Describing change management

Original post:  Feb 9, 2015

The UDI Program does hold powerful promise for the future. Unfortunately, many of our most important customers underestimate the incredible amount of change management that will be required in order to implement the program correctly. They also seem to have no idea how difficult it will be to transform the data generated by UDI into meaningful improvements in patient safety.

One way to help people understand is to relate these struggles to terms that they might have experienced in their own lives. In a discussion earlier today preparing for an upcoming panel presentation on UDI, I stumbled onto something that might be helpful.

There have been many changes to surgical procedures over the years. Each one of them started out as a new, unproven procedure. Someone had to invent the procedure. They had to try it out on a patient. When it worked, they had to document the procedure. They then had to show it to others. Once other surgeons agreed that it was an improvement over the status quo, they had to learn how to do the procedure in the same way and practice on their own. Over time, the repitition would eventually become the new practice.

We are in the earliest stages of UDI adoption. We still don't know all of the ways it can eventually improve healthcare. We've got to slowly build up our portfolio and then train others with a similar approach.

What do you think?

Emotion trumps reason

Original post:  Apr 16, 2014

We like to believe that people are rational. We often argue that if we can marshal enough evidence to prove our point that we can win the day. The truth is actually much more complicated than that. It turns out that people are often guided by their emotions as much as their intellect. We often bow to tradition even when we know it might not be the correct path.

Doctors are no different than everyone else. Despite their long years of training, many of them are also subject to this effect. In this article from the Atlantic, many of them are demonstrating that it is often extremely difficult to undo years of practice even in the face of contradictory evidence.

David Jones tells the story in his book, Broken Hearts: The Tangled History of Cardiac Care. At first, cardiologists believed that coronary artery disease was due to cholesterol and other substances building up blockages. Bypass surgery, balloons, and stents helped to increase oxygenation and clean out the clogged arteries. These procedures became the gold standard in care. However, there were others who felt that heart attacks were due to ruptures caused by plaques built up with cholesterol and other substances. They felt that statins could help relieve these conditions and help reduce heart attacks.

Jones has other theories about why practice is slow to change:

Jones readily admits there are financial reasons for the continued use of these procedures. Bypass and angioplasty make money for physicians and hospitals. But other explanations—what he terms “emotional and psychological”—are more interesting and especially relevant to current debates about treating high cholesterol and hypertension.

The physician who wrote the article also adds his own opinion:

....Quite simply, it is hard to practice medicine one way for so many years and then change. I have become adept at mixing and matching medications to get to the old recommended levels while minimizing side effects. And while I do not do formal outcome studies on my patients, and some have clearly experienced heart-related issues, I can generally state that those that take their pills have done quite well.

But Jones’ research provides a cautionary tale for my type of reaction. Studies that asked cardiologists why they continued to recommend elective bypass and angioplasty despite the plaque hypothesis revealed emotional and psychological reasons of dubious validity. For example, some justified their decisions because they had a “zero tolerance” policy for angina. Others worried that they would have “anticipatory regret” if a patient who had not been revascularized had a heart attack. Others were disinclined to leave the catheterization lab without doing “something.” Finally, others feared lawsuits. None of these opinions, Jones correctly asserts, should carry the day.

We should keep these types of issues in mind as we develop new techniques and systems that might run counter to current practices. Even with documented proof, it will still require an extensive campaign to change hearts and minds!

Here is the link to the full article:  When Doctors Act on Tradition and Emotion Over New Science - Barron H. Lerner - The Atlantic

The secret to innovation? Winning hearts and minds....

Original post:  Nov 14, 2013

This post is linked to part one.

As the article goes on, Dr. Gawande discusses simple innovations to combat infant mortality in rural hospitals. One of the simplest methods is to keep newborn infants warm. While high-tech incubators exist, the most effective tactic is using the mother's own body warmth. Yet even this simple advice is consistently ignored.

