“Innovation” is frequently offered as the “way out of the woods” for American healthcare. And why not? As Americans we are reminded of the power of innovation to reshape our world many times a day as we tap on our cell phones to find our way through traffic to a place we have never been, purchase a new pair of shoes from an online retailer, or check out our friends on Facebook as we pass the time in the waiting room of a specialist to whom we have been referred. It’s not just consumer electronics that demonstrates the power of innovation in our world. If you have ever gotten a ride from Uber or booked your weekend lodging through Air B and B, you know that they have transformed the business model and disrupted their industries through innovation. In a negative way international conflicts have been transformed by those willing to move beyond conventional warfare and use terrorism as an “innovation.”
Adam Ward is an engineer who produced innovations for Honda and other corporations before he signed on with Simpler Consulting as their “innovation coach.” I met Adam while I was CEO of Atrius Health when we sought to move beyond just improving our processes to searching for new ways to provide care that would delight both patients and providers. On first encounter I knew that Adam knew a lot of things that I wanted to learn. Over the time I have known Adam he has changed the way I think about innovation. I’ve come to understand that “innovation” does not usually arise from a “light bulb moment” of genius in the mind of someone special like Steve Jobs. Innovation is hard work best accomplished by a team. It arises from a focus more like Malcolm Gladwell’s 10,000 hours of tedium and practice that leads to competence than from innate genius or serendipity.
I was quite honored when Adam contacted me recently and asked if I would read the rough draft of a book that he was writing about innovation. It is very good and now I want to share my impressions with you in anticipation of its publication.
Much has been written about how healthcare is a contrary industry. The “invisible hand” of the market does not seem to be able to find the handle in healthcare that opens the door to lower prices, profitability, and consumer satisfaction. Financial incentives seem to raise costs without improving performance. Despite growing concerns about unsustainable financial burdens and looming workforce shortages that will cost many access to care even as hospitals are shuttered, practices vanish, and many doctors and nurses are driven to early retirement or alternative careers, innovation does not seem to be able to save our day or bring a new day as it has in so many other industries.
Some say that innovation requires substantial resources and a larger enterprise. The rationale that a larger organization will be able to “innovate” has been frequently offered to regulators as justification for mergers that create virtual regional monopolies in healthcare in many markets. I am unaware of any of these promises that have yielded much fruit although I am aware that some large systems like Kaiser, Cleveland Clinics, UPMC, and Geisinger have been more innovative than others.
Almost 500 years ago Niccolo Machiavelli advised in The Prince.
It must be considered that there is nothing more difficult to carry out nor more doubtful of success nor more dangerous to handle than to initiate a new order of things; for the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from the incredulity of mankind who does not truly believe in anything new until they actually have experience of it.
For clarification he said:
Innovation makes enemies of all those who prospered under the old regime, and only lukewarm support is forthcoming from those who would prosper under the new.
Has anything changed over the last five hundred years? Is innovation too expensive for most organizations to attempt or sustain? Is there a shortage of talent or creativity? Is today’s workload too heavy to allow most organizations to look beyond the moment toward a future accessible only through innovation? Does innovation in healthcare fail because leading innovation requires a mindset not found in most healthcare executives? Do the “internal politics” of stressed organization preclude innovation? All these and many other questions come up in Adam Ward’s new book Lean Design in Healthcare – A Journey to Improve Quality and Process of Care.
Do we need a new book on innovation in healthcare? To answer that question I recently employed the innovation that has made going to the library a rare activity for me. I went to Amazon and typed in various configurations of phrases like “Healthcare Innovation.” My “research” produced fifteen books written since 2010. Titles like Innovation and Entrepreneurship in the Healthcare Sector: From Idea to Funding to Launch (2011) and the more recent Managing Innovation in Healthcare (2016) were intriguing, as was Before Disrupting Healthcare: What Innovators Need to Know (2016). Surely it would be a good idea to buy Innovation the Cleveland Clinic Way: Powering Transformation by Putting Ideas to Work. There are many options but none seemed appealing and the books themselves would probably be rather dry and technical and amount to yet another barrier for a busy leader or management team that had come to the conclusion that they must become innovative. It is barriers like that that keep consultants employed. Unfortunately, just hiring any consultant does not guarantee much more success than buying a boring book.
