Healthcare Holdups, Death-By-Pilot, And The Scourge Of Incrementalism

True story: When I was a medical student, many of the patients I saw on rounds each morning had a lot of questions for me. Inevitably, however, they forgot to ask some of them. In the afternoons, I’d often pass a nurse in the hallway who would say something like, “Patient X says she’d like you to come back to her room because she forgot to ask you something.” 

Often, when I went back to visit Patient X, she’d say something like, “Oh, yes, I had a question about what you said this morning…But I forgot what it was.” 

I totally got it. These patients were in a hospital, often quite ill, and surrounded by strangers and odd machines. Meanwhile, we’d come in every morning and feed them a barrage of unfamiliar medical terms. Of course they had questions! And of course they forgot to ask some of them!

So I got an idea. “Let’s get our patients notebooks,” I said to an attending I had been shadowing. “That way they can write down their questions and never forget to ask them.”

“Good idea,” the attending said, hoping to encourage my idea for a quality improvement project. “Let’s take it to the division chief.”

So I proposed my idea to the division chief. “Good idea,” the chief said. “Let’s take it to the division all-staff meeting.”

“Good idea,” resoundingly said members of the divisions. “Let’s take it to the nursing steering committee.” 

No doubt you can see where this is heading.  

I’ll admit it. 

They wore me down. 

I gave up. 

Each time the idea gained traction, its time to implementation grew by 6-8 weeks as I waited for it to get scheduled on various meeting agendas. And with each meeting, the “data collection” requirements grew and the scope of a pilot narrowed. As I neared the nursing committee, the simple idea I had to buy some inexpensive stationery for our patients had been turned into a several-week pilot project that would be implemented in just one solitary ward. Even if the pilot proved successful, I knew my life (outside of my duties as an aging medical student) would involve going to even more committee meetings to evangelize about what I thought was a stupidly simple, mostly obvious idea. 

If you’re a patient in that busy hospital (and many like it around the country), you still don’t have a notebook next to your bed on which to write your questions. I’m sorry for that. But after taking my simple, inexpensive idea to every committee in the building, I simply ran out of enthusiasm for the project.

It’s been a few years since my experience in that hospital. In the interim, I’ve held roles with successively greater authority in the government, pharmaceutical industry, clinical medicine, and managed care, and I’ve come to understand that what I was being exposed to was what I call a classic “Healthcare Holdup.” The Healthcare Holdup is the reason so many good ideas in healthcare die a slow death. 

Healthcare holdups, prevalent throughout healthcare organizations of all kinds, take on many forms, so here’s a complete taxonomy of the various types to be on the lookout for:

• The organization where no one reports to anyone else. We’ve all worked here. This is the place where, even though people have job titles with words like directorsenior and chief in them, actual hierarchy is frowned upon. When you work in this place, if you want something done, you learn to do it yourself. Because no one believes they actually report to anyone else, and no one is going to disabuse them of that notion. In organizations like these, good ideas die because no one can ask anyone else to help them get started.

This concept is particularly acute in hospitals with voluntary medical staff where physicians are rarely employees of the hospital—and more often customers of the hospital. In these settings, physicians can admit patients to a number of different hospitals—so their relationship is less like that of a team member more like that of an independent contractor. This organizational structure explains why rates of adoption of electronic health records were so low for so long prior to the HITECH Act.

• The Buy-In Bazaar. This is the organization, like the hospital where I worked as a resident, where every decision—no matter how small—needs “buy-in” from every stakeholder in the place. Which means that if you fail to get everyone’s buy-in, the project is killed.

Another true story: at a healthcare organization I led, we had an arrangement to provide care to a group of patients at a local hospital. Even though our treatment model was different from that of other providers, our patients were scattered throughout the facility. So we asked to create a ward dedicated to our patients. We said we’d pay for it.

The hospital’s senior executives supported the idea. Then they sent us shopping in the buy-in bazaar. Various physicians and executives agreed that it made sense for us to treat our patients in one location. Then the nursing administrator got hold of the proposal and vetoed it. Headmitted it made a certain amount of sense. But he also said it would require him to change some of his processes. Which he adamantly refused to do. 

One nursing administrator who didn’t want to change a few practices single-handedly torpedoed a multimillion-dollar investment in a hospital ward. It pains me to think about the patients that organization still admits to that hospital, and how they’re still scattered across a dozen floors—rather than collocated with enhanced services for patient benefit.Too many common-sense ideas die because our model of change-management too often requires 100% buy-in from 100% of the affected people to gain traction. And we wonder why healthcare seems to change so little over time?

