The line between radicalism and realism in healthcare

Is it possible to be too radical in one’s thinking when it comes to changing healthcare? I guess with most things there is likely a fine line. Let’s dissect our words for a second:

rad·i·cal

adj \ˈra-di-kəl\

3a : very different from the usual or traditional : extreme b : favoring extreme changes in existing views, habits, conditions, or institutions c : associated with political views, practices, and policies of extreme change d : advocating extreme measures to retain or restore a political state of affairs <the radical right>

re·al·ism

noun \ˈrē-ə-ˌli-zəm\

1: concern for fact or reality and rejection of the impractical and visionary

Breaking from the usual tradition in healthcare is not a rare thing. In fact, we see this happening more and more in our communities.

In an excellent series on innovation in healthcare, the Harvard Business Review wrote a story on “Radically rethinking healthcare delivery”. An excerpt from that piece really spoke to why radical thinking in redesigning healthcare was appropriate:

“What we describe as a “health care system” is no system at all. It’s a collection of fragmented, non-communicating parts, implicitly dangerous in design. During an average four day hospital stay, a patient sees 24 different clinicians and administrators; when a physician places an order for medications in a hospital, there are seventeen steps between when that order is given and when the medication reaches the patient’s bedside – all opportunities for error. And this complexity happens within a single health care delivery organization. When multiple physicians, clinics, hospitals – and insurance companies – are involved in the care of a patient, the complexity can be overwhelming, both for the patient and clinicians.”

 

Everywhere we look in healthcare there seems to be opportunities for radical change. When electronic medical records rolled on to the scene, they were viewed as disruptive and radical. Now look at where we are with the adoption of these tools. One needs to look no further than the wonderful website and resource put out by AHRQ on innovations in healthcare. But the question remains – are these ideas radical?

For a moment let’s compare healthcare and radicalism to a biological system.

Biological systems function smoothly in homeostasis – they are self regulating and static. Frequently something perturbs that biological system, throws it out of homeostasis, and creates an imbalance. While homeostasis most often is used to describe biological creatures, the message is applicable to healthcare.

When someone in the healthcare system identifies a threat, a perturbation, and attempts to reset to achieve homeostasis, or a balance (read status quo), they “fight” the change. Active perturbation is not comfortable if you are the person being disrupted. Radicalism in healthcare often is disruptive.

Now consider making a change in healthcare on level with a perturbation that is so strong it forces change. Is it possible to have this change be so significant that in essence it creates a new balance, a new baseline for homeostasis?

“Supposedly, everyone working in health care wants the same thing: to help people get and stay healthy. “Everyone” includes primary care doctors, medical specialists, nurses, hospital administrators, health insurance providers, nutritionists, pharmaceutical companies, medical technology manufacturers, fitness gurus, paraprofessionals, public health commissioners, and charities dedicated to a disease The problem is that everyone can have a different view of the meaning of getting and staying healthy. Lack of consensus among players in a complex system is one of the biggest barriers to innovation. One subgroup’s innovation is another subgroup’s loss of control.”

The above quote is another piece from the Harvard Business Review and really hits the nail on the head for radical change in healthcare – for healthcare to change, one “subgroup” will need to lose control. Not everyone can be a winner when you are redesigning a system like healthcare, someone is bound to lose. The problem now, with the current system, is that it is often the community that loses.

Isn’t it time we start to think slightly more radical in how we can redesign healthcare? Do we want to incrementally play it safe through a piecemeal approach to redesign? Are we bound by realism and therefore unable to be radical? Where is the line?

After all, the IOM said it best: “the healthcare system is incapable of meeting the present, let alone future needs of the American public”

What do we really have to lose through being radical that we haven’t already lost?

Community empowerment

Last week, there was post on this website discussing how to create a community contagion.

The point of the contagion post was to think through ways the community can begin to work together and spread their message. While this remains thechallenge, let’s take this a step further. Let’s begin to consider the role of engaging the community and community empowerment.

According to the World Health Organization (WHO):

“Community empowerment refers to the process of enabling communities to increase control over their lives. “Communities” are groups of people that may or may not be spatially connected, but who share common interests, concerns or identities. These communities could be local, national or international, with specific or broad interests. ‘Empowerment’ refers to the process by which people gain control over the factors and decisions that shape their lives. It is the process by which they increase their assets and attributes and build capacities to gain access, partners, networks and/or a voice, in order to gain control.”

How often is the community empowered in healthcare? How often is the community voice heard?

While there are ample studies on community empowerment (e.g. May, 1995, Eng, 1992, Rose, 2002), how often do we hear of the community stepping up to do demand more from healthcare?

Could it be that the community, as the WHO defines it, does not have a common “interest, concern or identity” as it relates to healthcare? Surely there are some communities that have made healthcare their mission to change. It is hard to imagine that after hearing stories of healthcare failing communities that more is not done. Just pick a story. Any story.

Is it that “we” have failed to actively engage the community in changing healthcare?

Rather than describe here examples of community empowerment for healthcare, let me pose the question – what have you seen? What are examples from your community where the community, feeling empowered, have demanded change in healthcare?

Where is the wildfire?

One of the amazing aspects to the occupy Wall Street movement is the spread. The movement has gone from a few on Wall Street to thousands in other cities nationally. As of yesterday, the Occupy Wall Street movement is in 25 cities. A gentleman on NPR recently described the movement like “wildfire”. Granted, there are just as many reasons why a movement like this can gain traction and momentum as there are reasons why movements like this lose traction.

