to the next thing you have passion for. If it’s not, make plans for continuing the conversation.

How Open Space Works When There Is Conflict The Law of Two Feet gives participants freedom to move at any time to a discussion they care about. Caring creates common ground, and helps to remind participants of higher purpose. The Steps of Open Space in Brief 1. 2. 3.

4.

5.

6. 7. 8. 9.

Select a focusing statement or question for your gathering. It should frame the higher purpose and widest context for your discussion in a positive way. Invite the circle of people: all stakeholders or all the people you'd like to have in the room. Include the theme, date, place and time of gathering in the invitation. Create the circle: Set up chairs in a circle or in concentric circles, leaving space in the center. Choose a blank wall for the Agenda Wall and label it AGENDA: AM, PM across the top. Set up a table for computers near a wall you label NEWS. Put blank sheets of paper (about quarter size of a flip chart page) and colored felt pens in the center of the circle. Near the Agenda Wall and the News Wall put masking tape for people to post papers on the walls. To begin the gathering: Facilitator explains: the theme, the simple process the group will follow to organize and create a record, where to put things up and find out what is happening, the Law of Two Feet, and the Principles of Open Space. Then, facilitator invites people to silently reflect on what is important for each of them in responding to this challenge. Opening the marketplace: the Facilitator invites anyone who cares about an issue or challenge to step into the middle of the circle and write the topic, their name, a time and place for meeting, announce it and post the offering on the Agenda Wall -- one sheet per topic—as many topics as he/she wants. They will be conveners who have responsibility for leading their session(s) and seeing to it that a report is made and shared on the News Wall. A recorder in each room will assist each leader. When ALL offerings are concluded, the Facilitator invites people to sign up for what they are interested in and take responsibility for their schedules, using the Law of Two Feet. People participate in discussions. The Facilitator takes care of the space. Recorders enter discussion reports in the computers and printouts are posted on the News Wall. Evening News & Closing Circle: all reconvene an hour before closing to share highlights, "ahas" and key learning in a dialogue format: simply listening to whatever people have to offer without discussion. Mail out, simulcast, or post the record that is created. Share the Gameplans and include more people in the efforts underway.

Adapted from Anne Stadler, [email protected].

Page A-2

Innovation Learning Network 2006

ILN In-Person Meeting #1 April 26-27, 2006 Agenda Day 1 Start 8:00 8:30 8:45 9:00 9:30

Finish 8:30 8:45 9:00 9:30 15:30

Duration 0:30:00 0:15:00 0:15:00 0:30:00 6:00:00

15:30 16:00 17:00 18:30 19:00

16:00 17:00 18:30 19:00 21:00

0:30:00 1:00:00 1:30:00 0:30:00 2:00:00

Discussion Closedown/Break CIMIT Simulation (back to hotel) Cocktails (hotel) Dinner (hotel)

Day 2 Start 7:30 7:45 8:15

Finish 7:45 8:15 8:45

Duration 0:15:00 0:30:00 0:30:00

Task Welcome Back CIMIT Presentation 1 CIMIT Presentation 2

8:45 9:00 9:30 10:00 10:15 11:30

9:00 9:30 10:00 10:15 11:30 11:45

0:15:00 0:30:00 0:30:00 0:15:00 1:15:00 0:15:00

Break CIMIT Presentation 3 CIMIT Presentation 4 Break Closure/Connections Delta/Plus

Task Welcome/Settle In/Rapid Re-Intro ILN Story Open Space Technology Setup Open Space Agenda Creation Open Space

Notes

Each topic leader should have documented the flow of discussion, major points, and next steps

Notes OR of the Future Medical Device Interoperability Plug-n-Play Ambulatory Practice of the Future Connected Health Initiative

Page A-3

Innovation Learning Network 2006

Discussion groups Accelerating Education and Implementation of Innovation - Capturing Best Practices and Diffusion CIMIT/Partners HealthCare - Beverly Brown ([email protected]) HealthTech - Joanne Asercion ([email protected]) This group explored different processes that their organizations were using to diffuse innovations internally. The group how to create a safe environment that allows for risk taking, and concluded that a key indicator for successful innovation is being replicable on a larger scale. The group brainstormed elements of successful diffusion, including: enlistment of opinion leaders, executive sponsors, and good facilitators; celebrating small successes as part of a larger strategic plan; sharing failures as part of the learning experience; and managing expectations. This group continued their conversation over the summer and disseminated a survey about diffusion. For the results of that survey, please see Appendix 1-6. Innovative Work Environments and Innovation Labs CIMIT – Janice Crosby ([email protected]) This group discussed several projects underway at their organizations relating to work environment, including a multicenter study of where and how nurses spend their time, and innovation “laboratories” for both ambulatory and inpatient care. The group emphasized the need for a mechanism to share ideas, trials, successes, failures, and lessons learned. Patient Experience Alegent Health – Ann Jones ([email protected]) The group discussed how to learn more about the patient experience, and what tools could be used. Tools discussed include interviewing patients, following them, and observing behaviors. The group noted that patients’ vulnerability makes the industrial model less applicable in the healthcare arena, as the intensity of emotions and the complexity of the processes are clear differentiating elements. This group continued to work over the summer; the ultimate result of their collaboration was a panel discussion that opened the second in-person meeting. For a summary of that meeting, please see Appendix 5-1. Open Innovation Alegent Health – Ted Schwab ([email protected]) This group asked the question, “How do we continue to include outside sources of information and keep the innovation open as we begin to implement?” The group discussed major projects within their organizations that could use innovative thinking, lessons learned about how innovation works, and major challenges to open innovation. Virtual Collaboration Processes and Tools Massachusetts General Hospital/Partners HealthCare – Jim Noga ([email protected]) The group discussed what works and doesn't work in virtual space. Preferences included a basic list serve that any member of the group can use to quickly post a question to the entire group. The group also preferred an approach to information sharing that allowed members to choose their areas of interest, and then sent out relevant email updates with a link back to a central site; the group also hoped for wiki capability. The group chose four areas of interest: Ambulatory Practice of the Future, Facilities Design, Medication Administration, and Changing Corporate Culture to Support Innovation. Positive Deviance and Other Liberating Structures: A Tale of Two Innovators Social Invention Group – Keith McCandless ([email protected]) Liberating Structures are the processes, rules and infrastructure that make it easy for people to be creative, adaptable, build on each other ideas, and get results. This group shared innovation stories and the approaches taken. A few themes emerged:

Page A-4

Innovation Learning Network 2006 • • • • •

The importance of including multiple stakeholders in the selection, research, and design effort not separating the design and spread activities. The importance of "air cover" tone that encourages risk taking -- from leaders. The need to create space and time for an innovation culture to bloom. Diminishing fear of job loss ("if my role or work process changes, I may lose my job"). While healthcare innovates fabulously in medical devices, innovation in other key aspects is lacking.

Making Meaningful Changes in Organizations Mayo Clinic – Alan Duncan ([email protected]) The group began the discussion by talking about the ways in which incorporation of innovations in a systemic fashion in organizations requires the organization to structure itself differently. The role of senior leadership was emphasized repeatedly. Risk acceptance and tolerance, in particular, were seen as the groundwork for a culture of innovation. The group talked about the ways in which innovation organized through "projects" can lead innovators astray because of the pressure for timelines, immediate deliverables, and the like. The group discussed how metrics could either foster or stifle innovation, and about constraints and enablers. Finally, the group discussed simple rules that can help innovators and organizational leadership to accomplish the goals of increasing both autonomy and integration. Healthcare Reform Based on Quality Franciscan Missionaries of Our Lady – George Burgess ([email protected]) This group discussed current attempts to change how health care is delivered, and the barriers and opportunities present. The group discussed what assumptions and requirements would lead to the realization of the Institute of Medicine’s six goals. The group discussed starting a planning improvement process to develop options for improved model(s) for healthcare, along with potential next steps. George Burgess continued to build on the ideas arisen within this group, and presented the results of his work during a Virtual Friday. The Link Between Accelerating Change and the Use of Incentives Catholic Health Initiatives – John Anderson ([email protected]) This group asked the question, "What impedes the unleashing of the talent pool of creativity within health care?" The group discussed different ways in which incentives could be used to encourage innovation at the core of health care, and cited the difficulty of merging incentives of clinicians with those of other healthcare professionals. The group also addressed the importance of maintaining personal and emotional connections to the well being of individual patients even the system begins to innovate and explore.

Page A-5

Innovation Learning Network 2006

Diffusion Survey Results – Summary Implementation is influenced significantly by the scope of desired implementation and ability to marshal a multi-disciplinary team to drive implementation across entities. Implementation success factors -

The innovation team needs a respected, inspirational leader. A physician leader can help produce buy-in. Successful spread can come two-fold. First, an innovation starts to spread naturally; then leadership acknowledges it as a best practice and mandates it for everyone. Let the end user customize the innovation to reduce the need for training. o Get manufacturers to participate in the training of their devices. Implementation requires a robust social network that allows change agents to use relationships to navigate through committees.

Barriers to successful implementation -

Lack of high-level sponsorship. Unclear scope and definition of problem. Inability to prioritize problems to be solved. An organization committed to putting out “point fires” and not seeking a comprehensive solution to improving patient safety. Organizational culture that makes it hard to convince people to embrace changes instead of being afraid of them. Challenge of maintaining the integrity of an innovation when handing off from the designers to those implementing the innovation. One group’s solution: o Implementation is the responsibility of those who created the project and asked the question. The design team considers implementation throughout the process by maintaining a primary focus on the human aspect of the desired/intended change.

Notes from Partners HealthCare -

-

“Translating innovation into eventual implementation takes a ‘village.’ At Partners, the Corporate Sponsored Research program and CIMIT can provide such a village environment to help technologies traverse the rocky shoals of development, commercialization and implementation.” “At the highest levels, Partners is seeking to do the right thing first and figure out how to get reimbursed later. “

Notes from Kaiser Permanente -

Kaiser has an innovation team that can support operations throughout the organization. The team has two major approaches for assisting groups: o The team conducted a seminar for a region on rapid cycle change, then invited others to submit ideas to implement. They started with nine teams, and cut down to two teams. Met every other month for a year and half. o The team held an application process for groups to receive their support. The team helped applications to fill out the application, especially defining the problem to solve, metrics, etc. Questions included: How does this strategically align with organization? How will this idea improve affordability? What kind of support are you seeking from the innovation team?

