Implementing Change in Organizations and Healthcare Systems

Dan Heath, a senior fellow at the Center for Advancement of Social Entrepreneurship at Duke University and coauthor of the books “Switch: How to Change Things When Change Is Hard,” and “Made to Stick,” outlined strategies for implementing change within an organization at a presentation at the 2014 American College of Chest Physicians (ACCP) meeting in Austin, Texas.

“Change is hard, and many people are trying to make changes in their lives,” remarked Heath. Larger changes, such as changes within organizations, are also difficult to effect.

Heath noted that for many years, psychologists have been researching successful approaches to implementing change. Fundamental to this research is the idea that we have a certain split or duality in our desire to complete a task. For instance, part of us may genuinely want to lose weight, but another part may want to eat a large pastry upon arriving at an airport after a long flight.

This built-in conflict has been identified by psychologists as the interplay between 2 systems: a rational, conscious, and deliberative system, and an emotional, unconscious, and automatic system. Heath described these 2 systems as analogous to a tiny rational rider attempting to control an emotionally driven several-ton elephant. “If these 2 disagree, who is your money on?” asked Heath.

Essential to implementing change is getting the emotional system to move toward the goal. Heath referred to this task as “motivating the elephant.”

Often, the way change is approached in an organization is via the rational system—frequently through a careful, rational search for problems. This analytical task, which is characteristic of the rational portion of our brains, generally takes up the bulk of the time decision makers spend working on change.

Alternatively, Heath proposed looking for solutions (“bright spots”) that are already present within an organization. A solution to a large problem may already have been implemented on a small scale.

One dramatic example of the power of finding the “bright spots” comes from the Kaiser Permanente healthcare system in Northern California. Administrator Alan Whippy asked the heads of 21 hospitals to study the last 50 patients who had died in each hospital. Of these deaths, sepsis was identified as the cause of death in one-third of the cases. The large proportion of deaths due to sepsis surprised many hospital leaders.

To identify strategies for reducing rates of death due to sepsis, Whippy identified top-performing hospitals with low rates of sepsis mortality. This search led to the identification of Diane Craig, MD, who noted that her strategy involved carefully adhering to a simple protocol: administering large quantities of antibiotics and fluids at the first sign of sepsis. To help improve outcomes in cases of sepsis, Dr Craig also distributed pocket cards showing the mortality risk among patients with sepsis, ensured that patients received a test for lactic acid levels with every blood culture, and set up “sepsis alerts” that are similar to similar to “code blue” alerts. A “sepsis alert” would trigger a team to quickly convene at a patient’s bedside at the first sign of sepsis. Through the implementation of these interventions across 21 hospitals, the risk-adjusted mortality from sepsis decreased by 28%.

Heath cited another example in which quality improvement researchers sought to improve adherence rates among patients taking medication for cardiovascular disease. One physician, Timothy Ho, MD, had higher-than-average rates of medication adherence among his patients. When asked how he did it, Dr Ho noted that when he received a patient’s laboratory results, he drew a star by favorable results and added simple motivating statements. For instance, by a starred cholesterol reading, Dr Ho wrote, “Continue taking your cholesterol medication to keep your arteries open.” According to Heath, this intervention appeals to patients’ emotions and “motivates the elephant.”

Another important part of motivating change is what Heath called “shaping the path.” The ACCP shaped the path for smoking on airplanes. Mere decades ago, smoking on airplanes was commonplace. Today, it is prohibited—largely through the lobbying efforts of the ACCP.

Heath then asked a controversial question: “Can we error-proof hospitals the way we child-proof rooms?” Many “error-proofing” strategies have already been implemented. One example of an intervention to reduce error rates in hospitals is the use of checklists. The use of checklists has been associated with improvements in outcomes. For instance, in Scotland, use of checklists in hospitals reduced surgical mortality rates by 19% over a 2-year period.

Making changes within organizations is challenging. Hospitals, organizations, and healthcare systems can work toward higher-quality care delivered cost-effectively by finding the bright spots, motivating change by appealing to emotion, shaping the path, and implementing “error-proofing” strategies.