Phil Baumann, in a recent piece on the Unthinkery site, said the following:

“We must understand – at least metaphorically – the half-lives of revolutions. The better we understand them, the better equipped we shall be in their formation, direction and sustenance. The questions are: Where is it coming from?; What’s its energy?; Whereto does it hither?; and What will be the sources of its nourishment? Most importantly: how do we prevent the fate of many revolutions – the all too often disaster of one tyranny replaced by an even more harrowing dystopia?”

Phil is spot on with this one. How well do we, the community, understand what is happening in healthcare?

Community can be defined in so many different ways that for simplicities sake I find it easiest for my work to place community into the following categories: Patient, provider, payer and policy maker. (And yes, I do recognize that it is entirely possible to be more than one of these “categories.”)

It is often said that knowledge alone is not indicative of change. No matter who you are introducing knowledge to, there still must be an attitudinal shift and subsequent behavior change for that knowledge to have had an impact.

Some have written extensively of the role of emotion in change. Without going into all the psychological literature here, let me direct you to a very nicely written Fast Company piece from this past January.

“Knowledge is rarely enough to spark change. People have to want change. Say it’s your job to lure companies to set up shop in Detroit.”

Bringing this full circle, will any attempts to change healthcare fall short as the larger community does not want change?  Does the larger community understand what is happening in healthcare, or are we going to continue to ““periodically kick the responsibility for healthcare down the road”? (quote attributed to TR Reid – posted on this site by Dr. Frank Reed)

If we are to sustain revolution and work towards substantive change, we must believe it is important. Phil is right, too many movements lose steam and putter out. So how do we make healthcare more important to the community to want to change?

If we fall back on the health behavior change literature, we know that:

“Studies have also shown that [health behavior] goals are easier to reach if they’re specific (“I’ll walk 20 minutes a day,” rather than “I’ll get more exercise”) and not too numerous (having too many goals limits the amount of attention and willpower you can devote to reaching any single goal). Another recurring theme is that it’s not enough to have a goal: You also need practical ways to reach it. For example, if your goal is to stick to a low-calorie diet, have a plan in place for quelling hunger pangs (for example, keep a bottle of water or cup of tea nearby, or chew sugarless gum).”

Changing healthcare must start with specific changes. What is the “biggest bang for the buck” that we can get?

Changing healthcare must be important to those making the change – this includes each member of the “community”. They all have to want it.

We all have to want it.

Maybe once we have collectively recognized the importance of changing healthcare we will change it.

…and the change will be like wildfire.

Creating a community contagion

How can the healthcare community be best positioned to create a contagion of change?

According to Merriam-Webster dictionary definition #3:

con·ta·gion

a : rapid communication of an influence (as a doctrine or emotional state)

Is it possible to create a contagion or momentum with no one street corner to stand side by side with like minded individuals? How can communication of influence be started when healthcare also is so broad and diffuse?

This is the challenge that many are taking on.

Take for example Regina Holliday.

Regina’s walking gallery highlights getting out in front of people and the importance of the patient in healthcare. If you have been at a conference and seen someone walking around in a jacket with a beautiful painting on the back, you are likely witnessing the walking gallery in action. You can see here an example of Regina’s beautiful work.

I would encourage each of you to read Regina’s wonderful explanation of  this jacket.

Regina has taken her message to the streets and not only let her voice be heard, but also let her message be seen. This is an excellent example of creating a contagion. Consider this:

Regina paints a jacket for someone who attends a healthcare conference. At that conference someone asks the person wearing the jacket about what it means. The person wearing the jacket explains. The message has been transferred to a new person. This goes on and on and on. A contagion.

People long to be connected, and often align their work to learn from others doing similar work. “Learning communities” are in abundance, and at the heart of these groups are a sense of community, learning and ongoing support. Often learning communities are created to allow for some group (e.g. healthcare providers) to come together and exchange stories on what is working and not working – they teach each other how to be successful and share resources). Ideally lessons learned in these communities can expand outside of the group and impact the larger community these individuals are trying to serve.

What happens when you take a novel dissemination strategy, such as what Regina has done, and combine it with a larger national community that aims to “occupy healthcare”?

Let’s consider for a second the story of Dorothea Dix.

While Dorothea’s history is important in understanding why she began to do what she did, I am going to fast forward ever so briefly.

Dorothea’s second career began when she was thirty-nine years old. In March of 1841 she entered the East Cambridge Jail. She had volunteered to teach a Sunday School class for women inmates. Upon entering the jail she witnessed such horrible images that her life, from that point on, was changed forever.”

Dorothea recognized that there was a problem. The problem that she witnessed was so “horrible” that it literally changed her life. In her community she set out to be a contagion. She set out to express her outrage and concern. She set out recognizing the problem, but also a proposed solution.

From Wikipedia:

“Dix conducted a statewide investigation of how her home state of Massachusetts cared for the insane poor. In most cases, towns contracted with local individuals to care for people with mental disorders who could not care for themselves, and who lacked family and friends to provide for them. Unregulated and underfunded, this system produced widespread abuse. After her survey, Dix published the results in a fiery report, a Memorial, to the state legislature. ‘I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.The outcome of her lobbying was a bill to expand the state’s mental hospital in Worcester.”

What is not explicitly stated here is that Dorothea, as woman, was not allowed in the state house. Rather than decide to take this on as another cause, she stood on the steps of the courthouse and engaged any and all legislators that walked by on their way in and out of work. Dorothea was informed, educated on the problem and offered solutions for change. She became a community contagion.

We all have seen the problems in healthcare. If you want outrage, read Jonathan Cohn’s brilliant book SICK: The untold story of America’s healthcare crises – and the people who pay the price (who also mentions Dorothea). But the question now becomes, what do we do with this knowledge?

Maybe the first step is to become a contagion in our own community. Could this be the first step to occupy healthcare?