Page A-6

Innovation Learning Network 2006

Survey #1: Regional Kaiser Permanente Innovator 1) Where does innovation occur? Innovation happens all over our organization, from the top to bottom. How do you define innovation in your organization? Innovation is trying something new to address a problem. In your organization, where are technologies, workflow improvements and IT upgrades either developed internally or identified externally? Technologies and workflow improvements come out of clinical areas based on needs and desires, and working with our regional Strategic Management Consulting, Innovation Team or the Clinical Research Unit. I am not sure how this happen in the IT side of our organization. a. If a separate group exists, how large is it, how is it funded and what is their charter? The Innovation Team is made up of twelve people (five are MDs, four directors of departments, union representatives and two project managers) and the group is led by Bill Marsh. The Innovation Team is part of the operating budget for the region, and its mission is to promote a spirit of innovation and risk taking throughout the organization in order to improve affordability. How does its work get implemented and by whom? There are two main ways groups can tap into the Innovation Team’s resources: first, we conduct seminars on rapid cycle change and often invite folks to submit ideas to implement. An example is that we had nine teams thinking about new ideas. We shaved that down to two, and then met every other month for development. Second, there is an application process that we can assist folks with, especially with defining the problem to solve and metrics development. Part of the process is answering the questions: “how does this strategically align with organization?”, “how will this idea improve affordability?” and “what kind of support do you want from the Innovation Team?” 2) Specific Example of Success: Across your entire organization what is a good example of a recent successful implementation of a new technology or a significant process improvement across a large percentage of your organization (an example might be EMR)? Be prepared to talk in some detail about how the implementation was planned and staged as well as the results. An example of success is with our Practice Management initiative (in Colorado) where the Primary Care MD manages their whole panel of patients. It was well spread because there was a regional mandate to do so. Originally it started to spread naturally. However because of the great results, and determination that it was a best practice, leadership mandated as a standard. The implementation started about two years ago. 3) Specific Example of Failure: Across your entire organization what is a good example of a recent failed implementation of a new technology or a significant process improvement that was attempted across a large percentage of your organization? Be prepared to talk in some detail about how the implementation was planned and staged as well as the results. Were you able to understand why it failed? Please give the details. I can’t think of one at the moment. 4) Training (how, who and what worked and didn’t): Is the training included in the implementation plan? Who owns the training and how much of the total effort (time and budget) is devoted to training? What are the tools that you have used successfully and unsuccessfully? Please detail why some worked and others did not. Training is not a significant part of what we do with implementation, and is done ad hoc. We encourage folks to connect with each other by phone and site visits, and also hold innovation fairs where they can connect. Specific training we do is around the rapid cycle change process. 5) What are your metrics for success? For the innovation team it is to improve affordability (for example: decreased ALOS). We use a value equation and quality indicators to

Page A-7

Innovation Learning Network 2006 determine if we are on the right track; however we have not seen improvements in cost just yet. 6) What are some of the key barriers to successful implementation and how did you overcome them? One key barrier is the lack of sponsorship. We identify and bring in sponsors early on in the project, and have them co-developing measures of success to help remedy this. Another barrier is a lack of clarity regarding what the problem is. Our insights have helped us to more clearly define the problem to be tackled with our sponsors, before beginning a project. 7) Is there anything that is really unique to your organization that makes implementation either easier or harder than elsewhere? Please provide details. In our part of the organization its fairly easy: we have an innovation team that is sanctioned by the medical group and health plan leaders, and is led by Bill Marsh, one of the most respected physician leaders. Are you able to provide incentives to early and easy adoption? We try really hard to recognize people who are trying new things: monetary rewards, email commendations to their supervisors to name a few. And the Innovation Team helps to make it easier for teams to adopt things early. What are some of the motivations that have worked for you? Bill Marsh is certainly motivating; he is an inspirational leader. Also finding and working with people around the organization that are kindred spirits—those willing to put themselves out there to take risks.

Page A-8

Innovation Learning Network 2006

Survey #2: Nat Sims, Partners Health Care Smart Infusion Pump Learning Lab Smart Pump: Device IT convergence through multidisciplinary cycles of innovation and implementation Nov. 21, 2006 This is a great story to highlight as the underlying technologies are “mature,” in the market place, and implemented across the country. The story is a long one, spanning 20 years, and it embodies success and failure of this critical life saving integration of a dumb device with a knowledge database of drugs and institutional guidelines within the context of a clinical diagnosis to minimize drug errors in acute care settings. Implementation can drive innovation which in term accelerates implementation….as the “inventors” are the users. The story highlights the fact that in ideal projects, innovation is best done with implementation in mind. 1) Where does innovation occur? It occurs all over an organization, in all corners of the clinical environment. Basically, health care providers see unmet needs, come close to or make critical mistakes in caring for patients. This drives them to seek to correct the systems that contributed to the errors. “Years ago, an anesthesia resident was caring for a newborn baby with congenital heart disease who needed a precise intravenous infusion of a powerful drug to dilate the blood vessels prior to surgery. After the infusion was started, the baby remained inadequately oxygenated. Eventually the clinicians discovered that an error in the complex dose calculations had led to a serious underdosing of the critical drug. This sentinel experience resulted in a personal resolve by the anesthesiologist to devote significant energy to addressing patient safety.” Out of that vision, a multifunctional team was formed at MGH to study the problem. They concluded that there were two deficiencies: 1)There were inadequate systems to disseminate intravenous drug knowledge to physicians and nurses at the exact moment of need and 2)We had inadequate systems to ensure that the right drug and the right drug dosing at the time of bedside administration. The team concluded that both problems could be substantially resolved with a single technological solution, along with associated care-process changes. This insight led to the conception and implementation of “smart” infusion pumps with “onboard drug libraries.” Translating innovation into eventual implementation takes a “village”. At Partners, the Corporate Sponsored Research program and CIMIT can provide such a village environment to help technologies traverse the rocky shoals of development, commercialization and implementation. 2) Specific examples of success: 1)Develop close working relationships with the local technology transfer and industries who will fund development and commercialize the eventual product – this is critical. 2)Grant non-exclusive licenses of the basic technologies so many companies can innovate, compete and accelerate the implementation. 3)Seek to engage the front line in customization of the product. This helps overcome company liability as it moves it into the “practice of medicine” at the local level and confers ownership to those who are customizing it. It automatically meets the customers’ needs as they are in control of the final product. This provides context aware information at the right time that follows the institutions’ guidelines. 4)Keep the inventor at arm’s length for conflict of interest issues relating to purchasing but engage them on strategic discussions of future products. This is somewhat neutralized if many vendors have licensed the technology and are selling products.

Page A-9

Innovation Learning Network 2006 3) Specific examples of failure: 1)We granted exclusive license to an early industrial sponsor (for a very small amount of money) resulting in the company sitting on the technology for 5-8 years as they did not want to cannibalize their current products and there was no competitive pressure to launch - the innovation was so far ahead of the competition. Initially, research hospitals thought that they could make large revenue on medical devices through exclusive licenses. Over time, they came to realize that devices are not drugs and wide spread access brings more revenue in the long run. 2)Companies who first commercialized it ran into huge resistance by dictating to institutions how they practice medicine, how drugs are formulated and how physicians make decisions. With this approach, the companies took ownership for the liability as well. In acute care settings, “every way we use drugs in the hospital is off-label”. When the companies gave control of the workflow back to the customer (hospital), guidance rules and programming belonged to the clinicians. This immediately shifted the liability to the hospitals and the companies started selling units. 4) Training (how, who and what worked and didn’t): 1)When the customer does the customization, they have automatically reduced the need for training. New medication rules, workflow and guidelines are not required. All that is needed is the actual use of the device itself. The “customizer” becomes the trainer as well. 2)Manufacturers participate in the training of their devices that are standardized across the industry. 5) What are the metrics of success? There are really milestones to success with this project. First came the vision of solving the bedside drug errors. Then came the invention of the smart pump with a drug calculator and guidance by user defined “guard rails” to reduce or eliminate the dose errors. Next came coupling automated drug recognition (through RFID or barcode) to prevent harm. Finally, the holy grail will be to incorporate the vital signs of the patient with the EMR and other data systems to provide an end to end solution. Success is in sight but not achieved yet. 6) What are some of the key barriers to implementation? 1) No top level commitment to implementation 2) No centralized IT or vision of IT for the organization, 3) Not enough wireless expertise to make smart pumps reliable in a “noisy environment and 4)An organization committed to putting out “point fires” and not seeking a comprehensive solution to improving patient safety. 7) Is there something unique to your organization that makes implementation easier than elsewhere? Yes, at the highest levels, Partners is seeking to do the right thing first and figure out how to get reimbursed later. As a top strategic direction, Partners has set it’s vision on High Performance Medicine. Through the promise of improving the quality of healthcare delivery, it will make safety a profit center at some point in the future. This requires the lofty but comprehensive vision of integration of all of the safety initiatives such as Smart Pumps, CPOE, eMAR, Auto ID, IT across all affiliates and information systems into one focus. Funding will ultimately come from the revenues conserved by reducing patient errors. The ILN is in a unique position to advance the thinking and sharing so that many healthcare systems can accelerate their thinking to comprehensive solutions. The Smart Pump story is an excellent case study with considerable information available to all who request it.

Page A-10

Innovation Learning Network 2006

Survey #3: National Kaiser Permanente Innovator 1) Where does innovation occur? Innovation is sprinkled throughout Kaiser Permanente (KP) from our technology sector to direct patient-care delivery to population care. We have teams at the unit level all the way to the national (corporate) level that tackle pressing challenges. On the macro level, we have intentional efforts to collaboratively design solutions such as Nurse Knowledge Exchange and the Perinatal Journey Home Boards. On the micro level, or unit level, we’ve embedded the skills for innovation in the individual so that innovation can happen spontaneously. The formalized innovation structures include the Sidney R Garfield Center for Health Care Innovation (Garfield Center) and the Innovation Consultancy. We even have regional innovation teams such as in the Colorado Region. How do you define innovation in your organization? We’ve never formally defined innovation, and it remains elusive. However it seems most KP folks are comfortable with the following definition: “any concept that is newly introduced that generates value.” In your organization, where are technologies, workflow improvements and IT upgrades either developed internally or identified externally? That depends on the scale of the design challenge. It could be on the fly for a particular unit or at the regional or national level, such as at the Garfield Center. a. If a separate group exists, how large is it, how is it funded and what is their charter? i. Garfield Center – 2 FTE funded jointly by IT, Facilities and Patient Care Services ii. Innovation consultancy – 3 FTE funded by Health Plan and Operations iii. Regional and Medical Center groups – varied How does its work get implemented and by whom? That is very good question. Handing off evidence-based innovation to a team that can implement is an area that KP (and many other organizations) is struggling with. The current model seems to be that teams that innovate also implement. Organizationally, we know that it’s not ideal, however the plus side of this is that there is consistency in terms of who is “running” the project. One model that KP is experimenting with is having a “transition team”, where members of an implementation team would join the Innovation Team during the last round of testing so that they become embedded with the content and can easily move into implementation. We say “experiment” because we will test this model in 2007. 2) Specific Example of Success: Across your entire organization what is a good example of a recent successful implementation of a new technology or a significant process improvement across a large percentage of your organization (an example might be EMR)? Be prepared to talk in some detail about how the implementation was planned and staged as well as the results. A good example is definitely Nurse Knowledge Exchange (NKE). It was planned using the IHI Rapid Scale-up methodology, being staged geographically and by time. We let each hospital region decide their approach, and asked them to plan not more than three waves to complete the hospitals that joined the collaborative. We will be implemented in twenty-one hospitals by 12/2006 and the remaining ten in 2007 (See Virtual Friday presentation on KP NKE). 3) Specific Example of Failure: Across your entire organization what is a good example of a recent failed implementation of a new technology or a significant process improvement that was attempted across a large percentage of your organization? Be prepared to talk in some detail about how the implementation was planned and staged as well as the results. Were you able to understand why it failed? Please give the details. I’ll approach this question from a different perspective. NKE is made up of four components, one being Bedside Rounds. During the first wave of implementation we noticed that the Bedside Rounds were not being done across the system, and the other three