The author goes on to discuss why people struggle to adopt new ideas. He writes:

The most common approach to changing behavior is to say to people, “Please do X.” Please warm the newborn. Please wash your hands. Please follow through on the twenty-seven other childbirth practices that you’re not doing. This is what we say in the classroom, in instructional videos, and in public-service campaigns, and it works, but only up to a point.

Then, there’s the law-and-order approach: “You must do X.” We establish standards and regulations, and threaten to punish failures with fines, suspensions, the revocation of licenses. Punishment can work. Behavioral economists have even quantified how averse people are to penalties. In experimental games, they will often quit playing rather than risk facing negative consequences. And that is the problem with threatening to discipline birth attendants who are taking difficult-to-fill jobs under intensely trying conditions. They’ll quit.

The kinder version of “You must do X” is to offer incentives rather than penalties. Maybe we could pay birth attendants a bonus for every healthy child who makes it past a week of life. But then you think about how hard it would be to make a scheme like that work, especially in poor settings....

Besides, neither penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching. “You must” rewards mere compliance. Getting to “X is what we do” means establishing X as the norm. And that’s what we want: for skin-to-skin warming, hand washing, and all the other lifesaving practices of childbirth to be, quite simply, the norm.

In his eyes, here is the solution:

But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.

This is something that salespeople understand well. I once asked a pharmaceutical rep how he persuaded doctors—who are notoriously stubborn—to adopt a new medicine. Evidence is not remotely enough, he said, however strong a case you may have. You must also apply “the rule of seven touches.” Personally “touch” the doctors seven times, and they will come to know you; if they know you, they might trust you; and, if they trust you, they will change. That’s why he stocked doctors’ closets with free drug samples in person. Then he could poke his head around the corner and ask, “So how did your daughter Debbie’s soccer game go?” Eventually, this can become “Have you seen this study on our new drug? How about giving it a try?” As the rep had recognized, human interaction is the key force in overcoming resistance and speeding change.

As we develop our own innovations, it will be important to keep this in mind. We must never forget the human factor in change management.

You've got a great idea. Now how do you get it adopted?

Original post:  Nov 13, 2013

I like to think that the world is logical. In this idealized version of reality, simply making the case for a good idea is enough. Everyone agrees that this new method is the right thing to do and it gains adoption. Unfortunately, that is rarely the case. Most of the time, the good idea itself is only the first step. Then comes the long slog of convincing those who are vested in the status quo that the change will be worth all of the disruption it takes to get there.

If you've ever sat in a monster traffic jam as they work to expand a freeway, you will know exactly what I am talking about.

Atul Gawande has another great article on this very subject in the New Yorker. "Slow Ideas" discusses how some (medical) innovations spread more rapidly than others. He opens with two clear-cut examples of revolutionary innovations in medicine:  anesthesia and infection control in surgery.

Anesthesia spread more quickly. Prior to its invention, surgeons were judged for their speed. Even minor procedures like tooth removal still required restraints and struggle. Once William Morton demonstrated the idea and Henry Jacob Bigelow published an account in a medical journal, the idea spread like wildfire. Within two months, the idea had already spread to London and Paris.

Despite this rapid uptake, there were still skeptics:

There were forces of resistance, to be sure. Some people criticized anesthesia as a “needless luxury”; clergymen deplored its use to reduce pain during childbirth as a frustration of the Almighty’s designs. James Miller, a nineteenth-century Scottish surgeon who chronicled the advent of anesthesia, observed the opposition of elderly surgeons: “They closed their ears, shut their eyes, and folded their hands. . . . They had quite made up their minds that pain was a necessary evil, and must be endured.” Yet soon even the obstructors, “with a run, mounted behind—hurrahing and shouting with the best.” Within seven years, virtually every hospital in America and Britain had adopted the new discovery.