I have always been drawn to stories, and early in my tenure as a CEO I was delighted to discover Patrick Lencioni’s little gem, The Five Dysfunctions of a Team: A Leadership Fable. After reading the “fable” I gave a copy of the book to everyone on my leadership team. Later on I discovered John Kotter and Lorne Whitehead’s little book, Buy-In: Saving Your Good Ideas From Being Shot Down, another “fable” pregnant with great advice. Just last year I wrote the preface to another healthcare fable, The Patient Centered Value System: Transforming Healthcare through Co-Design by Anthony DiGioia, MD and Eve Shapiro. I hope that is enough proof to establish that I really like “how to” books that use narratives to help the reader absorb information that is experiential but is denied to them because they have not “had the experience of…” To my list of favorite books that offer difficult to acquire wisdom and knowledge through “experiential” fables I will now add Lean Design in Healthcare – A Journey to Improve Quality and Process of Care.
The subject of innovation is complex and there is no settled or widely accepted set of practices. As the story implies there are experienced “gurus” or coaches who have received knowledge from other wise ones and often been part of the practiced art in industries that live or die on the ability of teams to constantly develop products that attract and delight customers. Adam Ward has such a background. He worked for many years for Honda and other innovative companies before he brought established industry concepts of innovation, that he personalized and advanced through his own experience, to healthcare.
One of my most positive experiences as a CEO was being a part of the introduction of Lean to Atrius Health. As we got into the work of improving existing systems of care with Lean, it was easy to see that what we were doing was similar to what audio engineers were doing in the dying days of analog recording. You could wrestle incremental improvements from the old way of doing things, but what was really needed were innovations that enabled more portable and widely available devices for both recording and enjoying music. Once the shift was underway it did not take long for my old turntable to be moved to the attic. Our early work with Lean led me and others in our practice to realize that “running faster and more efficiently” was a move in the right direction, but it was time to begin to think about a whole new ballgame. Healthcare transformation meant redesign with bold objectives as the goal. Near the end of the book there is a conversation between two of the characters that captures part of the concern that made the need to develop our own innovative skills seem so important to me:
“Patients don’t always want the next available appointment, they want the appointment when it works best for them.”
“Our doctors’ panels average 2,000 patients. We are pushing them to increase that number to 5,000 with our goal set at 10,000. There won’t be enough physicians in the future to keep panel sizes low,” Georgina explained.
“Even now, giving the patient the time most convenient for them is difficult. When we double or triple the number of patients for each doc, we have to focus on who sees the actual doc and who doesn’t need to,” Hoggs added.
The story demonstrates how vulnerable the idea of setting up a systematic approach to innovation will be to potential failure. It is not an overnight process and in organizations that are dominated by “operations” with leaders desperate to have results that are obvious within the next quarter there is little chance for success. It would be nice to think that good leadership would guarantee success, but that is not the story that is told. There are many subplots of misunderstanding, resistance from senior executives with alternative strategies. It is hard work to build an innovation team in an environment where there volatility, uncertainty, complexity, and ambiguity when an industry under attack for its failure to produce a sustainably affordable service for everyone. There were moments in the story when the lines of Rudyard Kipling’s famous poem “If” seemed to be playing in the background:
If you can keep your head when all about you
Are losing theirs and blaming it on you…
Not to be a spoiler, but at the end of the fable there is still uncertainty. It is a real story. What is accomplished is that a team has been created. The innovation team, the CEO, and probably most of the surviving management team has learned that innovation is the product of intense curiosity that requires thousands of hours of inquiry and research with potential customers. Innovation is not a solo act. Its success is grounded in the patience required to try and try again. They have learned that a guide that can coach, mentor, and encourage them to be patient and trust one another is an essential catalyst. If the team stays together, and if ripples of understanding of the process can begin to create understanding in the larger organization while expectations of miracles are managed along with those who would go another way that offers an easier path that is a blind alley, then there is hope.
It will be several months before you can read the story. I have only skimmed the surface. For those who want a more explicit debate of various concepts of the management of the process of innovation, do not despair because those ideas are all woven into the plot. My suggestion is that the place to start is with an internal assessment of your organization’s readiness to entertain change. If you are trying to survive by cutting programs and cranking up individual productivity without attention to the welfare of your employees and to the service you provide to your customers, then you are among the walking dead. If you realize that you can’t cut your way to lasting success but need to manage for efficiency and improvement, you are taking the first step toward thriving through innovation.