Page A-11

Innovation Learning Network 2006 components were. We were puzzled. As we began getting data from the twenty-one hospitals and antidotal evidence, it became clear that we had two major barriers to overcome. The first being HIPAA. Many nurses were confused about what they could say at bedside in front of the family or another patient. The second issue was that many nurses had “stage fright”; being uncomfortable talking in front of the patient with another nurse. With these two issues, we saw failure of this component across the system. However our process metrics triggered us to look deeper, and by uncovering the “barriers” we were able to target KP-wide interventions to push this initial failure into success. One of the major infrastructure insights from this experience was learning how to tap into the awesome resources at the local level. Nurse educators became our “best friends” for simulating Bedside Rounds with the nurses. This is something that we never considered in the innovation phase of the work, but was integral for a rapid scale-up. 4) Training (how, who and what worked and didn’t): Is the training included in the implementation plan? Who owns the training and how much of the total effort (time and budget) is devoted to training? What are the tools that you have used successfully and unsuccessfully? Please detail why some worked and others did not. For NKE, we developed a change package that included customizable training materials. Actual training was done by and at the local medical centers. To deliver content to a broad audience (all twenty-one hospitals) we used webcasting as our main mechanism. 5) What are your metrics for success? This varies project to project, however the dream metric and also the most difficult is ROI. We’d love to able to standardize ROI, and I can see that this may be a goal for 2007. Currently we rely on process metrics to at least help us know we are going in the “right direction”. The process metrics are chosen by doing a chain analysis from the outcomes we are trying to achieve. What are the criteria that are used to select what technologies to implement and how to measure success? Again, this varies by project. For example, for NKE, the prototype metrics indicated a major improvement, and therefore we received the green light to move forward. 6) What are some of the key barriers to successful implementation and how did you overcome them? For NKE, it was getting leadership to clearly understand its role in implementation. Some leaders are much more hands on, and the typical result of this approach was success. The hands-off leadership was a more difficult challenge. I’m not sure we overcame that one, however we attempted to by creating a communication time line that leaders could use to guide their actions across time. We’ve had some mild success with this approach. 7) Is there anything that is really unique to your organization that makes implementation either easier or harder than elsewhere? Please provide details. Implementation at Kaiser Permanente is much harder. We have an extremely distributed power structure with the local facilities being nearly as or stronger than the region and the region as strong as or stronger than national operations. We have a tri-leadership with the health plan, physician group and labor groups equally having a say in how to do work. Therefore it’s imperative to have strong agreement across these entities. But there is a huge benefit in this structure as well, mainly that when you get agreement it is very powerful. Are you able to provide incentives to early and easy adoption? Formally, no; however, we’ve always paid special attention to early adopters by highlighting their work. For example in NKE, we always “storytell” that Baldwin Park, Moanalua, and South Sacramento were early innovators and adopters. Additionally its beneficial for our early adopters as they get more say in the design of solutions. What are some of the motivations that have worked for you? The motivations that have worked best for me is knowing that we are on the cutting edge of design, and being recognized for it. Having the Institute for Healthcare Improvement and Wall Street Journal recognize your work is very, very motivating!

Page A-12

Innovation Learning Network 2006

Survey #4: Anonymous Respondent 1) Where does Innovation occur? - Innovation Centers within our Organization - Several grass-roots/local initiatives that are connected with innovation are taking place within our institution Within the Institution at this time, a variety of efforts are underway to stimulate and foster innovation. Groups working in this arena tend to be housed in local business units thus funding comes from operational budgets. A unifying institutional infrastructure is being developed to aid these current efforts and drive diffusion. Innovation efforts are guided by the common notion of creating new value for patients. To date, there is no easy way to answer the question of implementation. Implementation is influenced significantly by the scope of the project and the ability to marshal a multidisciplinary team to drive implementation across entities. Regardless, implementation tends to require people being able to add this activity to an already full to-do list and a robust social network that allows change agent to use relationships to navigate through committees. 2) Specific Example of Success: The project in question focused on improving the summary visit process, which in simple terms is the concluding experience for patients as they prepare to return to their home environment. Nine insights/recommendations were derived primarily from ethnographic research and rapid prototyping in real time patient care episodes and these findings were formally presented to departmental project sponsors. As of this writing, a guiding document that contains six elements culled from the aforementioned design process is close to becoming a reality. The MD sponsor of the project has been pursuing approvals for the past four months, which is a rather quick period of time in our environment. Based on feedback and observation during the design phase, it is believed that virtually no training for users will be required. In this case, implementation is the responsibility of those who created the project and asked the question. The design team considers implementation throughout the process by maintaining a primary focus on the human aspect of the desired/intended change and design principles and criteria at the conclusion of the project in essence provides a blueprint for a solution(s) and the required change process to the sponsor. The sponsor then must engage in the process of making change happen through our committee based environment. 3) Specific Example of Failure: Due to the new and unique manner by which her team works, the individual I interviewed chooses to see lack of implementation as a joint inability to share and apply micro-learning to larger systems. This individual indicates that as their program and methodology have grown and matured it is becoming easier to engage the larger system in the necessary conversations for both re-imagining a complex system and developing the capacity to act on both short and long term projects that will flow from that disciplined human research oriented process. 4) Training (how, who and what worked and didn’t): With respect to the project being focused on in this case study, no training was needed. The research and rapid prototyping process led to the creation of a tool that worked effectively for patients and clinicians. The tool in essence is an enabler of an existing work task so adoption and use

Page A-13

Innovation Learning Network 2006 by practitioners was high and intuitiveness of tool led to no needed training. 5) Metrics for Success: The primary measure of success here is the ability to set a big picture vision for how a system or experience could be re-designed/re-imagined. The value of the meta-vision is the creation of concepts that can then become the focus of/for further ideation, development and implementation. The vision would be composed of design principles and criteria, which ought to strongly inform implementation. 6) What are some of the key barriers to successful implementation and how did you overcome them? First is an inability to prioritize which systems and experiences need to be redesigned. Secondly, implementation and the rigorous activity of navigating through the committee structure is a secondary duty for MD’s. 7) Is there anything that is really unique to your organization that makes implementation either easier or harder than elsewhere? The operating principles of our robust and timeconsuming decision-making process generally results in highly effective and rapid implementation of solutions. A decision to implement means that critical mass has been achieved in a way that guarantees resources and leadership for implementation to be successful. Another critical variable that cannot be overlooked is our patient centered approach to all things. This focus allows for solutions to be implemented that usually create value for them first which eases acceptance and adoption by staff. Implementation is made more difficult primarily due to strong emphasis on shared services, an intimate engagement in the project by numerous committees, and a riskaversive environment that makes it easy to delay and/or reject outright innovative solutions. Due to the integrated nature of our delivery system, the scope of projects can rapidly expand beyond the local unit of study adding complexity and efforts required to involve ancillary units into the overall change process. Obviously, this presents significant challenges for those driving for change and implementation.

Page A-14

Innovation Learning Network 2006

Elements of Successful Spread Taken from Kaiser’s Virtual Friday presentation on the Diffusion of the Nurse Knowledge Exchange (NKE) practice. Project Attributes 1. Trialability • Use of rapid cycle PDSA (Plan-Do-Study-Act) is empowering and allows for learning through trial and error • Can test and implement in any order • Adaptable to any unit 2. Complexity Although the NKE change package was simple in description… • Language was difficult • Front line staff don’t use tools • “NiKE: Just Do It” Social System • • • • Leadership

• •

Project lead is socially networked and respected Nurse champions spread to other nurses Communication plan Executive sponsor works closely with project lead Engaged facilitative executive sponsor Project lead attributes: – Passion – Excellent communicator – Organized – Able to access flex resources – Use measurement to tell the story

Organizational System • NKE is aligned with organizational goals • Structure “mirrors” the National collaborative structure • Use networks and champions to spread • Provides formal education and freedom to “test” implementation and share success Collaborative Structure • Face to face sharing and networking • Project lead calls • Coaching for project lead and hospital teams • Process metrics • Extranet to post tools Spread model • Know where you will spread to • Multiplicative spread • Use of pilot units

Page A-15

Innovation Learning Network 2006

Section B: Social Network Mapping Surveys – September 2006 and January 2007 Dear Participant: We invite you to participate in creating a Smart Network Map. The map is a visual representation of the social network that is emerging from Innovation Learning Network (ILN) interactions. Everyone that has participated or touched the ILN, however briefly, has been invited to participate. We will be collecting data to form these maps via an online survey. Your input to this survey is critical to successful map creation. We will use the maps to deepen our understanding of how innovations spread through social networks and to strengthen relationships among ILN members with an eye toward spreading innovations among ILN members. Together, we plan to use and interpret the maps on our September monthly member web-call 9-28-06 and during our Design-For-Diffusion meeting in California. Please follow the link below to complete the survey - It should take no more than 10 minutes to complete. Please respond no later than September 15th so we have time to prepare the network maps. Smart Network Survey Link In advance, thank you for participating. Sincerely, Chris McCarthy & Maggie Hentschel Questions: 1. 2. 3. 4.

Prior to the start of the ILN, who did you work with or exchange information on a project, topic or shared interest? Since the ILN started, with whom have you shared ideas or worked on projects that were catalyzed by your ILN interactions? Who has inspired you or given you new ideas since the ILN began? Who would you like to work with over the coming year on an ILN-inspired project or topic?

Page B-1

Innovation Learning Network 2006

Summary of Results Smart Network Map 1 Prior to the start of the ILN, who did you work with or exchange information on a project, topic or shared interest? Before March 2006

Page B-2

Innovation Learning Network 2006

Smart Network Map 2 Since the ILN started, with whom have you shared ideas or worked on projects that were catalyzed by your ILN interactions? As of September 2006

Page B-3

Innovation Learning Network 2006

Smart Network Map 3 Since the ILN started, with whom have you shared ideas or worked on projects that were catalyzed by your ILN interactions? As of 2007

Page B-4

Innovation Learning Network 2006

Smart Network Map 4 Who would you like to work with over the coming year on an ILN-inspired project or topic?

Page B-5

Innovation Learning Network 2006

Presentation of Findings: Notes from Social Network Maps discussions, October 19-20 Meeting (based on September 2006 Maps) Four Smart Network maps for the ILN were reviewed and discussed in detail. There are numerous ways to look at the graphs: • Different categories of people: boundary spanners, core connectors, periphery, • Overall patterns • Changes from before to after Three layers of meaning or story were explored: individual, organizational and cross-organizational. Metrics of network dynamics include: • Awareness (how likely is it that you know what is going on around the network... 2 or 3 degrees out) • Connectors (how connected are you to others that are connected) • Influence (who goes to whom for expertise or inspiration) • Integration (in the thick of things) • Resilience (what happens when people leave the network) The progression toward a "smart" network -- a tight or dense core with a loose or diverse periphery -- was noted by group members. Conversation centered around actions -- informed by the mapping -- than can help spread innovation. Practices included: • Closing triangles (introducing people that are currently not connected but should be) • Connect or try to influence the influencers • Engage the community in connecting to more of itself via building awareness or collective mindfulness • Bring people from the periphery into the specific innovation efforts • Focus mapping activities on strategic initiatives (e.g., diabetes care), using them to build generative relationships within and across local/regional communities of practice Group members were considering applications to many activities including ILN projects. Note from a participant: Each graph is in response to one question so if you are doing this in your organization, getting the question(s) right is key. Risks to creating maps: • People may game it when they see how the maps will appear. They may not want to show a connection or may want to show a connection that is not real. • Bosses might get ticked off if they don't show up as the right connection.

