Why Is Change So Hard In Healthcare?

Storify on ChangeThe IHI 24th Annual Forum was held this week in Orlando, and while I personally wasn’t able to make this year’s meeting, I was able to follow the conference through Twitter streams #IHI24Forum and #smIHI. As I await the release of the keynote addresses to the IHI website, the beauty of social media has allowed me to glean some highlights through the tweets of attendees. Thanks to all who added substance to the ~1.3 million IHI impressions on Twitter over the course of the week.

Of particular interest, was Dan Heath’s keynote on change. Heath, who co-authored best-sellers such as  Switch: How to Change Things When Change Is Hard and Made to Stick, has studied and written on why change is challenging, but also provides suggestions on how to make it happen. The image, On Change, links to a Storify aggregation of tweets highlighting his talk, as well as others discussing change at IHI. IHI’s email summary of Heath’s talk also provided key takeways:

Comparing the emotional and rational systems of the human brain, Heath offered guidance on how to impact change and reinforced the point that data alone is not sufficient to initiate change —- emotion is much more powerful. He urged attendees to tap into the emotional side of change as they lead improvement efforts in health care, and reminded all that failure in the process of change should not stop us in our efforts to lead improvement.

And, finally–please share your thoughts on healthcare change in the poll at the end of this post!

Series on High Reliability–The Journey Begins With A Single Step

Karl Weick and Kathleen Sutcliffe, both distinguished professors now at the University of Michigan, have spent years researching high reliability organizations (HROs)–organizations that despite operating under continual high-stress, high-risk conditions have very few failures. These organizations are also resilient by definition and as such, “practice a form of organizing that reduces the brutality of audits and speeds up the process of recovering.”

Aircraft carriers, air traffic control, commercial airlines and nuclear power plants provide examples of HROs, and now many healthcare organizations are looking to adopt and adapt the five principles of HROs outlined by Weick and Sutcliffe to prevent medical error from occurring within their institutions. Those five principles include:

  1. Preoccupation with Failure
    No matter how well these organizations are doing, they never rest on their success. They are constantly on the look out for any threat to successful execution, no matter how irrelevant it may seem.
  2. Reluctance to Simplify
    HROs embrace a critical eye and healthy skepticism of the ‘easy answers’. The more variables they can picture, understand, and plan for, the better.
  3. Sensitivity to Operations
    Front-line operations provide the situational information that drives the ability to adjust and adapt as necessary. HROs may be guided by strategy, but remain nimble and ready to react as the situation calls for change.
  4. Commitment to Resilience
    By preparing to prevent failure on a continual basis, HROs are ideally able to keep failures manageable or prevent them altogether. When errors do occur, HROs have ensconced within their culture, the ability to solve the problem and move forward without delay.
  5. Deference to Expertise
    HROs recognize that those with the most experience are not necessarily their experts. Experts on the front lines are called upon to make decisions on a regular basis in HROs.

Underlying all five principles is the core concept of mindfulness. Mindfulness, defined by Weick and Sutcliffe, is the ability of an organization to: 1) Notice the unexpected in the making, and halt its development; 2) Contain the unexpected if they can’t halt it; and 3) Restore as quickly as possible to normal function if they cannot contain it. A mindful approach to daily operations is a must have for any organization striving for high reliability.

Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement (IHI), along with Charles Kenney, an award-winning healthcare author, recently published, Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs, a book that highlights healthcare organizations that have become highly reliable, and how they have adapted Weick and Sutcliffe’s principles of an HRO to the healthcare environment.

Common to these innovative healthcare organizations are the following seven characteristics that have resulted in highly reliable safe outcomes for their patients. It will be these seven characteristics, built upon a mindful approach to daily interactions with one another, with patients and with the community, that will provide the framework for all entities to come together as one high reliability organization. These characteristics include:

  1. Transparency
  2. Patient Engagement
  3. Reporting
  4. Interprofessional Teamwork and Collaboration
  5. Measurement (HIT, data, outcomes)
  6. Respect/Support
  7. Strong Leadership

As Chassin and Loeb noted in their excellent article referenced in my previous post, the time for high-reliabilty thinking in healthcare is now. I couldn’t agree more.

Some additional excellent resources on HRO’s:

AHRQ: Becoming A High Reliability Organization—Operational Advice for Hospital Leaders

Joint Commission High Reliability Resource Center

High Reliability–Where Does It Fit In a Medical School Curriculum?

Articles on high reliability thinking continue to accumulate in healthcare journals…and for good reason. Research on high reliability organizations such as aviation and nuclear energy offer useful strategies and tools that have been shown to reduce risk in their environments, while providing hope for other high-risk industries such as healthcare. These studies reveal a number of common factors that help organizations achieve excellence. Creation of a just culture, leadership support, and a constant vigilance for kinks in the workflow that could lead to disaster are just three common themes that permeate the literature.

Like many aspects of safety science, high reliability education should be included in all patient safety curriculum, be it for students just starting a health science education, or for experienced caregivers as part of continuing education programs.  High reliability thinking is becoming the cultural foundation for many health systems across the country, and more healthcare organizations need to add high reliability knowledge, skills and assessment into their educational offerings.

An excellent resource that can be used for teaching high reliability concepts is an April 2011, Health Affairs article by Mark Chassin, the president of the Joint Commission, and Jerod Loeb, the executive vice president for healthcare quality evaluation at the Joint Commission entitled, The Ongoing Quality Improvement Journey: Next Stop, High Reliability. The authors suggest three interdependent and critical changes that must occur for an organizational culture shift to one of high reliability. These three changes are: (a) leadership commitment  (b) implementation of a safety culture that supports high reliability; and (c) tools of “robust process improvement” (e.g. Six Sigma, lean management) must be adopted.

Of particular educational value in the article is the discussion on collective mindfulness. It is an important concept I always share with my students – both at the medical school level, as well as with students in the Masters in Patient Safety Leadership program at UIC when our research and discovery is focused on high reliability thinking. Originally coined by Karl Weick and Kathleen Sutcliffe, and restated in the Chassin/Loeb article, collective mindfulness means “that everyone who works in these organizations, both individually and together, is acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse outcomes”. In other words, everyone always functions with an underlying uneasiness…a sense that things are just not right…as opposed to a feeling that nothing bad could happen.

As we move into a new era of healthcare, health systems that achieve the “Triple Aim” and provide the highest quality of care at the most affordable cost will be the ones who prevail. Arming health science students with the skills they will need to be successful given the changing requirements of healthcare seems only logical. But who is teaching these skills today? And better yet, when will students be required to have a working knowledge of, and demonstrate competence in, what it means to operate within high reliability organizations and work in interdisciplinary teams of excellence? Please comment and share programs you know that have started to incorporate high reliability training into their curriculum.