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Centering on...Innovation and Growth

There is a punch line from an old joke, which is told in various ways but always involves a city slicker lost in some rural patch who asks a local farmer how to get back to the city. The farmer, who doesn't actually know how, tries to answer but finally gives up, informing the stranger that "you can't get there from here."

No better words could be uttered about America's health care system. We know what kind of system we want - one that cares for everyone and does so in a manner that promotes high quality outcomes, uses resources efficiently, and costs approximately what other nations pay for health care systems with comparable quality and scope of coverage. But from where we are today, reaching this noble goal is a daunting task. As a nation, we spend $2 trillion annually on health care, fail to cover 45 million Americans, and watch fearfully as admission to the hospital becomes one of the leading causes of death. Our goal is uplifting but it seems impossible to reach from where we sit today.

Observing this state of affairs, part of us sometimes longs for a sweeping revolution throughout our entire health care system. One of the best student papers I ever received introduced a proposed reform of the health care system by invoking a 9.7 Richter scale earthquake. The writer saw destroying the current system as the only way to initiate health care reform in America. I think she was incorrect, but how can we bring innovation and creativity to bear on the development of strategies for reforming health care in an incremental manner? The question sounds like an oxymoron.

Over the past three decades, most of The Center for the Health Profession's work has been in health care and education, with a focus on understanding what reforms are needed in our health care system and developing leadership which could successfully enact these reforms. Over that time, the Center participated in the making of broad proposals for changing the entire system as well as focused strategies for change within individual teams. The circumstances and scale of these proposed reforms varied greatly, as did their locations, from schools, to hospitals, to clinics, and health plans. Yet each involved the development of an innovative idea or a creative new approach. While these ideas and approaches differed, they also shared a few key elements.

Successful innovations have a clear purpose or aim. True innovations are not about doing things differently for the sake of the new. They are about achieving a specific aim because it will better serve students or patients. The more focused the aim the more likely that the innovation will actually come to fruition. In health care, we often speak about patient centered care or the needs of students, but how often are our efforts at change really intended to alter the fundamentals of what we do, rather than changing the appearance of what we do while actually sustaining the status quo? Much of health care, both health professions education and delivery of care, exists in a protected zone that is not subject to the discipline of the markets or public accountabilities that impact our other major economic institutions. For creativity to work it must be guided by strong and talented leadership.

Such leadership works toward truly creative solutions when the motivators for change create a real sense of urgency. Humans are motivated to change because of both fear and lust, but change is likely to occur at a deeper level and last longer when it is motivated by survival needs, or fear, and opposed to a desire to change for the better, or lust. This is because the commitment to the status quo is strong; the dysfunctional aspects of our health care system still provide jobs and well being for the incumbents in the system. To reach the level of motivation necessary to adequately push on the status quo requires the recognition that current practices no longer meet the needs of those that we intend to serve.

While fear is needed to drive change to a truly creative level, it is a curious paradox that sponsoring a safe environment in which to develop creative or innovative strategies is just as necessary. Potential innovators need to know that they can raise first order issues, question foundational beliefs, and push for strategies designed to reach the real aim without fear of losing favor or opportunity. These days, many of the failures in patient safety are products of an environment in which individuals cannot acknowledge a mistake without incurring recriminations. We have fostered a culture that covers up and fails to identify dangerous conditions that exist. In such a culture, it is very difficult for creative strategies to emerge and develop. Building a culture that allows and even encourages creative strategies is one of the key responsibilities of a leader.

There is very little that is new under the sun. To hold innovators and creators to unrealistic standards of originality is not useful. There are of course real innovations that succeed at establishing new patterns or paradigms, but these are rare. For most of us, real innovation involves pattern recognition and application, or in our current vernacular, "connecting the dots." The process of responding creatively when current practices are challenged is fairly straightforward. First, what are the indications in the environment that new strategies are needed? Second, what innovations are out there in similar or even dissimilar institutions that might have relevance? Finally, how can these innovations be adapted to fit the culture, values, and vision of the new organization? Answering each of these questions requires creativity and openness to ideas from a variety of sources.

To this point the developing a creative response can be solitary work. But innovations that are only in an individual mind are often marginalized to the status of dreams or worse, hallucinations. Actualizing them requires the shared efforts of a larger team. This is important for two reasons. First, a diversity of perspectives is needed to fit creative innovations to a new organization. Enriched by new perspectives, teams are more likely to accept these innovations as their own solutions, rather than perceiving them as externally imposed. Empowering teams to make such adaptations is key to successful leadership.

Changes in the US health care system will, of necessity, come about through creative and innovative responses to the challenges now confronting health care in its every aspect. From one perspective, the challenges will seem like insurmountable problems, perhaps defeating us before we begin. Reframed creatively, these challenges will be our guides as we progress towards a remade healthcare system.

A version of this article was presented at the May 2, 2008 inaugural of Janis Bellack as the President of the Institute of the Health Professions of the Massachusetts General Hospital.

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