Page B-6

Building Smart Communities through Network Weaving by Valdis Krebs and June Holley

Communities are built on connections. Better connections usually provide better opportunities. But, what are better connections, and how do they lead to more effective and productive communities? How do we build connected communities that create, and take advantage of, opportunities in their region or marketplace? How does success emerge from the complex interactions within communities?

This paper investigates building sustainable communities through improving their connectivity – internally and externally – using network ties to create economic opportunities. Improved connectivity is created through an iterative process of knowing the network and knitting the network.

Know the Net Improved connectivity starts with a map – knowing the complex human system you are embedded in. The Appalachian Center for Economic Networks [ACEnet], a regional economic development organization in Athens, Ohio has long followed the connectivity mantra – create effective networks for individual, group and regional growth and vitality. Recently ACEnet has begun to map and measure the social and economic connections it helped create in the grassroots food industry in Southeast Ohio.

ACEnet, founded in 1985, provides a wide range of assistance to food, wood and technology entrepreneurs in 29 counties of Appalachian Ohio. This region has some of the highest poverty and unemployment rates in the country, and ACEnet works with communities throughout the region who want to improve their support for entrepreneurs as a means to provide more local ownership and higher quality jobs.

Network maps provide a revealing snapshot of a business ecosystem at a particular point in time. These maps can help answer many key questions in the community building process.

•

Are the right connections in place? Are any key connections missing?

•

Who are playing leadership roles in the community? Who is not, but should be?

•

Who are the experts in process, planning and practice?

•

Who are the mentors that others seek out for advice?

•

Who are the innovators? Are ideas shared and acted upon?

•

Are collaborative alliances forming between local businesses?

•

Which businesses will provide a better return on investment – both for themselves and the community they are embedded in?

These are all important questions that ACEnet wants to answer so that they can help build a more vibrant economy in Appalachian Ohio.

Before you can improve your network you need to know where you are currently – the ‘as is’ picture. A network map shows the nodes and links in the network. Nodes can be people, groups or organizations. Links can show relationships, flows, or transactions. A link can be directional. A network map is an excellent tool for visually tracking your ties and designing strategies to create new connections. A network map is an excellent tool for visually tracking your ties and designing strategies to create new connections. Network maps are also excellent ‘talking documents’ – visual representations that support conversations about possibilities.

Transformation that leads to healthy communities is the result of many collaborations among network members. Scientists describe this phenomenon – where local interactions lead to global

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-8

patterns – as emergence. We can guide emergence by understanding, and catalyzing, connections. For example, knowing where the connections are, and are not, allows a community development organization to influence local interactions. This is particularly important in policy networks where key nodes play an important role in what flows throughout the network. Influencing a small number of well-connected nodes often results in better outcomes than trying to access the top person or calling on random players in the policy network. If you know the network, you can focus your influence.

Recently ACEnet Food Ventures staff asked area entrepreneurs and organizations, “From whom do you get new ideas that benefit your work?” “From whom do you access expertise that improves your operations?” and “With whom do you collaborate?” The answers to these questions were mapped using Valdis Krebs’ InFLOW™ social network mapping software into an Innovation Network, an Expertise Network, and a Collaboration Network. Analyzing these networks led the team to realize that there were several entrepreneurs who played a critical role in the food sector, but with whom they had little relationship. The team developed a strategy for more explicitly working with these entrepreneurs, by asking them to conduct workshops for other entrepreneurs and finding out their needs for business assistance.

What does a vibrant, effective community network look like? Research has been done to discover the qualities of vibrant networks. Sociologists, physicists, mathematicians, and management consultants have all discovered similar answers about effective networks. The amazing discovery is that people in organizations, routers on the internet, cells in a nervous system, molecules in protein interactions, animals in an ecosystem, and pages on the WWW are all organized in efficient network structures that have similar properties.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-9

Five general patterns are observed in all effective networks: 1. Birds of a feather flock together: nodes link together because of common attributes, goals or governance. 2. At the same time diversity is important. Though clusters form around common attributes and goals, vibrant networks maintain connections to diverse nodes and clusters. A diversity of connections is required to maximize innovation in the network. 3. Robust networks have several paths between any two nodes. If several nodes or links are damaged or removed, other pathways exist for uninterrupted information flow between the remaining nodes. 4. Some nodes are more prominent than others – they are either hubs1, brokers2, or boundary spanners3. They are critical to network health. 5. Most nodes in the network are connected by an indirect link in the network. A-B-C-D shows a direct link between A and B, but indirect links between A and C and A and D. Yet, the average path length in the network tends to be short. There are very few long paths in the network that lead to delay and distortion of information flow and knowledge exchange.

Even though we know several keys to building effective networks, this knowledge is rarely put to use. Networks, whether social or business, are usually left to grow without a plan. When left unmanaged, networks follow two simple, yet powerful driving forces: 1. Birds of a feather flock together. 2. Those close by, form a tie.

This results in many small and dense clusters with little or no diversity. Everyone in the cluster knows what everyone else knows and no one knows what is going on in other clusters. The lack of outside information, and dense cohesion within the network, removes all possibility for new ideas and innovations. We see this in isolated rural communities that are resistant to change, or

1 2 3

Nodes with many direct connections that quickly disperse information. Nodes that connect otherwise disconnected parts of the network – they act as liaisons. Nodes that connect two or more clusters – they act as bridges between groups.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-10

in a classic “old boy network”. Yet, the dense connections, and high degree of commonality forms good work groups – clusters of people who can work together smoothly.

Instead of allowing networks to evolve without direction, successful individuals, groups and organizations have found that it pays to actively manage your network. Using the latest research we can now knit networks to create productive individuals and smart communities.

Knit the Net A vibrant community network is generally built in 4 phases, each with it’s own distinct topology. Each phase builds a more adaptive and resilient network structure than the prior phase. Network mapping can be used to track your progress through these four stages. 1) Scattered Fragments 2) Single Hub-and-Spoke 3) Multi-Hub Small-World Network 4) Core/Periphery

Experience shows that most communities start as small emergent clusters organized around common interests or goals. Usually these clusters are isolated from each other. They are very small groups of 1-5 people or organizations that have connected out of necessity, see Figure 1. If these fragments do not organize further, the community structure remains weak and underproducing.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-11

Figure 1 – Scattered Fragments

Without active leaders who takes responsibility for building a network, spontaneous connections between groups emerge very slowly, or not at all. We call this active leader a network weaver. Instead of allowing these fragments to drift in the hope of making a lucky connection, network weavers actively create new interactions between them.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-12

Network weavers4 begin with a hub and spoke network, with the weaver as the hub. The weaver has the vision, the energy, and the social skills to connect to diverse individuals and groups and start information flowing to and from them. The weavers usually have external links outside of the community to bring in information and ideas. This is a critical phase for community building because everything depends on a weaver who is the hub in the network. However, if multiple weavers are working in the same community, we may get multiple hub and spoke networks, with some overlap between them. Figure 2 shows a weaver connecting the previously scattered clusters.

Figure 2 – Hub-and-Spoke Network 4

While the Athens food network focused on one network weaving organization – ACEnet, there were actually several individual network weavers within ACEnet. Each network weaver within ACEnet had a particular focus. They all worked together from a common vision. If several network weavers are present and willing to collaborate, increased progress is possible.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-13

Initially a network weaver forms relationships with each of the small clusters. During this phase a weaver is learning about each individual or small cluster – discovering what they know and what they need. However, the hub-and-spoke model is only a temporary step in community growth. It should not be utilized for long because it concentrates both power and vulnerability in one node – the hub. If the weaver fails or leaves then we are back to a fragmented community.

In healthy networks, the spokes of the hub do not remain separated for long. The weaver begins connecting those individuals and clusters who can collaborate or assist one another in some way. Concurrently the weaver begins encouraging others to begin weaving the network as well. Even though it is a temporary structure, the hub-and-spoke model is usually the best topology to bring together the scattered clusters seen in most immature communities.

An organization with a vision, and contacts to external ideas and resources, can play the role of the hub. This is the role ACEnet took up when it saw that SE Ohio was home to many small, uncoordinated food clusters. There was the Farmer’s Market crowd, the natural bakery, a worker-owned Mexican restaurant and a few other entrepreneurs creating unique food products. ACEnet brought all of these unconnected groups together around a kitchen incubator – a state of the art facility for preparing and packaging a large variety of food items.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-14

When ACEnet decided to build a Kitchen Incubator—a licensed processing facility where entrepreneurs could rent the use of ovens, stoves and a processing line to produce their products—they used the need to design the incubator as an opportunity to link small clusters. For example, for one design session they brought people from the town’s restaurants together with small farmers who wanted to turn their produce into value-added products. Farmers were able to learn about food production safety from the restaurateurs who explained how these procedures could be incorporated into the incubator. Some of the farmers also used the opportunity to sell their produce to the restaurants, who were always on the lookout for unique raw materials. And, an unexpected bonus was that the restaurants realized that they could use the Kitchen Incubator’s storage warehouse for large orders they made from their suppliers, and as a result became an important part of the network.

As the weaver connects to many groups, information is soon flowing into the weaver about each group’s skills, goals, successes and failures. An astute weaver can now start to introduce clusters that have common goals/interests or complementary skills/experiences to each other. As clusters connect, their spokes to the hub can weaken, freeing up the weaver to attach to new groups. Although the spoke links weaken, they never disappear – they remain weaker, dormant ties, able to be re-activated whenever necessary. In order to accommodate new connections, the weaver must teach others how to weave their own network. Training in network building is important at this juncture. Network mapping reveals the progress and identifies emerging network weavers.

This happened with ACEnet as several of the businesses and small non-profits began to build their own local connected clusters. As the overall network grows, the role of the weaver changes from being the central weaver, to being a facilitator of network weaving in the community – coordinating with, and mentoring of other network weavers.

There are two parts to network weaving. One is relationship building, particularly across traditional divides, so that people have access to innovation and important information. The

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-15

second is learning how to facilitate collaborations for mutual benefit. Collaborations can vary from simple and short term—entrepreneurs purchasing supplies together—to complex and longterm—such as a major policy initiative or creation of a venture fund. This culture of collaboration creates a state of emergence, where the outcome—a healthy community—is more than the sum of the many collaborations. The local interactions create a global outcome that no one could accomplish alone.

Network weaving is not just “networking”, nor schmoozing. Weaving brings people together for projects, initially small, so they can learn to collaborate. Through that collaboration they strengthen the community and increase the knowledge available in it. After working with the authors, Jack Ricchiuto, a Cleveland-based management consultant and author, created a pyramid of network weaving involvement. Level 1 is a “networking” type interaction, while levels 6 and 7 are highly involved commitments to building community. A majority of ACEnet’s larger successes fall under the two top levels [6 & 7] of Ricchiuto’s Pyramid5.

