ORLANDO — Health care providers are facing a moment of transformational change. But how can leaders motivate their institutions to go forward?
That's the central question Dan Heath, a senior fellow at Duke University's CASE center and the co-author of Switch: How to Change Things When Change is Hard, took on at the Institute for Healthcare Improvement's National Forum Wednesday, as he urged attendees to rethink their approach to change in both their institutions and the overall health care system.
"Sometimes when I overhear health care discussions, it sounds like people believe that you can align the incentives and everything magically changes," Heath said. "We believe we're one ingenious bribe away from revolutionizing health care."
Instead, Heath urged providers to both closely examine the structural and emotional barriers to transformation while searching for positive examples of change already present in their hospitals.
For instance, Heath described an effort at Kaiser Permanente Southern California to reduce opioid use. According to the Centers for Disease Control and Prevention, more people die each year from opioid abuse than from heroin and cocaine combined. Kaiser Permanente was not immune; an analysis found that many patients were getting multiple prescriptions from multiple providers, amassing large quantities of drugs like Oxycontin.
One Kaiser facility, though, had a rate of Oxycontin prescriptions a 10th that of the medical center with the highest rate. The secret? Pain management review teams that promoted the idea of nonmedication-based solutions, headed by a physician who put his cell phone number in the electronic health record as a contact point any time anyone had a concern about a prescription.
"They exported that idea to other medical centers," Heath said, along with a pledge to get physicians to self-restrict their ability to prescribe opioids. Two years later, Oxycontin prescriptions were down 70 percent throughout the system.
The lesson? While leaders are often preoccupied with solving problems and replicating best practices from elsewhere, they shouldn't be afraid to look for the bright spots in their own institutions.
"When we come to conferences like this, it's a wonderland of best practices. Let's not forget best practices are not the only way to make ourselves better," Heath said. "We can get better by being more like ourselves at our own best moments."
It's also important to consider the structural barriers to change, Heath said. Heath recalled a conversation with a nurse at Brigham and Women's Health Center in Boston, who told him that over time, clinicians were ignoring signs in patient rooms warning of fall risks. "She said that in acute care hospitals, 80 percent of patients are at high risk for falls, so the signs fade out of consciousness," Heath said.
However, the nursing team realized it had enough information on each patient — from whether they had ambulatory aids to how they toileted — to tailor the signs specifically to their needs. The newer, more specific signs led to a reduction in falls of 25 percent, Heath said.
"If you invest a little time in the environment, you can get better outcomes," Heath said. And while Heath is skeptical of realigning incentives as the key driver of change in health care — "it represents a deeply impoverished view of human motivation," he said — he believes that appeals to more emotional forms of motivation can have a lasting impact. For instance, he noted, when former IHI CEO Donald Berwick, M.D., launched the 100,000 Lives campaign eight years ago, "he did not offer you an incentive and you didn't ask for one. He said, 'If we make this journey together, we will celebrate together.'"
In my final blog from IHI's 24th National Forum tomorrow, I'll recap Berwick's address scheduled for later today.