• Death-by-Pilot. A better word for this concept is incrementalism. It’s when we turn every decent idea into a science fair project instead of just doing it. Of course, when it comes to new medications and procedures, it’s essential that we test them thoroughly according to strict protocolsand that our findings be peer reviewed. 

But what about when we come up with ideas that simply and intuitively achieve the best outcomes at the lowest cost? Anyone who’s worked inside a large healthcare system knows that, more often than not, we turn every good idea into a research initiative instead of just trying it out. And then, when the research shows that the idea was, indeed, a good one, we send its creator off to the Buy-in Bazaar (if we haven’t already) to build support for it. 

Here are better ways to approach change management and the implementation of good ideas.

• Rethink organizational decision-models. One of the lessons I am hoping will not get lost as we emerge from the COVID-19 pandemic is that change does not have to be slow, plodding, and hyper-rational. At the height of the COVID-19 crisis, healthcare organizations showed remarkable agility because the situation demanded it. Crisis-mode decision-making that emphasized goals, outcomes, and necessity instead of consensus and buy-in enabled healthcare organizations to achieve 5-10 years of clinical transformation—including the adoption and scaling of telehealth—in as few as 5-10 weeks. Healthcare leaders demonstrated remarkable courage and an ability to pivot that had previously been missing. What would it look like if the same kind of decisiveness and courage found its way into post-pandemic leadership decision-making? I suspect we would see more of the changes for which industry reformers have long been clamoring. 

• Understand that scale and complexity are not competing factors. Too often, when we alight on a good idea, we assume that we should test it out with a small group. But given that we’re talking about healthcare, which has many legal and regulatory hurdles, it’s worth understanding that doing something for 100 patients can be just as complicated as doing it for 10,000 patients. 

Nevertheless, because of the desire to prove an idea’s worth through extensive testing and study, we often delay widespread implementation of beneficial programs, which both costs the healthcare system money and, more important, deprives patients of the ability to be treated according to best practices. We have to acknowledge that there is an inherent ethical failing when we delay scalingsomething that we know to be effective in order to feed an organization’s defective decision-making processes. 

Moreover, we ignore the fact that illness often manifests itself in the same ways in most patients. This is, after all, the core conceit behind medical education. Put another way, a diabetic patient in Memphis is no different than a diabetic patient in Los Angeles. If you discover a better way to improve outcomes among diabetic patients in Memphis, why limit it to them instead of sharing the idea with your patients in L.A.? Too often, we hide behind “all healthcare is local” in order to build a customized process where a standardized one would do just fine.

• Don’t let proven ideas die. Sometimes it makes sense to test a program or idea out with a small sample group—especially if the idea is, in fact, expensive to scale. But too often, even when ideas prove their value, they end up dying through inattention or, more often, dismissed by a leader who says, “Yeah, it worked among that small group, but it won’t work with a larger group.” 

This is, of course, nonsense. When I led CareMore Health, we had the idea to use ride-sharing to transport members to their appointments and were the first Medicare Advantage care delivery organization to try this approach. It seemed like a good idea, so we tried it out with a few hundredmembers over a several month period. The members loved it. They found the rides easy to schedule. Clinicians loved it too, because the change increased on-time arrivals and decreased no-shows. 

The day we saw the data on the ride-sharing demonstration project, we changed our transportation model and openedup ride-sharing to all of our members. No one sought buy-in. No one suggested we try a slightly larger population group to run a second pilot with. Instead, we trusted that we had come up with a good idea, found a way to implement it, and scaled it up quickly. When problems arose—and they did—we dealt with them in real time as a necessary step in achieving scale.

In some ways, what I’m proposing can be summed up by saying, “At some point, you have to move someone’s cheese.” Who Moved My Cheese? is a well-known business book about organizational change. Too often, this book has been handed out to employees facing cost-cutting measures and imminent job-losses. I with that weren’t the case, because the book offers a better, more instructive lesson for both employees and managersalike: You can’t wait for everyone to be comfortable with everything. 

If you want to implement change, then you’ve got to go ahead and do so. You can’t wait around for everyone to buy into your idea. You can’t endlessly test every idea with every committeein an effort to increase buy in. And you can’t delay implementation as a means to avoid making others uncomfortable.

We’re talking about healthcare. The good ideas we have curtail illness, improve the quality of people’s lives and keep them alive longer. In the end, that’s something we should all be able to buy into. We can’t afford to have potentially life-saving ideas languish in the gluey cauldron of organizational inertia.

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