Level

Activity

7

Introducing A to B in person and offering a collaboration opportunity to get A and B off to a successful partnership Introducing A to B in person and following up with A and B to nurture connection Introducing A to B in person Introducing A to B in a conference call Introducing A to B in an email Suggesting A talk to B and calling B to look for a contact Suggesting to A that A should talk to B

6 5 4 3 2 1

5

http://www.jackzen.com/archives/2006/01/the_7_circles_o.html

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-16

This transition from network weaver to network facilitator is critical. The weaver is identifying and mentoring new weavers who will eventually take over much of the network building and maintenance. If the change is not made then the community network remains dependent on the central weaver and his/her organization. At the transition point the weaver changes from being a direct leader to an indirect leader, influencing new emergent leaders appearing throughout the community. This transition is necessary for the network to increase its scale, impact and reach.

Moving from a single hub/weaver network to a multiple hub/weaver network has many advantages. The first advantage of a multi-hub topology is elimination of a single point of failure. ACEnet is still a dominant hub in SE Ohio, and its failure would affect the region greatly – but not as significantly as five years ago when the network was sparser and more dependent on ACEnet. Now ACEnet has the luxury of spending time in new pursuits such as teaching others to knit their nets and expanding the network to other areas inside and outside of Appalachia.

As the weaver connects various individuals, organizations and clusters, these entities connect to each other loosely. A new dynamic is revealed here – the strength of ‘weak ties’6. Weak ties are connections that are not as frequent, intense, as strong network ties that form the backbone of a network. Strong ties are usually found within a network cluster, while weak ties are found between clusters. As clusters begin to connect to each other, the first bridging links are usually weak ties. Over time weak ties may retain their structure by bridging separate clusters or they may grow in to become strong ties binding previously separate groups into a new larger cluster.

6

Mark Granovetter

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-17

Bridging ties between clusters are also important in innovation. New ideas are often discovered outside the local domain. To get transformative ideas you often have go outside of your group. A successful formula for creating ties for innovation is to find other groups that are both similar and different than your own. Similarity helps build trust, while diversity introduces new ideas and perspectives. Connect on your similarity, and profit from your diversity.

To bring in new ideas from outside the region, ACEnet has developed several “innovation learning clusters” that bring together leading edge organizations from around the country who share their innovations with each other. ACEnet staff who participate then bring information about those innovations back to the region and adapt them to the local environment. For example, Larry Fisher, one of ACEnet Directors, participates in a rural entrepreneurship policy cluster where he learned the basics of building a policy network from organizations with many years’ experience. He is now leading ACEnet’s efforts to change the policy of local counties so that it is more supportive of entrepreneurship, but he can move forward with a more sure hand since he is building on the experience of others—and can contact them when he has questions. Now that other hubs [network weavers] are emerging in the network, the various weavers begin to connect to each other, creating a multi-hub community. Not only is this network topology less fragile, it is also the best design to minimize the average path length throughout the network – remember, the shorter the hops the better for work flow, information exchange and knowledge sharing! Information percolates most quickly through a network where the best connected nodes are all connected to each other.

Figure 3 shows a multi-hub small-world network. Here four clusters [designated by the thick red links] have created many weak ties [gray links] to each other. The weak ties may, or may not, strengthen to create one tightly coupled larger cluster. The multiple hubs can be small businesses or other community development organizations.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-18

Initially, the ACEnet Kitchen Incubator was a major gathering place, a physical network hub, where people ran into each other, hung around to talk, and often cooked up some kind of deal: joint orders of jars so they could get a cheaper price, an arrangement to jointly market their products, or an agreement to trade labor on a project. However, after a few years, many other network hubs popped up. For example, the Athens Farmers’ Market hosted more than 90 farmers and local food vendors who networked with each other and their avid customers. Several years ago, 4 local organizations set up a Farmers’ Market Café that provides tables and chairs under tents so that people could hang around longer and network with more neighbors. Casa Nueva, a worker-owned Mexican restaurant, is not only a networking hub, but has played a major role in organizing most of the locally owned restaurants into the Athens Independent Restaurant Association which donates money each month to community non-profits and is increasing the amount of area restaurants purchase from local farm families. Six miles outside town, more than 200 people flock on Saturdays to enjoy fresh baked focaccia, pastries and hearth bread on the outdoor terrace outside the Big Chimney Bakery. The proprietor is a major network hub himself, who helps new entrepreneurs develop their recipes and learn strategy from a pro.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-19

Figure 3 – Multi-Hub Small World Network

The next step is to strengthen the appropriate loose ties in the network so they become strong ties. This happens after turf issues have been handled. A multi-hub network may be difficult to achieve if political and ‘turf’ issues are raging through the network. If two or more community development organizations start battling over turf and control of the community then the result may be two or more competing, single hub networks that ignore the larger community needs and just focus on survival of their own network.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-20

The end-goal for vibrant, sustainable community networks is the core/periphery model. This topology emerges after many years of network weaving by multiple hubs. It is a stable structure that can link to other well-developed networks in other regions. The network core in this model contains the key community members, including many who are network weavers, and have developed strong ties between themselves. The periphery of this network contains three groups of nodes that are usually tied to the core through looser ties: 1) Those new to the community and working to get to the core 2) Bridges to diverse communities elsewhere 3) Unique resources that operate outside of the community, and may span many communities

The economic landscape is full of imperfectly shared ideas and information. The periphery allows us to reach ideas and information not currently prevalent in our network. The core allows us to act on those ideas and information. The periphery is the open, porous boundary of the community network. It is where new members/ideas come and go. The periphery monitors the environment, while the core implements what is discovered and deemed useful7.

ACEnet has helped form the Appalachian Ohio Regional Investment Coalition (AORIC) which includes another community organization, a regional foundation, the Ohio Arts Council, and an Ohio University based institute. AORIC is now mobilizing a large network of organizations interested in supporting entrepreneurs as a way to create a healthier regional economy. This network is reaching deep into communities to identify barriers entrepreneurs face, and then collaborating on projects that will develop new supportive infrastructure to increase their success.

7

Influenced by the research and analysis of Ronald S. Burt.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-21

Figure 4 – Core/Periphery Network

Figure 4 shows a well developed core/periphery structure. The blue nodes are the core, while the green nodes reside in the periphery. This network core is very dense8 -- not all cores will have as high a concentration of connections as this one. Too much density can lead to rigidity and and

8

Network density is calculated by the number of existing connections as a percentage of the total possible. Any density greater than 50% is very high.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-22

overload of activity. Monitoring your network using social network analysis can help you see where your network needs to shift connections to match the current environment.

At this point the network weavers’ initial task are mostly completed. Now, attention turns toward network maintenance and building bridges to other networks. The network weavers can begin to form inter-regional alliances to create new products, services and markets—or to shape and influence policy that will strengthen the community or region. This happens by connecting network cores to each other utilizing their peripheries. The network weaver maximizes the reach of the periphery into new areas, while keeping the core strong. The weavers now focuses on multi-core projects of large substance that will have major impact on the community.

Conclusion As we have seen weaving a network requires two iterative and continuous steps: 1. Know the network – take regular x-rays of your network and evaluate your progress. 2. Knit the network – follow the four (4) phase network knitting process.

All throughout this process network maps guide the way – they reveal what we know about the network and they uncover possible next steps for the weaver.

Starting with a disconnected community, network builders can start weaving together the necessary skills and resources to build simple single hub networks. This will be followed by a more robust multi-hub network, concluding with a resilient core/periphery structure – maximized for learning and implementation.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-23

Valdis Krebs is a organizational consultant and the developer of InFLOW software. www.orgnet.com [email protected] June Holley is founder and President/CEO of the Appalachian Center for Economic Networks. www.acenetworks.org [email protected]

June and Valdis and Jack have created a training seminar for Network Weavers, please contact either one of them for further information.

Building Smart Communities through Network Weaving © 2002-2006 Valdis Krebs and June Holley

Page B-24

Innovation Learning Network 2006

Section C: Virtual Fridays Process Guide The ILN utilizes web conferencing to enable members at a variety of locations to interact and collaborate in real-time. Virtual Fridays are web conferences where members view and share presentations, documents, or web pages on their computer while simultaneously dialing in to a teleconference over the phone. There are various technologies available to conduct web-based teleconferences, including: WebEx, Qwest, Raindance, MeetingOne, and many others. These vary significantly in price and available features. Suggested Roles: •

• •

Coordinator: Coordinates web-meeting, schedules and communicates meeting details to participants, collects presentation from presenter in electronic format, uploads presentation to web conferencing site, and trains presenter on use of web conferencing technology. Generally facilitates Virtual Friday discussion. Presenter: Prepares and gives presentation. Participant: Logs into web meeting and teleconference, listens, and participates in Q&A.

Process: Step 1: Group identifies topics; coordinator sets schedule. Step 2: Coordinator communicates event details to participants. (i.e. date, time, dial-in number, web conference address, login and password or meeting number…how to join will vary depending on what web-conferencing technology is used). Step 3: Prior to meeting date, coordinator and presenter perform a “test run” of logging into web conferencing to ensure their computers are set up and to avoid any technical difficulties prior to web meeting. Step 4: Coordinator sends out a reminder to participants (a few days in advance of event date), including an Adobe PDF version of the presentation for those that will not be able to join the web portion of the call. Reminder should also provide tips or recommendations for joining meeting. Tip: Coordinator should encourage presenter and participants to join web conference ten minutes prior to start time. This ensures participants are able to fix any technical difficulties they might encounter prior to start of presentation, and generally ensures the web-conference can begin on time. Step 5: If technology requires, coordinator or presenter uploads presentation to web conferencing site. Step 6: Coordinator should start meeting at least 20 minutes in advance to allow ample time for presenter and participants to join. Step 7: Coordinator starts recording and presentation begins! Step 8: Coordinator makes presentation recording available online for those members who were unavailable during the call.

