Dec 232013

Why Change is Hard

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There are few universal constants in life (aside from death and taxes), but one pervasive truth exists: change is hard. There are many reasons for this; inertia, taking comfort from familiar routines, and a misdirected desire to function at peak efficiency are just some of the reasons that people resist change. In the end, we are all creatures of habit.

In the world of healthcare, change is doubly hard because of several complicating dynamics. Firstly, healthcare systems are complex. Healthcare, by its very nature, is a team sport, and identifying who is “in charge” is challenging. As a result, decision making is diffused across multiple stakeholders, each with their own interests and objectives. While the overarching long-term objectives are usually aligned (e.g. delivering high quality care), the more immediate and tactical objectives are often at odds (e.g. providing the best care versus reducing the drug budget). Since incentives are not aligned with singular objectives, the outcomes are usually sub-optimal.

Secondly, clinicians are generally risk averse. There are few scenarios more worrisome to a clinician than the thought that they caused a patient harm through their actions. The very notion of doing no harm is enshrined in the Hippocratic Oath, the traditional oath sworn as a rite of passage for many clinicians. It is woven into the fabric that makes up the industry’s ethical doctrine. As a result, change is often viewed through the lens of downside risk rather than upside potential.

When one considers that many health interventions, such as surgery, carry with them considerable life-threatening risks, it is entirely understandable why clinicians want to mitigate all other avoidable risks. The consequence is a tendency to hold on dearly to the status quo and to require overwhelming evidence in support of a change – typically far more evidence than was ever provided to justify the status quo! After all, the devil you know is almost always better than the devil you don’t.

Thirdly, change is typically nobody’s job, although everybody does it. Change management as a discipline is fairly new in the business world, with only about four or five decades of experience applying rigour to the concepts of spreading innovation. Compared to accounting, which can be traced back before ancient Babylon, change management is in its infancy. In healthcare, it is even more immature, with few certified change management experts available to facilitate successful change projects. Naturally, healthcare workers carry with them numerous scars of past projects that have gone poorly, or implementations imposed upon them with insufficient attention paid to change management. The resulting reluctance in the face of change is virtually unavoidable. Poor recognition of the value of disciplined change management strategies can manifest in seemingly cavalier attitudes towards operational impacts, which can further distance workers.

Finally, there is generally poor information flow in healthcare, as compared to other industries. The reasons are diverse:

  • concerns for privacy and legislation designed to protect patient privacy often limits the ability to share data beyond the scope of direct care delivery;
  • antiquated information systems that are  integrated poorly, if at all, limit the completeness of available data;
  • capital budgets that are dependent upon the ebbs and flows of provincial tax revenue make long-term infrastructure planning incredibly challenging, often resulting in “feast or famine” procurement and IT investment;
  • the traditional focus of health documentation is tied to medical and legal liability rather than to planning and process improvement, which slants data capture more to the narrative than to discrete data elements capable of being easily analyzed; and
  • the preponderance of paper-based data capture makes extracting useful information exceedingly difficult.

The irony in all of this is that evidence-based medicine is a paramount priority across the health system. Patient advocates, policy makers, clinicians and administrators widely acknowledge that evidence-based medicine is beneficial and necessary to building and maintaining a sustainable health system, and yet access to evidence is a huge barrier, despite terrabytes of health information being stored in various information silos.

What we have failed to accomplish in healthcare is a seamless method to liberate data for planning and decision making in a way that properly protects patient privacy. Despite the fact that the technology exists to encrypt and protect data from malicious access, and that there are massive payoffs to be reaped in terms of improved efficiencies and patient outcomes, there is still no easy way to “mine” health information for the nuggets of gold that can revolutionize health care delivery. In fact, the very notion of mining health data raises immediate privacy alarms and triggers enhanced scrutiny to the point of discouragement.

The areas in which we have been most successful in Alberta, at least in bone and joint health, have often come through partnerships with trusted third parties to bring the pieces together. Whether it’s through independent organizations like the Alberta Bone and Joint Health Institute, academic institutions like the Universities of Calgary and Alberta, or hybrid operational and research groups such as APPROACH, their independence facilitates the process of assembling meaningful and actionable data because it can (and, in fact, must) be done collaboratively. After all, they have  no authority to reward or penalize players, and therefore must function as support groups.

By working collaboratively with little authority, change management becomes a paramount concern, because the initiatives live or die only through the engagement of front-line caregivers. If the data capture is too onerous, or the outputs not valuable, compliance and participation will whither.

What does this all mean looking forward? Over the past two years, Alberta Health Services (AHS) has demonstrated a clear commitment to the newly-formed Strategic Clinical Networks (SCNs). This has manifested through personnel being allocated to SCN initiatives, SCN priorities trumping other groups, and support for  collaborative SCN research projects, such as Partnership for Research and Innovation in Health Systems (PRIHS).

By their very nature and reach beyond the traditional AHS borders, SCNs require a collaborative approach unlike anything AHS has done in the past. This is both good and bad: good because change management will be a do-or-die component of every initiative, and bad because it is breaking new ground that will inevitably result in some growing pains. At this early stage, I am enthusiastically awaiting their full potential.

Stay tuned.

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