Infection control took a more torturous path. It was the leading killer of surgical patients. It was so common that oozing pus was considered a sign of healing! Dr. Joseph Lister read a paper by Louis Pasteur about how microorganisms could cause fermentation and spoilage. He had an idea to use small amounts of carbolic acid to improve surgical infection rates. By 1867, he published the results of years of study showing that the common use of his method dramatically reduced the rates of sepsis and death. Despite these findings, his ideas faced a much colder reception than anesthesia. Gawande reports:

....The surgeon J. M. T. Finney recalled that, when he was a trainee at Massachusetts General Hospital two decades later, hand washing was still perfunctory. Surgeons soaked their instruments in carbolic acid, but they continued to operate in black frock coats stiffened with the blood and viscera of previous operations—the badge of a busy practice. Instead of using fresh gauze as sponges, they reused sea sponges without sterilizing them. It was a generation before Lister’s recommendations became routine and the next steps were taken toward the modern standard of asepsis—that is, entirely excluding germs from the surgical field, using heat-sterilized instruments and surgical teams clad in sterile gowns and gloves.

Why did one innovation have such an immediate impact while the other took decades to take root?

We'll discuss Gawande's insight into the answer tomorrow.
Here is a link to part two.

The link to the full article is in the title above and here:  http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande

Not as easy as it looks

Original post:  Oct 17, 2013

Yesterday, I was working with a colleague who is an early adopter of a new technology. Working in Information Systems, we are constantly exposed to these types of devices. Even so, we struggle just the same when things don't quite work the way that they were drawn up.

In this particular instance, this individual is making an honest attempt at getting the device to work the way that it should. He has spent hours of his own time every day trying to learn the device. He had hoped it would be easy enough to figure out without any real training. For the most part, he has been able to accomplish tasks. From his feedback, I can classify his issues into two major groups.

The first group of issues could be called "knowing what you want to do but being unable to figure out how to do it". I had a similar experience recently in a hotel room. There was a single-serve coffee maker. I added water and put in the cartridge. I then knew I needed to turn the unit on. There were no instructions on the unit. I searched all around the unit but could not seem to locate the correct button. After about two minutes, I finally realized that there was a slight protrusion that doubled as the on switch. After I pressed it, it lit up and I knew I had located the correct button. It's experiences like that that can make new technology difficult.

The second group of issues could be titled "you are making me do things differently." There is nothing necessarily wrong with this. The changes just make people temporarily uncomfortable. One example from my own experience is fairly recent. About a month ago, I received a new laptop. With the old laptop, every time I stepped away for a few minutes, my computer would go to sleep. Upon reviving it, I would be presented with a lock screen. I would have to type in both my name and my password. It was annoying, but I had lived with this for nearly four years so I was quite used to it. With the new laptop, the system now recognized who I was. In these situations, I would now only have to type my password. Any neutral observer would agree that this is a benefit. However, for the first week or so, I was constantly running into the problem where I would automatically start typing my name and this would mess up the password. Until I got used to the switch, I was actually taking longer to get past the lock screen!

No matter how diligent we are, there will always be time needed to make the transition. It will be vital for us to incorporate solid training programs geared for the average user. It will also be important for us to start each session from the point of view of the end user. As we begin to roll out these devices to more and more personnel, it will be important for us to be patient. It will be equally important for the end users to be patient as well. The road to adoption may be quite frustrating. The good news is that once we get past the initial trauma, we should be able to benefit from the new features this new technology provides. After some time, we may even be able to laugh at our previous inadequacies!

Predicting the future is kind of hard

Original post:  Mar 20, 2013

"There is no reason anyone would want a computer in their home."    

Ken Olson, president, chairman and founder of Digital Equipment Corp., 1977

It is easy to look at the quote above with the benefit of hindsight and laugh. We can look at the world around us and see just how wrong this statement was.

Perhaps there is a simpler explanation at work. In 1977, computers cost tens or hundreds of thousands of dollars. There was little to no software available that would do much of anything. Mr. Olson may have made this statement while talking to analysts about his business. Digital probably focused on their core audience of major business enterprises. At that point in time, it may have been difficult to predict just how rapidly Moore's law might drive the evolution in computers from the hulking behemoths of the past to the mighty midgets of today. Perhaps Mr. Olson just didn't spend enough time with his engineers to know what was coming. Perhaps his engineers lacked the insight to imagine why you might want to market to a personal consumer. Whatever the case, these words look spectacularly silly today.