Page C-1

Innovation Learning Network 2006

Topics and Abstracts Nurse Knowledge Exchange Kaiser Permanente - Chris McCarthy ([email protected]) The Nurse Knowledge Exchange (NKE) was a set of protocols implemented to improve the process of shift change. This Virtual Friday describes the initial problems that Kaiser faced, the process of creating the NKE program, goals, planning, prototyping, implementation, and plans for rapid scale-up. The SPARC (See, Plan, Act, Refine, Communicate) Innovation Program Mayo Clinic - Alan Duncan ([email protected]) The SPARC Innovation Program at the Mayo Clinic is an “innovation lab” used to rethink the delivery of ambulatory care. This Virtual Friday describes the development of the concept, including origins, planning and goals, along with lessons learned and examples of use. Bar Code Expansion Project Department of Veterans Affairs - Jon Zeller ([email protected]) and Ruth Jara ([email protected]) The VA has used barcoding for several years for lab specimens and blood product delivery. This Virtual Friday describes the expansion of this technology’s applications, including medication administration and the collection of data such as vital signs to support documentation compliance. Integrating Healthcare and Retail Services Alegent Health - Joan Neuhaus ([email protected]) Alegent has investigated the retail service industry for parallels that might be applicable to health care delivery. This Virtual Friday describes the initial goals of the investigation, their findings, some potential methods of implementation, and barriers they have forseen. My HealtheVet Department of Veterans Affairs - Ginger Price ([email protected]) My HealtheVet is an electronically based personal health record that the VA is currently piloting testing. This Virtual Friday describes the creation of My HealtheVet, including the technology the VA used, the patient base served, regulatory barriers they faced, and how they built the technology to serve both providers and patients. Oncology Human Experience Alegent Health - Myra Ricceri ([email protected]) Alegent undertook an ethnography project to follow eight cancer patients throughout their entire treatment process, in order to improve the patient experience. This Virtual Friday describes the project process and next steps for adopting the lessons learned. Human-Centered Design IDEO - Ilya Prokopoff ([email protected]) IDEO is a company that provides consulting services to help organizations rethink attitudes about innovation and prioritize the experience of end-users in order to create value. In this Virtual Friday, IDEO presents their philosophy of innovation. This also marked the first Virtual Friday presented by a non-ILN member organization. st

21 Century Care Kaiser Permanente - Hannah King ([email protected]) and Ruth Brentari ([email protected]) Kaiser’s 21st Century Care project was designed to re-envision the function of primary care teams. This Virtual Friday describes the goals of the 21st Century Care project, the four major changes envisioned, and some of the emerging results.

Page C-2

Innovation Learning Network 2006

Introduction to the ILN Wiki Kaiser Permanente - Maggie Hentschel ([email protected]) In September, Maggie Hentschel created an ILN wiki - a collaborative website that can be modified by all ILN members. In this Virtual Friday, Maggie gives a tour of the wiki and its various features. Louisiana: An Opportunity for Innovation Franciscan Missionaries of Our Lady - George Burgess ([email protected]) In the wake of Hurricane Katrina, the Franciscan Missionaries of Our Lady have emerged as the sole health care provider in the St. Bernard parish. This Virtual Friday describes the efforts at recovery that the Franciscans have undertaken to provide a completely rebuilt model that provides access to all. Time and Motion Study Kaiser Permanente - Marilyn Chow ([email protected]) Ascension Health - Ann Hendrich ([email protected]) Kaiser and Ascension have undertaken a joint, multi-site study, funded by the Robert Wood Johnson Foundation and the Gordon and Betty Moore Foundation, to learn about the workflow of medical-surgical nurses with the ultimate goal of improving patient safety. This Virtual Friday describes the components of the study, its goals, initial results, and next steps. This Virtual Friday was the first joint presentation from two participant organizations. EHR Tools for Pneumococcal & Influenza Vaccine Compliance Evanston Northwestern Healthcare – Bobbi Schramek ([email protected]) Evanston Northwestern currently uses EPIC’s electronic medical record software, and recently undertook an effort to use EPIC’s reminder tools to help increase the number of patients who received two vaccines. This Virtual Friday describes the process of creating and implementing these tools. Personal Health Records Committee Alegent Health - David Tew ([email protected]) During the open space meeting in October, a committee of ILN members interested in developing nationally available portable, personal electronic health records came together to exchange ideas and set goals. During this Virtual Friday, the committee presents their progress to date and asks other ILN members for assistance. Diffusion Kaiser Permanente – Kristene Cristobal ([email protected]) and Lisa Schilling ([email protected]) This Virtual Friday revisits Kaiser’s Nurse Knowledge Exchange program to examine the rapid scale-up process in greater depth. The presenters describe their process of spread and some of the lessons learned. IS Innovation Program Partners HealthCare/Massachusetts General Hospital – Jim Noga ([email protected]) Partners HealthCare runs an Innovation Program, in which selected employees spend half of their time working in teams to come up with an innovative solution to an organizational problem. This Virtual Friday describes the selection criteria used, initial results, and program logistics.

Page C-3

Innovation Learning Network 2006

Section D: Online Collaboration Site map – ILN website • • •

• • •

ILN Overview o Participating Organizations Virtual Friday Archives (link to wiki) Resources o Articles and Recommended Reading o ILN member survey results o April ILN Cambridge, MA Meeting 2006 Presentations: Overview of CIMIT: Clinical Innovation Labs OR of the Future Part 1 - Warren Sandberg MD, PhD OR of the Future Part 2 - Warren Sandberg MD, PhD Medical Device Interoperability Plug-n-Play - Julian Goldman MD Ambulatory Practice of the Future - Susan Edgman-Levitan Connected Health Initiative - Penny Ford Carleton RN Member Directory Event Calendar o Event list Message Board o ILN April Open Space Discussions Accelerating Education and Implementation of Innovation - Capturing Best Practices and Diffusion Innovative work environments and innovation labs Patient Experience Open Innovation Virtual Collaboration Processes and Tools Liberating Structures Making meaningful changes in organizations Healthcare Reform based on Quality The Link Between Accelerating Change and the Use of Incentives o Innovation Articles and Case Studies o Website Feedback

Page D-1

Innovation Learning Network 2006

Site map – ILN wiki • • • • •

Front Page Monthly ILN Archives Virtual Friday Archives Building Smart Networks o Social Networking Tools Design For Diffusion Conference o Design For Diffusion Games Plans Collaboration and Utilization of Innovation Labs Within ILN ILN 2007 Information • ILN 2007 Member Organization Status Personal Health Records Game Plan • Personal Portable Health Records • Personal Health Records Resources • Personal Health Records survey Virtual Simulations plan • Second Life o Design For Diffusion Report Outs Allowing Space for Play in Innovation and Relaxing Control Creating Internal Structures of Diffusion and Learning Creative Communication - Of Large Scale Plans Culture Change for Innovation Effective Collaborative Design Effective Engagement of Customers in the Design-Innovation Process Enabler - How to Drive An Innovation into Action External Diffusion Funding Strategies for Innovation Healthcare Beyond the Institutional Walls ILN 2007 Patient Driven Care Design Personal Electronic Health Records Physician in Change Process Report on Innovation ROI on Innovation Social Network Mapping #1 Social Network Mapping #2 Staff as Customer and Engaging Staff Virtual Simulations o Design For Diffusion Conference Pre-Reading o Design For Diffusion Panel Bios

Page D-2

Innovation Learning Network 2006

Screen Shots

Page D-3

Innovation Learning Network 2006

Section E: Second Meeting/Collaborative Projects ILN In-Person Meeting #2 October 19-20, 2006 Panel Discussion – Participants Robin Boyar – Electronic Arts Robin Boyar is the Senior Director of Research at Electronic Arts, the world’s largest videogame publisher. In her role, she leads consumer research supporting EA’s PC, console, handheld, online, and mobile games. She and her team support the development of these products from pre concept to post launch and use a wide range of methodologies ranging from standard focus groups and surveys to more in depth ethnographic and lifestyle approaches. Robin has over ten years research experience. She began her career as a researcher specializing in education and technology, working for such companies as McGraw-Hill, PBS, and various educational software companies. Previous to her role at Electronic Arts, she was Manager of Consumer Insights at InsWeb.com, an online insurance company. Jim Buckmaster – craigslist Since 2000 Jim has led craigslist to be the most used classifieds service in any medium, with over 10 million new ads submitted each month, and one of world's most popular websites, with over 5 billion page views per month, while maintaining its renowned public service mission, unorthodox business philosophy, non-corporate vibe, and staff of twenty. Jim formerly served as craigslist's lead programmer and CTO, contributing the site's multi-city architecture, search engine, discussion forums, flagging system, self-posting process, homepage design, personals categories, and best-of-craigslist. Before joining craigslist, Jim directed web development for Creditland (defunct) and Quantum. In 1994-95, Jim built what may have been the world's largest website at the time, a terabyte-scale database-driven public website for the Interuniversity Consortium for Political and Social Research at the University of Michigan. Jim graduated summa cum laude from Virginia Tech with a bachelors in biochemistry, and studied medicine and classics at the University of Michigan. Jim has been the subject of feature stories in New York Times, Wall Street Journal, Fortune, Business Week, Telegraph, SF Chronicle, and many other publications. He has been interviewed for dozens of television and radio programs, and is possibly the only American CEO ever accused in major business periodicals of being anti-establishment, a communist, a socialist, and an anarchist. Joy Mountford – Yahoo! S. Joy Mountford has been designing interfaces for over twenty-five years, ranging from applications on aircraft to personal computers to consumer devices. She has become an internationally recognized leader in user-centered interaction design. She has led design efforts creating interfaces to audio and visual devices, interfaces between the electronic world and printed materials, and toys, as well as for interactive music creation and generation systems. Joy most notably headed the Human Interface Group at Apple Computer for eight years and then moved to Interval Research for five years. At Interval she led a series of innovative and influential consumer music creation and jamming software and hardware devices for various consumer

Page E-1

Innovation Learning Network 2006 products. After Interval she formed her own interaction design firm, idbias, working for a range of clients to design, redesign, prototype, and evaluate interfaces to help people be more effective with technology. Past clients encompassed a broad range of businesses, from banks, libraries and music publishers, to the toy companies Lego and Mattel. In 1990 Joy pioneered forming the Interface Design Project which sponsors interdisciplinary design at universities around the world, continued to lead this effort for various sponsor companies and now has brought this to Yahoo! which held their first successful Design Expo in Aug 2006. Joy joined Yahoo! Research in Sept 2005, as a Distinguished Scientist and Senior Director in User Experience and Design for products in the Communications, Communities and Front Doors business areas. She has recently expanded her charter to start a design innovation studio for Yahoo!. Her project interests center around building extensible and creative spaces such as hotels using technology, and in creating wearable technology-aware ensembles. Joy is most intrigued about how best to bring artists and scientists together to create usable and appealing new 'tools'. She believes that this merger of disciplines working side by side is the best way to encourage real innovations for consumers. Sarah Snudden – Clorox Sarah Snudden has worked on a variety of innovation, advertising and market research projects in the Consumer Packaged Goods sector. Her projects include the Clorox Bleach Pen, Clorox ToiletWand, Glad ForceFlex and Children's Instant Oatmeal. She has worked at Ecolab, Pillsbury, Quaker and, for the past 5 years, Clorox. She has also worked in social marketing and health advocacy on projects such as smoking cessation and drinking and driving. Throughout all her ventures, Sarah essentially considers herself an "anthropologist and sociological super-sleuth." In her spare time, Sarah works on documentary film projects and enjoys cooking, entertaining and fixing up her old craftsman home. Ron Volpe – Kraft Foods Ron is Customer Vice President – Supply Chain for Kraft Foods, and leads Kraft’s Global Center of Excellence for Supply Chain Innovation. Labeled ‘The Collaborator’ in the book The Ten Faces of Innovation by IDEO General Manager Tom Kelley, in 2005 Ron was awarded the inaugural Global Supply Chain Excellence Award by Kraft Foods for his work around customer collaboration and innovation. In 2004, Ron’s led a Kraft project designed to bring product design and innovation techniques to the Supply Chain process arena. This partnership project with Safeway was the inaugural winner of the Grocery Manufacturers of America AMC CPG Award, which honors innovation through creativity, product innovation, and industry collaboration. Presently, Ron is involved in expanding Kraft’s use of the IDEO process to Kraft customers in both the EU and Asia Pacific. Ron is a graduate of the University of Massachusetts, and resides in Danville, California with his wife Sue and four children.

