Sunday, December 02, 2012

What could he do?

I was talking recently with one of the world's experts on patient quality and safety--you would recognize his name--about another world expert, who has written widely and elegantly on the topic--you would also recognize his name.  I said, "Isn't it ironic and a shame that the author's own hospital has failed to adopt many of the practices he so eloquently sets forth?"  The response, "Well, what can you expect him to do?"

I think he was suggesting that it is very hard for a doctor (particularly a junior faculty member) to make waves in his own academic medical center when the senior administrative and clinical leaders have chosen not to make patient quality and safety a strategic priority and when they have not endorsed the importance of clinical outcome and cost transparency in support of process improvement.

W. Edwards Deming said of process improvement:  "Long-term commitment to new learning and new philosophy is required of any management that seeks transformation. The timid and the fainthearted, and the people that expect quick results, are doomed to disappointment."

Our writer is not the only person facing this issue.  Of all the questions I receive around the world after talking with doctors, nurses, respiratory therapists, and others, the one most often heard is, "I believe in what you are saying: How do I get my CEO (or chief of service, or division head) to buy into this and let us move forward?"

I am told that Deming's answer to this question was that you should quit and find a new job if the organization was not committed to the kind of learning environment he described.  While that might be good advice for some, others have constraints that make this remedy unsuitable.  So, what could you do?

Our patient safety author is devoting his efforts to systematically analyzing process improvement approaches, reporting on his experiments at other hospitals, and proselytizing through his writings.  There is certainly something to be said for that.  The bully-pulpit, after all, is powerful.

But it is only a matter of time before credibility is weakened by a lack of performance of the host institution.  After all, if you can't walk the walk, you won't long be able to talk the talk.  And, indeed, such observations among clinical leaders are already being made.  Simply put, people have seen that leadership in implementation of quality and safety improvements is regularly and modestly occurring elsewhere.  Many of the world-renowned academic medical centers are being left in the dust.  Nonetheless, they persist in arrogantly believing that they are "the best in the world" and even "God-given gifts to society."  (Yes, those are the actual terms used.)

My advice to those nurses and doctors who want to make progress in their hospitals is to find like-minded people on their floor, their unit, or other departments and slowly and quietly conduct some experiments in redesigning work.  Don't look for large global changes.  Just find some small area where an obstacle has arisen and, instead of inventing a work-around, try to do a root cause analysis of the problem and design an possible solution.

Deming called this "Plan-Do-Check-Act."  The idea is that a multitude of incremental improvements is a more effective way to enhance the work environment and give better service to the customer.  You make one small set of changes to go from the "current state" to the "future state."  Then, the future state becomes the new current state, and you move on from there.

While administrative and clinical leadership is essential to nurture and support these measures, sometimes--just sometimes--a clever administrator or chief of service will notice that his or her staff has quietly and effectively been producing measurable improvements in quality, safety, and efficiency.  It may actually be possible to "manage up" and teach that person what you and your colleagues need to do the job right and to become a learning organization.

It is worth a try, whether you are a world famous author or a junior nurse or intern on the night shift.  If you don't think it is possible where you work, you really should do what you can to find a place where your skills and abilities and commitment are better put to use.

Margaret Mead reportedly said, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

Arlo Guthrie put it in different terms (in a very different context):

You know, if one person, just one person does it they may think he's really sick. And if two people, two people do it, they won't take either of them. And three people do it, three, can you imagine, they may think it's an organization. And can you, can you imagine fifty people a day. And friends they may thinks it's a movement.


e-Patient Dave said...

As someone who REALLY wants to create change, I react to this voraciously. Much to think about.

Among other things it seems to reinforce that the institutions themselves perpetuate harm and are structured to be unlikely to shift.

As you know, my own isolated contribution is to awaken consumers to the reality of variation and the usefulness of educating ourselves. That's one aspect of the grass roots approach.

Whatever lies ahead for change, I really really want the best providers to be rewarded for doing a good job. That applies to clinical excellence and to the issues raised in The Waiting Room, which you wrote about above. It's why I wrote this in the new SGIM newsletter, ending with:

"I want every one of my providers to do well during the change. They’re capable, and they’re patient centered. And I believe that compared to our norm, they provide better care, at lower cost. I want them rewarded."

John Hunter said...

I agree, the way to change people's minds is to make the improvements you can and then build from there. I have written about this on my blog: