Meaningful Change

By Gerrit Van Wyk.

The USS Benfold.

When Michael Abrashoff took over as commander of the USS Benfold, it had a reputation as the worst ship in the US navy. Within months he turned it into the most exemplary one by making improvements based on crew suggestions for change, engaging in ongoing listening and conversation to keep the crew informed of what’s happening and why, and getting the crew to cooperate towards goals they believed were important. Quick wins are possible with the right approach.

The default clockwork approach to change in health care is; identify poorly functioning parts that can be improved, copy, or design a formula for changing it, give instructions to people, and wait for the benefit. It doesn’t work other than short-term and never has, because it ignores the social complexity involved. That’s how the Benfold was commanded before Abrashoff took over.

If you take the idea of social complexity seriously, then change comes about based on how well an entity functions. Health care consists of thousands of people interconnected and interacting, with outcomes, good or bad, emerging from the interconnections and interactions, not rules and regulations, usually more or less according to plan, but sometimes surprisingly not. No-one is insignificant; we impact health care through how we interact with others and they on us, we learn from each other and our experiences, and retain a memory of what works and what not, we constantly adapt to each other and ongoing change, and we interact through conversation. If you want to bring about meaningful change in health care, you must therefore pay attention to cooperation, action, adapting, learning, and conversation.

A surgical procedure requires the cooperation of many people. We tend to think of it as a surgical team interacting to produce the outcome, but forget layers of cooperation behind it; housekeeping, scheduling, sourcing medication, technology and technicians maintaining it, pre and postoperative nursing care, and so on. If everyone cooperates well, we have a good outcome, but if someone does not or refuse to, it can turn into the opposite.

No two surgical procedures are ever precisely the same, hence inter-acting means doing the procedure and adapting to keep progressing to the desired end. We don’t start a procedure with a blank slate, we already have an idea what to do based on past learning, but as the procedure proceeds and we adapt in real-time, we change that learning, which influences how we will do things next time. Even if a team knows each other very well, to act and adapt, it must engage in ongoing meaningful conversation.

Changing health care at all levels requires the same principles. We need to identify the right people to engage in conversation in a structured way. Because we deal with a complex problem, we cannot know in advance exactly what the problem looks like and the best way to solve it, we need to listen to many people to build up a picture or story explaining it, which will point to methods that may be useful in solving it.

By engaging different perspectives from doctors, nurses, managers, patients, and more about the problem situation, one of them may emerge as the most promising one to bring about meaningful change, we can then figure out what everyone needs to do to make that possible, determine how we will know it works, trial it in the real world, compare it to our chosen measure, discuss it, if necessary, adjust, trial that, and so on, in an ongoing cycle. It will take time to progress towards the ideal solution, but as Abrashoff showed, immediate progress is possible, which motivates people to cooperate as they begin to understand everyone contribute to the outcome, no matter in what way. You don’t have to be important or super smart to participate, just willing. We learn from acting and adapting, which increases learning, both individually and collectively.

Starting small and growing from there using the right approach can bring about big change to health care, but the key to it is starting, to which there are two major obstacles; we lack visionary leadership, and there are high barriers to overcome.

As a child, Tommy Douglas grew up poor, and when he developed a bone infection, ended up in a hospital for poor children where the standard of care was to amputate the diseased limb. Through sheer luck he was chosen to participate in a study at the hospital for rich children where his leg was saved with more conservative treatment. When he became premier of Saskatchewan, he vowed no poor child will ever lose a limb again because they couldn’t pay, and started transforming health care accordingly. We don’t have politicians cut from that cloth anymore, now it’s about self-promotion and self-interest. To stand any chance of meaningful change, we need someone with the same passion and willingness to go where no-one went before.

There are many barriers. Physicians traditionally resist change; the British Medical Association opposed National Health and doctors went on strike in Saskatchewan when Douglas introduced universal tax-funded care. Bureaucracies by definition resist change, or adapt, and then constrict it with new rules and regulations. Businesses produce drugs and technology on which we depend for profit, not out of altruism, and will lobby against any change not suiting their interests. Health care is politicized and deeply divided today and instead of cooperating on this issue, political parties seek quick solutions making them electable within a 4-year election cycle. The existing health care information technology in Canada is archaic, poorly designed, and not integrated, which is a vital missing cog. Finally, there is much hand-wringing and wailing about health care and its failings which requires deep surgery, but nothing happens by talking and not picking up the scalpel. In short, there are many small jackals which can destroy the vineyard.

Everything cycles back to leadership; who will have the courage to take the first step? And, we shouldn’t have to keep waiting for our politicians to do the right thing, there is no reason the HMS Health Care can’t be turned around from inside the health care professions.

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