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Spread in Health Care

Paul Plsek of Paul E. Plsek & Associates addressed the spread of ideas in health care quality and the barriers to spread. Plsek discussed the following three questions: What do we know about how improvement spreads? Why is spread so problematic in health care compared to other industries? How do we increase the likelihood of something actually spreading? These questions were asked to help give context for the importance of quality improvement research, which will be discussed in the next chapter. To address these questions, Plsek quoted Albert Einstein, stating, “We can’t solve problems by using the same kind of thinking we used when we created them.”

Plsek presented a systems perspective, stating that every system is perfectly designed to achieve the results it yields; to get different results, the system must be changed. The first step to transforming the system, Plsek said, is to be able to clearly see the system. He likened the problem to walking through a forest in circles: Getting out of the forest would be much easier if all the paths could be viewed from above. Previous attempts to spread improvements in health care have not revolutionized the system, perhaps because they have suffered from walking in circles by repeatedly using the same types of interventions. Examples might include repeatedly presenting the results of studies showing the effectiveness of specific treatments, with the hope that key individuals will see the need for change, or always assuming that certain individuals, such as chief medical



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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary 2 Spread in Health Care Paul Plsek of Paul E. Plsek & Associates addressed the spread of ideas in health care quality and the barriers to spread. Plsek discussed the following three questions: What do we know about how improvement spreads? Why is spread so problematic in health care compared to other industries? How do we increase the likelihood of something actually spreading? These questions were asked to help give context for the importance of quality improvement research, which will be discussed in the next chapter. To address these questions, Plsek quoted Albert Einstein, stating, “We can’t solve problems by using the same kind of thinking we used when we created them.” Plsek presented a systems perspective, stating that every system is perfectly designed to achieve the results it yields; to get different results, the system must be changed. The first step to transforming the system, Plsek said, is to be able to clearly see the system. He likened the problem to walking through a forest in circles: Getting out of the forest would be much easier if all the paths could be viewed from above. Previous attempts to spread improvements in health care have not revolutionized the system, perhaps because they have suffered from walking in circles by repeatedly using the same types of interventions. Examples might include repeatedly presenting the results of studies showing the effectiveness of specific treatments, with the hope that key individuals will see the need for change, or always assuming that certain individuals, such as chief medical

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary officers or chief executive officers, are the best ones to lead change. But more profound change is clearly needed. An adequate characterization of the health care system is needed to identify opportunities for improvement. There are three types of systems: simple, complicated, and complex. A simple system follows a standard recipe to yield results. A complicated system involves combining multiple subsystems and can be recreated by following the same procedures (e.g., sending a rocket to the moon). A complex system is made up of multiple subsystems, but each application is unique (e.g., raising a child). Health care is sometimes mischaracterized as a complicated system. In reality, health care is a complex system, and the spread of improvement both inside and outside health care is complex as well, Plsek said. Much is known about complex adaptive systems and spread of innovations within such systems,1 Plsek said, referencing the work of Trish Greenhalgh (Greenhalgh et al., 2004; Plsek and Greenhalgh, 2001) and others. Spread of improvement and innovation within a complex system combines characteristics of the innovation itself, characteristics of the system, characteristics of the people adopting the innovation, and characteristics defining the context of the system. Plsek pointed out that while there are many characteristics of complex systems, three that are particularly important in understanding how improvements spread are the nature of relationships and coordination; attractors, described as the underlying motivating factors for the behaviors we observe in ourselves and others; and the interactions among structures, processes, and patterns. The first characteristic of complex systems is that relationships and coordination are often more important than the parts of a system, Plsek said. Management expert Henry Mintzberg identified six basic mechanisms of coordination in organizations: mutual adjustment, direct supervision, standardization of work processes, standardization of outputs, standardization of skills/professions, and standardization of norms (Mintzberg, 1989). The particular mechanisms driving health care are the standardization of skills/professions, mutual adjustment, and standardization of norms. Professional organizations—the term Mintzberg uses to describe health care, law firms, and other such entities—coordinate naturally through professional standards such as education and regulation, at the heart of which is 1 A complex adaptive system is a collection of individual agents that have the freedom to act in ways that are not always predictable and whose actions are interconnected such that one agent’s actions changes the context for other agents (IOM, 2001).

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary mutual adjustment, Plsek said. Professional organizations also coordinate under the standardization of norms mechanism, so that an understanding of the norm exists (e.g., having a zero infection rate). To achieve the end goals, the people leading change—the change agents—have the choice of either attempting to force organizations to work against their natural coordination mechanisms or reframing the needed change in a way that takes advantage of these natural mechanisms. Second, behavior in complex adaptive systems can largely be explained by attractors. Again, change agents have two choices: attempting to directly confront and change others’ behaviors and motivators, or reframing the needed change in ways that leverage people’s innate reasons for doing what they do. The third characteristic of complex systems is that integrated changes in structures, processes, and patterns are required for sustainable transformation. Structures refer to the physical environment and policies; processes may be guidelines and protocols; and patterns reflect behaviors and the nature of relationships, decision making, conflict, power, and learning. Understanding of all three is necessary for transformation to occur. For example, adoption of electronic medical records would be a structural change, which must be accompanied by processes such as guidelines. However, improvements may not be sustainable if people do not feel included in decision making, or if conflict avoidance behavior occurs when certain powerful individuals refuse to use the system as it was designed. Answering the questions mentioned in the beginning of his talk, Plsek said the spread of improvement is complex. Improvement in health care spreads much slower in comparison to other industries. Perhaps this is because the coordination strategies that work in other industries do not necessarily apply in health care. Finally, with respect to what can be done to enhance the likelihood of spread, Plsek said that spread cannot be forced and that context plays a large role. People conducting interventions need to be more conscious of the interventions so that factors contributing to spread can be identified. Storytelling is as important as evidence-based research findings to improve spread of ideas. People have to be willing to change, and change has to start somewhere in the current culture of the organization (the mechanism of mutual adjustment). People also have to be willing to adapt, while the leadership of an organization must be willing to “muddle through,” which, Plsek said, has been an effective strategy in complex systems.