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Is Incremental Change Enough?

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Nothing has changed; but in health care, everything has changed. -- Former Senate Majority Leader William Frist, MD

Though he did not attend the Institute for Healthcare Improvement’s (IHI’s) National Forum last week in Orlando, Senator Frist’s words served as its chorus. Frist’s observation came during a meeting hosted by IHI in Washington, DC, two days after the national election in November. The meeting, titled “Out of the Blocks,” was scheduled to assess the effect of the election—however it turned out—on the Affordable Care Act and, therefore, also on the U.S. healthcare industry.

I was not at the meeting in Washington, which drew more than 100 people, but I did attend the National Forum, where the discussion of change continued among a much larger audience, where Frist’s comment was often repeated. While it’s easy to argue that the U.S. healthcare industry would face significant changes in the short term regardless of election results, much of the IHI community experienced the results as a sudden shove out of the starting gate on a race to capture and control excessive medical spending.

In her Tuesday morning keynote address, IHI’s President and CEO Maureen Bisognano acknowledged that recognition of financial constraints must now be part of all improvement efforts. As she laid out a 5-point checklist designed to accelerate the spread of innovations that have been shown to improve quality, she called for every project to include an estimate of the cost of implementation. In remarks to the press later that day, Bisognano said, “[I’ve] heard more in the last several weeks about having to control costs than I’ve heard in the past 20 years.” While she expressed confidence that IHI has learned through its efforts across the world how to improve the safety, effectiveness, and efficiency of healthcare, there was new urgency in her remarks about accelerating the rate of “spread”—implementing best practices and proven innovations widely and quickly—beyond incremental improvement.

The question “Is incremental change enough?” was a recurring theme in the sessions I attended at the National Forum. During a half-day Picker Institute Special Session on patient-centered care, former IHI president and CEO and CMS administrator Don Berwick, MD, asked a panel of experts to discuss how to make profound changes that have eluded most organizations. In the context of patient-centered care, Berwick commented,

We’re there in terms of resources; we have the scholarship, the examples, the accountabilities, the metrics, we may have the business case… but assembly is not the same [as making profound change].

During the discussion, Berwick nudged the panelists to aspire to more than incremental improvements in patient-centered care. He asked them whether or not the practice of patient-centered care is “deep and authentic.” The consensus was that, despite some improvement, we’re “not there yet.” Berwick wondered how to “flip the switch” and transform—not just improve—the patient’s experience, which led to discussion of the role of leaders, board members, education, and payment reform. At the end of the session, he asked the panelists,

If you were czar or king… and could make one change that would allow us to get together in a year or two and say, “Wow, we’ve really got this one going,” what would it be?

The answers included establishing a national institute of patient engagement, closing poor-quality hospitals, imposing financial sanctions on hospitals, “democratizing” our knowledge of medicine through a Home Depot of health, and mobilizing a national march on Washington. It was clear we don’t yet have a clear answer to Berwick’s question; it is difficult even to have the discussion. With his experience and skill, Berwick was able to mid-wife a conversation that was more creative and revealing than most.

On Wednesday, the discussion that had started in November at “Out of the Blocks” resumed in an hour-long session open to all at the National Forum. Earlier that day, IHI published an action plan for healthcare leaders, based on the November meeting. During the National Forum session, it was clear that creating a frank and open discussion about how to reduce spending in healthcare is hard work. A number of people expressed frustration with the lack of an easy answer as they looked to IHI, in particular, for direction.

We need a path. It’s not enough to say that we’re going to decrease costs. We need a simple path to move forward. Maybe we need a bundle or an IHI healthcare reform campaign that’s going to simplify the path. We’re not going to get there until we make it reasonable for everyone to understand.

Another pleaded for IHI or perhaps another organization to point the way:

I expected to find the path here, at this session, and instead I heard that change is coming… If not here at IHI, is there another conference I should have gone to [find the answer]?

Barbara Balik and Gail Nielsen—both are healthcare professionals, patient advocates, and IHI senior faculty members—pointed out that patients and family members must be included in analyzing the challenge, designing solutions, and participating in new models of care delivery. Balik reminded the group that healthcare is responsible in part for financial problems caused by “over-designed” care delivery and that the larger community of stakeholders must be involved in designing the solution. Nielsen pointed out that healthcare professionals too often assume what patients need and want. Often, when included as true partners in decision-making, patients choose simpler, less expensive solutions.

IHI co-founder and Senior Fellow and Dartmouth medical school Professor Paul Batalden observed that in the context of this discussion,

The word professional doesn't seem to mean ‘master of value-adding care,’ and the system isn’t really inclusive of those who benefit. So we focus on “patient-centeredness” when actually we might focus on co-production and get rid of this language, “patient centric.” There’s a deep professional bias in the use of that term.

Batalden’s observations about terminology remind me that many people wish there were a good alternative to the label “patient,” and now we’ll be looking for a term to replace “patient-centered,” too. Something important is happening when commonly used words seem out of date, no longer quite right. Batalden’s comments were one more indication that incremental change may not suffice.

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