Recently I suggested many health care organizations were afraid to try something new despite the evident need to take risks in the face of a changing environment. Asch and associates have written on how health care leaders can encourage experimentation. They begin by noting the paradox that complex science is easier to do than service/process improvement in health care organizations.
“The resistance to change in health care is sometimes simple intransigence but mostly it is a natural byproduct of thoughtful professionals trying to avoid mistakes in a setting that is expensive, regulated and high stakes…Highly-specialized expertise and narrow licensing and credentialing make health care organizations so matrixed that it seems anyone can say no, and no one can say yes.”
When I was a student doing my rotation on general surgery, I heard this notion expressed as “If it was good enough for Dr. (William) Halstead, it is good enough for me.” Few remember who he was, (the first chief surgeon at Johns Hopkins,) but the attitude remains. I always preferred the aphorism suggesting it was best to be the second or third person to try something new.
Given this reality, how to respond? First, delay consensus. They present an experiment they are doing to reduce admissions of patients with COPD, which involves having patients “call in” through an app activating a traveling ER with all the tools needed to address common causes of COPD exacerbation urgently in the patient’s home.
“Traditionally, health system leaders presented with this concept would insist we first coordinate with a range of clinical and administrative services…certainly delaying, and likely dooming the project from the start. Instead, when leadership’s first exposure to the new model is in the form of promising results from initial tests, conversations tend to focus instead on how to work out kinks, make it part of regular business processes, and scale it up.”
The second recommendation is to enable exceptions. “In health care, even seemingly small exceptions to protocols create outsized concerns about setting new precedents. The gambit here is that those concerns can be overcome with explicit stopping criteria experiments provide.”
The third recommendation is to free the data. “Processes created by electronic health record vendors and hospital information technology policies aim for scale, reliability, standardization, and security. The threat to innovation is that these processes typically lock systems down, limiting experiments that explore new ways to leverage data.” Although not mentioned, one of the major sources of clinician frustration with the EMR is the need to standardize data in ways that make sense to the IT person, but not necessarily to every clinician in every field. Certainly “getting rid of stupid stuff” is another fruitful area for experimentation.
But you may object, as this ignores all the value-based care initiatives out there forcing providers to make unwanted changes. I suggest part of the problem is we can lose track of the forest for the trees. Thus, another paper on hbr.org by Marc Harrison from Intermountain Health is helpful. He lays out the principles they use to guide their efforts. For simplicity, I will show them as a list.
1. The enemy is disease, and we must speed up the connection between science and patient care.
2. We must be willing to disrupt the traditional for-profit model of pharmaceutical production.
3. We must link health care providers and health insurance providers so that they—and patients—jointly benefit from improving the health of a population.
4. We must reduce the cost of health care while at the same time improve care. That again may seem counterintuitive, but it shouldn’t.
5. We must work with the public to confront the social determinants of health.
Dr. Harrison is President and CEO of Intermountain Healthcare, so he is leading his organization in these efforts, each of which requires many experiments to see what can be done to make these goals reality. Of course, they may also serve as guardrails—experiments which don’t line up with these goals are not as important and may need to be shelved.
I suspect the challenge for most organizations is the “tyranny of business.” It seems like everyone I know has more to do that they can handle. Getting folks who are addicted to this way of life to stop and reflect on changes is tough—it looks like a timewaster twice. First you have to think, and then any change is going to require more thinking until it becomes the new way to do things. Is it wishful thinking to suggest we mute our electronic devices and look out the window and just ponder? Probably, but I think it is essential for personal and organizational survival.
5 November 2019
 Asch DA, Mahoney KB, Rosin R. 3 Ways Health Care Leaders Can Encourage Experimentation. 28 October 2019. Accessed at https://hbr.org/2019/10/3-ways-health-care-leaders-can-encourage-experimentation.
 Harrison M. A 5-Point Model for Value-Based Care. 23 October 2019. Accessed at https://hbr.org/2019/10/a-5-point-model-for-value-based-health-care
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