Should or must? That was the sticking point. After months of hard work, it had come down to this.
In a sense, these words are synonyms. In reality, they are words, and they are worlds apart.
This discourse occurred within a task force I am working with to clinically transform our medical center—that is, making an institutional commitment to quality improvement (QI), patient safety, and clinical efficiency. The effort, in part, is driven by value-based purchasing, public reporting, payment reform, and the like. But mostly it’s being driven by the fundamental premise of doing right by our patients.
We all agreed that we have to change, that it will be hard and even what types of change are needed. The struggle came down to “should” or “must.”
I’ve used several columns imploring hospitalists to lead the quality evolution. I’ve spent less time explaining how to do this. It’s one thing to say, “Hospitalists are perfectly positioned to fundamentally change the quality, safety, and efficiency of hospital care.” It’s another to fundamentally change the quality, safety, and efficiency of hospital care. So, with the disclaimer that my HM group’s efforts to improve quality have only begun to scratch the surface of success, here are some of the lessons I’ve learned.
Change is very hard for hominids. We favor the devil we know. Therefore, change requires establishing a sense of urgency for the change. Conceptually, QI is enticing—until it gets hard. Then the inevitable changes in workflow start to feel like a lot of work, often without obvious or immediate benefit.
As such, people have to believe there is a problem before they can muster the energy it takes to change. I’d submit to you that the problem with patient safety and quality in healthcare is that most of us don’t think there is a problem.
It takes someone to show us there is a problem before we can change. If you cannot create this sense of urgency for change, you should stop. Don’t continue to try to lead change. You will fail. Guaranteed.
Thus, the most important step in transformation toward quality is convincing people of the need to change. This is hard to do and requires our second step.
Leading The Ship
Leadership. By which I’m not talking about the person in charge, the autocrat, the boss. Leadership is getting people to go somewhere they otherwise wouldn’t have gone. A boss can do this, but most often this is done by the people in the trenches, by front-line people who see a problem and aspire for change, by people like you.
Quality needs leadership; we are its leaders.
A vision is the end game; it’s the finish line, that thing we are all striving for. It’s a big, inspirational, audacious goal that we can all rally behind. It’s things like “zero harm” or “no avoidable errors.”
The vision should not be confused with the plan. Plans are great. But plans that don’t tie back to a vision are destined to fail. Why? Because change is hard, and as soon as a plan (e.g. call PCPs on each discharge, reconcile 24 medications in a demented patient) gets hard, people stop doing it.
Show them, however, how the plan (often something they don’t want to do) ties back to the vision (something they want to do), and people are more likely to follow. I’ll put in the extra effort for medication reconciliation (plan) if I believe there is a problem (sense of urgency) and that this plan helps achieve the vision (no avoidable errors).