I think a similar analogy from a company perspective might be trying to imagine a world where an 840 ventilator might be placed into the home. At today's prices and with today's applications, that is improbable for anyone without a personal fortune. However, if we were able to continually improve the performance and miniaturize the technology, it may someday be possible to shrink the unit to a more portable size. Who knows? Fifty years from now, we might laugh at a prediction that stated no one would ever need a ventilator in their home!

At a recent workgroup meeting, we were discussing mobile technology. To give the attendees some sense of the rapid pace of change, the meeting opened with this photo below:

The world is morphing so quickly that it is difficult to imagine what the future will be like. We were discussing mobile applications. Ironically, up until a few years ago, mobile applications truly didn't exist in any meaningful numbers. Will it always be this way? Will the near term future rely on these streaking meteors that flash across the sky and disappear?

I'm not sure anyone truly knows the answer but it will certainly be entertaining to try and find out!

Lessons from the Cheesecake Factory

Original post:  Aug 8, 2012

Atul Gawande is a Boston area physician who writes extensively about healthcare. His latest article will appear in the upcoming issue of the New Yorker magazine. I found the article to hold some amazing insight about the future of healthcare. It is a long article, but well worth the time. Here is the link to the full article:  Big Med (The New Yorker)

The author opens with an explanation of how the Cheesecake Factory is able to bring high quality food at reasonable prices to a mass audience. The chain is wildly popular and the food is quite good. Through a combination of standardization and relentless quality control, they are able to take complicated recipes and reduce the variation dramatically. The result is a perfect wasabi-crusted ahi at any one of their restaurants all for the same moderate price throughout their chain.

He then compares that to our current healthcare system. In his words, we are getting "greasy-spoon fare at four-star prices." Proven medical innovations can take, on average, fifteen years to become the new norm. Expensive treatments that are proven to have little or no clinical value are routinely ordered. He wonders what might happen if healthcare could adopt some of the best practices of the restaurant industry.

To give one example, he cites the fact that controlling food waste is extremely important to a restaurant. The Cheesecake Factory is able to project demand so well that they only throw away about 2.5% of their food (on average)!

He goes on to discuss his mother's experience with a knee-replacement surgery. John Wright, a surgeon at Brigham and Women's, is reshaping the orthopedic department. He is taking best practices and creating new, standardized procedures for joint replacements. He says, "Customization should be five per cent, not ninety-five per cent, of what we do."

Those changes have not been easy for the staff to accept, but the results have been positive:

...He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).

Gawande then discusses the virtual ICU concept as practiced by the Steward hospital group. There are ten hospitals serving 8,000 patients per year. The centralized command center is not meant to replace the staff on site. They can augment the staff on hand by ensuring that the protocols have been followed and that important warnings are given proper attention.

These changes will bring savings but they will also create a great deal of disruption and uncertainty.

Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.”

He closes with an interesting flourish:

The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.

Viewing the future through the lens of the past

Original post:  May 9, 2012

We are often limited by our history. The lessons that we have learned imprint us powerfully. We often assume that what has succeeded for us in the past will always succeed for us in the future.

Much of that is inevitable. It's hard to imagine a world that takes our comfortable world views and completely inverts them. I can imagine that it is really hard for someone who is working at a newspaper trying to deal with the threat of online news. Yet that is the reality we are faced with today.

The theme of the GHX conference is "Shape What Comes Next." Bruce Johnson, the CEO of GHX, challenged us to collaborate towards a new, more effective healthcare supply chain in order to sustain the growing demand for affordable treatment. He cautioned that we should avoid "acting with yesterday's logic."

When I look at my boys adapt so quickly to new technologies and new ways of thinking, I begin to realize that it is much easier to adapt to change when change is all you have ever known. You don't have years of hard won lessons to rewrite.

The future will have many difficult lessons ahead for us. The only certainty is that it will arrive whether we wish for it or not.