Page E-2

Innovation Learning Network 2006

Panel Discussion – Summary How is innovation viewed at your organization? • Clorox: We developed structures to foster innovations. o We worked with a competitor to create a product. • EA: We’ve realized we need to seek new audiences. Do problems arise out of operations or outside ideas? • Kraft: All about operational issues – tend to depend on history. How to encourage innovation internally, especially on front line? • Yahoo: It’s hard when you have a legacy, so we buy companies. Let the brand deviate. o Design is the key to innovation. • Craigslist: It’s not our technology that’s innovative; it’s the business model. Why did people start using Craigslist? • Craigslist: We only do what users want. It’s hard to innovate in health care because everyone asks what the ROI is. How do you balance that with the need to explore? • Yahoo: There’s no easy answer; it’s very difficult. Experience and faith. o Be a better storyteller about design’s value. Speak your executives’ language. • Kraft: Customer feedback gives you working capital. Make the customer your codesigner. • Clorox: Figure out how to make things speak to people. • EA: You need to present your idea as sexy. Figure out what the story is, and then brand it. o Remember: we are not our user base! We’re known as an industry that is local and based of problem-solvers – how to break free? • EA: Understand what makes your user group different, then adapt to that – cultural relevance. • Clorox: Figure out what delights your audience, and keep those ideas throughout your day. We’re starting to partner with out patients. How do you do that? • Yahoo: Talk to users at the very beginning. The rougher the draft, the more interesting the ideas. o Use dyads instead of individual interviews – they talk differently, they’re more honest. • Clorox: Drive articulateness of the consumer up. Get to know long-term, develop real relationship. • Craigslist: We took opposite approach - leave it to users to find problems and propose solutions. o We come up with fastest solution possible, and see if people like it. Our basic tools for marketing are surveys, focus groups – any other means of engagement? • EA: Greatest innovation: surveys that are online, multimedia. • Yahoo: Ethnography/participatory design helps people participate. • Clorox: Look at emotional reactions – very telling. o Look at workarounds and processes because people won’t always tell you what they want.

Page E-3

Innovation Learning Network 2006

How do you get people excited? • Clorox: Know your target and how to reach them. Think about point of entry into system. It takes curiosity to both nourish innovation and relax control –how to allow that to happen? • EA: Failure. It’s a wake-up call. You seem to have a lot of autonomy. How do you keep that? • Yahoo: A manager has to protect people and let them do their jobs. o Can’t always try for a slam-dunk right away. • Kraft: It’s a cumulative process – use preliminary success to drive future projects. • Clorox: Knowing how to argue for right time frame for a win – it’s part of the art of storytelling. People are trying to bring consumers into health care decision processes more, but we believe that people can’t understand it. How can we reach them? • Yahoo: Different age groups use different types of media. How do we make more out of that? What should health care work on? • EA: My mom has a variety of illnesses and I took her through the hospital. Whenever I had a question, my mom said it wasn’t her place to ask. I would like her doctors to help her to be a more informed consumer. Be more interactive, want your patients to ask questions. • Yahoo: When I was in the hospital, I wanted to know what was happening and when and why. Explain to me what the task flow is. I want to make sure I’m on track and okay. I want unbiased advice but don’t ask me to be intelligent while I’m in the hospital because I’m not feeling well. Make it simple, with pictures. Use university students to help. • Kraft: My kids are 20, 16, 3 and 1. I want an opportunity for them to get information they can use throughout their lives – what can my daughter pick up when she is at the doctor’s office? I want an educational process that’s built into experience. • Craigslist: Push the needle from curative to preventive. Open up to user reviews – the American medical system is screwed up in terms of incentives. Why can’t we talk about national health care? o There are several IT trends we can lean on for improvement. • Clorox: Reduce my barriers to entry. I don’t know how to articulate the need for accessibility. I’d like to be able to feed back to my dad’s doctor from far away. How to balance optimism with reality.

Page E-4

Innovation Learning Network 2006

ILN In-Person Meeting #2 October 19-20, 2006 Agenda Day 1 Start 15:00

Finish 16:00

Duration 1:00:00

16:00

18:00

2:00:00

18:00

19:00

Day 2 Start 8:00 8:20 8:30 9:30 9:45

Notes

1:00:00

Task Tour of Garfield Center for panelists Non-Health Care Industry Panel on Innovation and Human Experience Reception

Finish 8:20 8:30 9:30 9:45 10:15

Duration 0:20:00 0:10:00 1:00:00 0:15:00 0:30:00

Task Breakfast Welcome Tour of Garfield Center Break Open Space Technology Setup

Notes

10:15 10:30 15:45 16:30 18:45

10:30 15:45 16:30 18:45 21:00

0:15:00 4:15:00 0:45:00 2:15:00 2:15:00

Open Space Agenda Creation Open Space Discussion Closedown (travel to hotel, travel to harbor) Dinner Cruise

Day 3 Start 8:00

Finish 8:45

Duration 0:45:00

8:45 12:00 13:00 13:15 14:45 15:30

12:00 13:00 13:15 14:45 15:30 16:00

3:15:00 1:00:00 0:15:00 1:30:00 0:45:00 0:30:00

Task Breakfast and Morning Announcements Open Space (continued) Lunch Selection of Gameplan Groups Action Planning with Gameplans Review of Gameplans Closing Session

Activity: share stories of successful diffusion Activity: Mad Tea Party

Notes

Activity: flocking exercise

Page E-5

Innovation Learning Network 2006

Discussion groups Allowing Space for Play in Innovation and Relaxing Control Kaiser Permanente - Adrienne Smith ([email protected]) This group offers the following advice to someone wanting to encourage innovative play in an organization, even the one that might be resistant to it: • Remember: It's okay to play within a healthcare organization. Play fosters creativity. • Try it in small steps. Find people who are willing to play and engage them. • Take ownership of your own playful spirit and be PROUD of it. • Have a conversation with leaders about how playfulness benefits the organization. • Stop doing the boring stuff, like PowerPoint presentations. • Use an arts exercise or incorporate physical activity or enactments. • Bring in an improvisationalist to work through challenges. • Find a spot to play and play anyway. It's infectious. At the end of the first day of Open Space, this group offered a delightful dramatic performance on how not to incorporate fun and play into innovation work. Creating Internal Structures of Diffusion and Learning Kaiser Permanente - Chris McCarthy ([email protected]) Members of this group discussed current structures that their organizations use to share information and diffuse innovations. The group brainstormed opportunities to share ideas, including: innovation fairs, conference calls, and small group discussions, in which groups rotate to other groups to learn, share and evaluate. The group discussed the role of the ILN and the importance of internal networks for diffusion. Creative Communication of Large Scale Plans Catholic Health Initiatives - Jeff Norton ([email protected]) This group brainstormed ideas for better communicating internal projects and activities. Key takeaways included: • Recognize bandwidth limitations – prioritize messages and make them fast. • Find alternative channels for communication, particularly multimedia. • Make it FUN! • Use social network mapping as a tool to figure out who can help you get a message out. Effective Collaborative Design Cleveland Clinic - Mary Partin ([email protected]) This group debated whether change can occur organically, or whether there needs to be a structure to design standards for implementation. The group also asked what decisions need to be made at a high level, and what can be decided collaboratively at the grassroots level. The group then discussed how to design an effective collaborative, including how to choose the right participants, what work is necessary before design begins, and how to ensure that the end product matches the initial problem set before the collaborative. Effective Engagement of Customers in the Design-Innovation Process Kaiser Permanente - Jan Ground ([email protected]) This group discussed the power of using stories to get attention onto a problem, and talked about the need to pay attention to behaviors to learn about people’s needs. The group emphasized the need to make it easy for people to participate, and the value of using prototypes to get immediate feedback and improve the design process.

Page E-6

Innovation Learning Network 2006

Enabler - How to Drive An Innovation into Action Partners Healthcare/Massachusetts General Hospital - Jim Noga ([email protected]) This group discussed ways to ensure that innovations take roots. Ideas included using incentives that "make it easy to do the right thing," and identifying social and informal networks to drive change. The group emphasized the importance of changing an organization’s value system. External Diffusion VHA Foundation - Linda DeWolf ([email protected]) This group discussed strategies for diffusing innovations to other organizations. The group discussed the difference between creating a common enemy vs. a common vision to galvanize a group, and suggested that using public transparency and even embarrassment were effective at pushing organizational change. The group also talked about communication strategies. Funding Strategies for Innovation CIMIT - Beverly Brown ([email protected]) This group acknowledged that currently, multiple sources fund innovation, but expressed concern for future sustaining funding. The group suggested a number of future models of funding, depending on the structure of innovation within the organization. The group also discussed engaging philanthropists and using the innovation centers to build a case for support. Healthcare Beyond the Institutional Walls Kaiser Permanente - Naomi Fried ([email protected]) This group discussed the future of community-based healthcare, with the home as the nexus of care. The group addressed existing challenges, from technology interoperability and userfriendliness to alignment of financial and business models. The group also talked about trends in health care that will make care delivery in the community more feasible, including consumer awareness and the integration of health care with retail service. ILN 2007 Kaiser Permanente - Chris McCarthy ([email protected]) This group brainstormed ideas for the structure and activities of the ILN in 2007. The group decided that the ILN would have two tiers of work: the first to explore the science of innovation and diffusion for the advancement of healthcare, and the second to help members find practical applications through collaborative projects. This group continued their discussion with the development of a Gameplan. For further information, please see Appendices 5-12 and 6-1. Patient Driven Care Design Partners HealthCare - David Judge ([email protected]) This group discussed patients’ current role in health care, and brainstormed ideas to increase patient involvement in the design of the care delivery process. The group highlighted the importance of sensitivity to variation among cultural groups, and of understanding the unique patient population’s needs. The group also discussed potential ramifications of greater patient involvement on health care delivery systems. Personal Electronic Health Records Alegent Health - David Tew ([email protected]) Department of Veterans Affairs - Tim Cromwell ([email protected]) In a highly animated discussion, this group debated what the ideal personal electronic health record should be. The group agreed that the personal health record is a collaborative approach that creates a complementary care model for enhancing the patient-provider relationship. The group hoped to build momentum among the ILN to push forward the adoption of this technology, and continued their discussion with the development of a Gameplan. For further information, please see Appendix 5-10.

