Why is transformation so difficult?

Transformation in healthcare needs to occur within a complex dynamic system (i.e. a chaotic mess). Clear communication, shared goals and problem solving are especially challenging in healthcare environments. There are multiple and sometimes conflicting missions. The socialization of healthcare professionals is fragmented and often exists outside the organization and pre-employment. Our organizational structures further strengthen these silos. There are incredibly strong external pressures, constraints and influences from multiple stakeholders (payers, consumers, government agencies, etc.). The core tasks in healthcare often occur locally in complex, dynamic, and ambiguous situations and settings. Patient-driven variability is often a necessity and yet there is a good amount of unnecessary variability. Healthcare is pluralistic. It’s a conglomerate of missions, values, stakeholders, professionals, regulations, processes and practices.

Here are some transformational changes we’ve all been considering with my assessments of where we are:

Team-based care –We’ve been talking about it so much it’s become a cliché, yet we’re not so good at it.  If we actually did it, it would be transformational.

Deeper and expanded competencies – Lot’s of problems get in the way of this, and we’re dreadful at solving problems in healthcare.  This tactic is necessary for reducing costs.  All stakeholders (internal and external) need to get on board.

Explicit goal setting incentivized using internal and external motivators – we think we’re good at this, and we’ve gotten better, but we’ve not transformed how we do this. Why? Because we think we can set goals at the highest level and have them make sense at the local level. Hello? McFly? It doesn’t work.

Local change with targeted centralized support – uh… what we ask for too often is local support for centralized change. Is that you again McFly?

Feedback and redesign with front-line workers and patients at the center of the work. – Who has time for that?  We can do this, but only if we integrate it into our daily workflows and practice.

Use systems, process and team-based thinking. – ugh.  Clinical pathways help change the paradigm and demonstrate the benefit of doing this, but one problem is that professionals don’t know how to do this kind of work without a lot of coaching.

Agile engaging high-performance management systems – Does anyone in healthcare even know what this means?

One last thought…Many of us have been on a journey to point out what we consider to be a cancer in healthcare - variability.  Could variability be the malady of all maladies for healthcare?  Yet variability is often necessary as is cell growth and tissue regeneration; variability at the right time applied to the right patient is the right thing to do.  Also, attacking variability with blunt tools has negative consequences, much like using radiation and cytotoxic chemotherapy to fight cancer.   A better way to frame variability: there is good variability, acceptable variability and bad variability (normal, benign and malignant). We need to address the malignant variabilities with targeted and intelligent tools.

Transformation: asking the right questions

Transformation starts with asking the right questions. My favorite first question is, “what problem are we trying to solve?” Followed by “why?” If you’re in the service industry and the problem you’re trying to solve is a financial one, that’s not transformational, it’s operational. If the problem isn’t about those you’re serving, then it’s the wrong problem. Loss of focus on true north goals often sends problem solvers down the wrong path; be sure staff define the right problem and stick to it.  And don’t let operational problems get in the way of solving the real big ones.

Common customer oriented problems are cost, convenience and experience. When considering these, it’s important to not forget the most important problem, “Why they’re coming to you or want to come to you in the first place.” – forget that fundamental, and you’ll go out of business.  Perhaps one question for transformation could be, “How can we solve patients’ problems quicker, cheaper and where they are?”

Transformation also starts with realizing what we shouldn’t tolerate, and generating paradigm shifts.  The  patient safety movement is an example of transformation. It started 20 years ago with Dr. Leape using data, and asking the right question, “why are we tolerating this?” We look back now and we can’t believe the things we tolerated. Another example is the patient- and family-centered care approach to delivering care, and designing that delivery. This movement brought about a paradigm shift in how people think about healthcare.

Perhaps another question to ask, “Is what we’re doing and how we’re doing it the best way when you consider the value it brings to the consumer assuming they have to pay every cent of the cost plus a margin?” People are willing to pay a lot to get their cancer cured. They aren’t willing to pay a lot to get a sore throat looked at and cared for.  To think about this try the “miss work” or “miss school” test (e.g. if a family that values their child’s education is willing to take their child out of class to go to the doctor, that service is of value. If it’s not then they will either not go, or they’ll go somewhere after school that is quick and convenient– i.e. CVS minute clinic).

We think patients and families value all healthcare equally, but their behavior suggests they don’t.  We need to provide value starting with thinking a little differently about what value means to those we serve: “if the patient had to pay every cent of the cost of their healthcare, how would we do it differently?”

In some cases we may need to be explicit about the value.  For example if a family takes their child to the doctor primarily to get vaccines, what would happen if they were to become solely responsible for the cost?   They would start going to CVS to get them.  Just walk in, get the shot and leave whenever at a cheap cost, no doctor involved (and by the way stop at the do-it-yourself height and weight station on your way out). Yet, there is value in going to and paying for the doctor visit that may not be entirely understood.