Thursday, April 17, 2008

Batalden updates Machiavelli

"There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it."

This famous quote by Machiavelli is both a hearty warning and a healthy piece of advice to those who seek to change a political or social system. If those in today's health care system were looking for the equivalent piece of warning and advice, they might just have obtained it from Paul Batalden, Professor and Director of the Center for Leadership and Improvement at the Dartmouth Institute for Health Policy and Clinical Practice. He presented it to a small group of us today, in a talk entitled "The challenge of leading the leading of the improvement of health care". I present it with his permission. I think he has nailed the issue and admire his ability to do it so succinctly.

The key slide had the following heading:

“Anchors” of a synergistic culture holding the present in place…

And the following four major observations about why change is so hard to achieve:

Lack agreement about what the common and individual work is (at the behavioral level) that will be necessary to create anything different than the present reality;

We seek and find reinforcement for our self-interests, beliefs in the current payment methods and systems of health care;


Desire to focus on “islands of excellence” (and we love to give “Island Tours”) rather than create and maintain uniformly safe, high quality, good value, reliable and accessible operations; and


A well-developed capacity to rationalize away the newsworthiness of potentially disconfirming data (financial, quality, safety) and external assessments by patients, payers, etc.

4 comments:

Sandhya said...

Really there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.

Anonymous said...

There are uncountable examples of cultural change where painful demands for adaptation broke the functioning of the system (e.g. colonization). This happens when the rewards of adaptation cannot be realized (e.g. decreased rather than increased access to resources), and the interactions that humans lived by fail.

But the rewards of this change to individuals and organizations are substantial, and attractive. Have the risks to slow adaptors really shifted? Can they do business as usual?

WongML said...

"Every system is perfectly designed to get the results it gets." -PB

Donald E. L. Johnson said...

In health care, there are two kinds of change:

1. Internal cultural and procedural changes initiated by executives or employees. Very difficult because, why do it? These changes often require intense CEO commitment and leadership.

2. External change, such as the da Vinci, CT, MRI, DRGs, HMOs, EEOC and other technological, market and regulatory forces. Easier. The superior outside authority says do it or lose business or do it or go to jail. CEOs can be less involved, if they are involved at all, I'm thinking.

I'm bemused by the call for "change" in the presidential campaign. Rostenkowski, Waxman, et al, found out what "change" meant to Medicare beneficiaries back in the late 1980s. It wasn't pretty.

Great blog. I've blogrolled you.