Page E-7

Innovation Learning Network 2006

Physician in Change Process Catholic Health Initiatives - David Swieskowski ([email protected]) The group discussed how to maintain physicians’ autonomy while working towards improvement in health care. The group brainstormed ideas for communication tactics that work with physicians, including the use of peer physicians to relay ideas, and demonstrating that a change can make physicians’ lives easier. Report on Innovation Kaiser Permanente - Christi Zuber ([email protected]) In this discussion, Linda DeWolf walked the participants through the VHA's "Report on Innovation." In summary, healthcare was viewed as an extremely "traditional" industry with very little activity considered "innovative." ROI on Innovation Alegent Health - Joan Neuhaus ([email protected]) This group discussed their need to demonstrate value from innovation in order to maintain a stream of funding for innovation-related activities. The group came up with a set of guidelines, including sponsorship from senior leadership, the facilitation of a pipeline for projects to eliminate failures early on, the development of a balanced scorecard to measure progress, self-promotion, and alignment with organizational priorities. The group also talked about principles of exerting influence within an organization. Social Network Mapping (two sessions) Social Invention Group - Keith McCandless ([email protected]) Keith McCandless convened two working sessions to review the results of the social network mapping surveys. For further information, please see Appendix 2. Staff as Customer and Engaging Staff Evanston Northwestern Healthcare - Bobbi Schramek ([email protected]) This group discussed ideas for better engaging staff, including using technology tools to solicit feedback, changing the role of middle managers, developing mentoring relationships, building an infrastructure to facilitate group interaction, and ensuring that all staff feel empowered to make a difference in patients’ lives. Virtual Simulations Kaiser Permanente - Christi Zuber ([email protected]) The group had a lot of energy around the topic of "virtual simulations." This group discussed the need to continue to expand methods of supporting collaboration and innovation between and among clinicians and patients, and saw simulated environments in the "virtual" 3D world as a potential tool to help support this collaboration and innovation. The two particular "products" discussed in the most detail were Second Life and Forterra. The group continued their discussion with the development of a Gameplan. For further information, please see Appendix 5-9.

Page E-8

Innovation Learning Network 2006

Project Game Plans Innovation Laboratories

Today (Now) JR to send welcome email Pick deep-dive target date May-ish Pick topic – medication administration

Days MP have assistant coordinate calendars for monthly call with team

Weeks Determine topics/sub-topics of medication administration Identify internal organization’s “key players” JR puts together “let’s get together” email of plan

Months 1) Scan of landscape (leverage off of Nurse Work *** Summit) 2) Hold deep dive on medication administration

Years Cross region/organization consultancy of organizations that can/able/makes sense Cross utilization of available “lab space” capabilities

Page E-9

Innovation Learning Network 2006

Personal Electronic Health Records

Today (Now) Query members for willingness to participate at organizational AND personal level Create a skeleton survey of patients One-page overview of the project for distribution Contact companies: - Google: Marty - Yahoo: David J - Intuit: David T - Facebook: Laura Jim writes up RFT - Tim will give system requirements to Jim Adrienne: research HIPAA

Next Week(s) Survey patients rd (get 3 party with $$) Get involvement from industry (Google, etc.) Get a patient (or two)

Months Working prototype for demonstration (36 months)

Years Nationwide availability

Testing (3 months) Engagement with political players and medical record vendors Develop scenarios for use with patients and vendors (1-3 months)

Goal Commercially available portable electronic personal health record managed by me/ trusted family member within 2 years or less 10/20/08 2:25 PM

VA to share “build demo” from Health University (VetHU) – to be shared with Steering Group

Page E-10

Innovation Learning Network 2006

Virtual Simulations

Now CA to email 2nd Life and Forterra to group Group – sign up for SL account CZ send status update to group (try to web conference training program) CZ send summit/Forterra sim measurements

In Weeks Rick to set up MS Live meeting for group to “try” SL together Bobbi to schedule meeting for group (within 3 weeks) try by Nov. 7-16 Email Rick if you cannot set up an account

In Months Try it with some stakeholders If momentum, buy an “island” together (have a virtual presence)

In Years Interaction of patients, health care providers, spaces, processes in some sort of virtual world…

Goal Understand how virtual simulations can be useful within healthcare and the people we serve

A forum for innovation…

Try it, try it, try it Engage with our stakeholders who like to interact in virtual worlds

Page E-11

Innovation Learning Network 2006

ILN 2007

Now Confirm membership Find new members Determine price Does KP coordinate and participate – 2007?

Weeks Smart networks – demonstrate value

Months Implement new tier structure

Grant - Bev/CIMIT - Duffy/HRET

Jan 07 teleconference ILN to vet Tier 2 projects

LIFE!!!

Goal

Write new purpose Formal agreement on services Explore potential Tier 2 topics (list serve)

Page E-12

G A M E P L A N

T E M P L A T E

Purpose: TEAM/ RESOURCES

IONS T C A / S TASK

• Leader: • Members:

Next Week

Today

• Action

• Action

• … • Resource

• • •

•

MEASURES

• … • …

SUCCESS FACTORS

Measure 1 • Success Factor

CHALLENGES • Challenge • …

… …

•

•

•

1. 2.

•

•

•

GOALS

•

•

•

•

Next Year

•

• •

•

•

• Member:

• Task

• Task

• Task

Next Q

• … • …

•

•

•

LINKS TO OTHER ISSUES/PEOPLE • Link • …

• … • …

Measure 2

Innovation Learning Network 2006

Section F: Going Forward ILN 2007 The purpose of the Innovation Learning Network is to foster discussion on the methods and application of innovation/diffusion, ignite the transfer of ideas, and provide opportunities for interorganizational collaboration. There are two tiers of work the ILN engages in: • •

Tier 1: High-level, open discussion on innovation and diffusion, often with senior leadership and champions of innovation within each organization o Example: Open Space Tier 2: Focused exploration and collaboration on a specific topic. The group could include Tier 1 participants, plus the content experts in each organization. o Example: a deep dive into medication administration

Activities and Service of the ILN 2007 • • •

•

• • •

•

Quarterly web conferences: These web conferences are for ILN sponsors and champions to conduct the business of the ILN, to share, to learn, and to network In-person meetings: two-three per year with each held at a different ILN members' campus. The purpose is for intensive, in-depth learning, sharing and networking Virtual Fridays: Short, topic-focused web conferences (up to two per month). Content on a topic is presented by a member organization for thirty minutes, followed by fifteen minutes of questions and answers. Virtual Fridays are archived into a virtual gallery which any ILN member can visit at any time ILN website: ILNOnline.org is our portal into the ILN. It contains a: o Searchable membership directory o Discussion board o Calendar of events o Archives ILN list-serve: The ILN list-serve is one email address that allows members to email all ILN members for quick and easy communications ILN wiki: The ILN wiki (accessed through the website) is a place that allows members to collaborate and create content on the fly, including uploading files. Any ILN member can edit and create. Group consultation: Any member organization that is facing a gnarly challenge can request a group consultation either via a monthly web conference or at in-person meetings. The group consult brings together the experience and creativity of the ILN members to help provide breakthrough. Loan an executive/expert: Any member organization may borrow an expert/executive for an on-site, focused experience. The ILN will help set up the trade/swap.

Page F-1

Network Mapping & Training ! Proposal

page 1 of 2

June Holley, Network Weaver 8 Lincoln St., Athens OH 45701 [email protected] 740-591-4705 Dear Maggie and Chris, I am delighted to offer you this proposal for training in Network Mapping and Network Weaving. This is just a suggestion. I would be glad to modify it to better fit your needs. The proposal includes use of the Smart Network Software by all of the participating groups at no cost, as it is still in beta testing (see attached agreement form which must be signed by an authorized individual from each organization). The only requirement for the use of the software is that the group provide information on any difficulties you find with the software and make other suggestions, as requested, about its revision. The goal of the training will be to provide provide a joint training with individuals from 3-4 ILN member organizations as well as ILN staff so that they are able to use the software in innovation projects in their organizations.

Part 1. Training in Network Mapping Outcomes: Each participant will have the skills necessary to: • generate survey questions, • implement a number of data collection methods, • enter data into the data collection sheets, • implement all steps necessary to generate a set of maps and measures, and • interpret the maps. Activities: Dec 18-31: Participants will have an initial call (1 hour) to identify projects for mapping, engage in a short session on Smart Networks and their role in innovation. We will go over projects for feedback, then get feedback on questions if some groups have them ready. Dec 18-31: Individual calls as needed to clarify who will be surveyed, how, and what survey questions will include. Instruction on how to enter data into spreadsheets. Early Jan: Training on the use of the software is provided, using the data from each organization’s projects. This will include 2 joint phone calls and some one-on-one time as needed. I will help them clean their data. Maps and metrics will be generated with guidance over the phone from me. Mid Jan:

Group teleconference training will be provided in analyzing the maps; we will go over maps with the group to deepen analytic skills.

Later:

Each group will determine when follow-up survey will take place and will conduct with assistance as needed. Group will analyze the new maps and metrics and will be trained in how to display the changes over time.

©2006 June Holley, Network Weaver

Network Mapping & Training ! Proposal

page 2 of 2

Part 2. Training in Network Weaving: Enhancing the Network Outcomes: • Individuals from participant organizations will use maps and metrics to develop Network Weaving strategies that will enhance their networks and lead to effective self-organizing. • Individuals from participant organizations will form a learning cluster for peer support in their NEtwork Weaving activities. Activities: Dec: Phone training in Smart Networks for background; discussion on how Smart Networks relate to their innovation/Network Mapping projects Jan: Introduction to Network Weaving. Network Weaving Self-Assessment to identify strengths and growth areas. Jan: Once participants have mapped and measured networks, session to understand stories in the maps and metrics, what they mean, “what ifs”; how the networks can be enhanced through closing triangles, increasing periphery, etc; basic Network Weaving strategies appropriate to their project. Set targets for metrics. We identify network leaders of various types using the metrics and discuss how to support their leadership activities. February: Face-to-face training session at gathering. 5 Dynamics that increase the effectiveness of networks. Network Weavers analyze the network maps and discuss how they could be enhanced using “what ifs” to see the impact of additional connections. Lead Network Weaver and I debrief session and discuss your follow-up role and tasks. February-June: Additional training & peer learning. Monthly or bi-monthly phone training, mentoring, and peer exchange session to the Network Weavers each month. Part of the time will be going over specific feedback on their Network Weaving activities, and part will be training in advanced techniques.

Please let me know if this meets your needs. All the best,

June Holley Network Weaver

©2006 June Holley, Network Weaver

Innovation Learning Network 2006

Section G: Resources ILN 2006 Members Alegent Health http://www.alegent.org/ Ascension Health http://www.ascensionhealth.org/ Catholic Health Initiatives http://www.catholichealthinit.org/ CIMIT (Center for Integration of Medicine & Innovative Technology) http://www.cimit.org/ Cleveland Clinic http://www.clevelandclinic.org/ Evanston Northwestern Healthcare http://www.enh.org/ Franciscan Missionaries of Our Lady Health System http://www.fmolhs.org/ Kaiser Permanente http://www.kaiserpermanente.org/ Mayo Clinic http://www.mayoclinic.org/ United States Department of Veterans Affairs http://www.va.gov/ Health Technology Center (HealthTech) http://www.healthtech.org/ VHA Health Foundation http://www.vhahealthfoundation.org/vhahf/

Page G-1

Innovation Learning Network 2006

Other Resources Clorox http://www.thecloroxcompany.com/ Craigslist http://www.craigslist.org/about/ Electronic Arts http://www.info.ea.com/ IDEO http://www.ideo.com/ Kraft http://www.kraft.com/default.aspx Networkweaving http://www.networkweaving.com/ Second Life http://secondlife.com/ Yahoo! http://info.yahoo.com/

Page G-2