Measurable change

“What gets measured, gets done” – Peter Drucker

When one sets out to occupy healthcare, what is the end goal? How will we know we have successfully made a difference in healthcare and created the system we all want and deserve?

As stated on our about page: “It has always been the right time to take on the issue of healthcare, but now we have the tools, the ability to organize and the knowledge to make a difference.” But yet, as we build momentum for our movement, how will we know what success has been and what impact, if any, we have had with our movement.

One thing we all do know – the healthcare system will not easily change.

Systems seek homeostasis and balance. Constantly systems are barraged by actions that perturb the system, threaten homeostasis, and create an imbalance. Homeostasis most often is used to describe biological creatures, yet the message is relevant to policy discussion. A system identifies the threat, the perturbation, and attempts to reset to achieve homeostasis, or a balance. Policy changes constantly in response to internal and external perturbation. The changes are generally modest, tolerable within the operating system and not requiring novel reorganization.

Gregory Bateson suggested that changes that merely reorganize systems without core changes in operation and organization are first order changes. These changes are familiar to healthcare (e.g., covering a new procedure or medication, managed care not requiring preauthorization for a specialty care visit). However there are some shifts that require new rules to govern, that reorder the operation of systems. These are not mere accommodations; these are outside the box, and for Bateson, second order change.

What are second order changes in healthcare?

If occupy healthcare was simply about first order change, measuring success would be easier. Healthcare regularly reorganizes without making substantive changes – it doesn’t exactly require a movement to see these changes.

For example, it is well established that healthcare is costly and in need of new payment mechanisms to support the delivery system. Creating a new way to pay for healthcare is a positive step in the right direction, but how much does it change the delivery of healthcare? One could argue that just changing the payment system is a first order change insofar that is does not go far enough to transform practice. Additionally, if healthcare only focused on changing payment there would be still be a need to change the clinical and operational components of healthcare.

In healthcare we have gotten used to seeing shifting dollars and priorities as well as redistribution and paying more/less for a given service or provider. These first order changes are incremental steps that may never lead us to a bigger change; often, they lead us right back around to the status quo.

Second order change – now that is a more challenging proposition.

Back to the importance of measurement and change.

One of the reasons that first order change in healthcare is so often seen is that is easier to measure than second order change. When you are working within a system that reorganizes without core changes in operation and organization, the measurement of such change is not as  difficult as measuring second order change.

Will occupy healthcare be satisfied with only first order change? No.

Will first order change “create new rules” in healthcare? No.

Will first order change “reorder the operations of systems” in healthcare? No.

Isn’t first order change the “low hanging fruit” of healthcare policy? Isn’t the persistence of first order change part of the reason why we need to occupy healthcare?

As our movement gather steam, what are the second order changes that we want to see? How will we know what they are and how will we measure our impact?

Ideas about this? Join the discussion below in the comments section, in our Google group or on our Facebook page.

I close with another Drucker quote:

“Efficiency is doing things right; effectiveness is doing the right things.”

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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  • Phil Lawson

    Second order change is essential.

    But the sheer complexity of the current ad hock, non-integrated, reactionary healthcare delivery “system” (it has been built piece by piece in reaction to medical advances, economic, business, governmental and social changes and unfortunately, in many cases, personal self-interest) makes it virtually impervious to second order change.

    To make the situation even more challenging is that the momentum of this ad hock system is so great (so many have vested interests in keeping it going as it is) that the implementation of any form of significant change is far more challenging than may be expected at first glance.

    Ad hock reactions to the existing HC “system” will only give us more of the same. We must answer questions such as; What is the whole of health? What would a fully integrated healthcare system look like? How would it act? What are the benefits? How could fully integrated healthcare be made a reality? As well as a few more questions. This is not a little endeavor.

    For those who are serious about seeing second order change happen in healthcare; how do you (as a group) get on the same page about what second order change is and why it is needed?

    And in the happy even that these questions are answered satisfactorily, how do you cut through the complexity of the issue and the prevailing mindset to quickly and effectively communicate the new vision of the whole of health to others, to everyone?

    Second order change will not happen without a new vision of a truly integrated healthcare system.


  • NateOsit

    I think Occupy Healthcare needs the power of Occupy Wall Street to achieve second order change. We need to shift the national conversation, and this is extremely difficult when companies can easily buy the ear of representatives. It’d also help to have a more diverse media, as the way things are set up now the voices of advocates for change get drowned out in the sea of those defending the status quo.

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