Rock our world

THURSDAY, JULY 24, 2008

Ch-ch-ch-ch-changes
(Turn and face the strange)
Ch-ch-changes
Don't want to be a richer man
Ch-ch-ch-ch-changes
(Turn and face the strange)
Ch-ch-changes
Just gonna have to be a different man
Time may change me
But I can't trace time.

"Changes" by David Bowie, 1971

Perhaps it is serendipity that in a year when presidential candidates collect votes while they exalt change, change has emerged as a mantra among some leaders at Kaiser Permanente.

Or maybe it's more than that. Maybe it's inevitable. Just as voters in the United States are reaching beyond their disappointment to support a candidate who they hope can transform the country into something that reflects their better instincts, so, too, do health care leaders hope we can transform care into a better version of itself.

It's a daunting challenge that is driving almost every health care provider in the system, including international providers.

Maybe that's why health care innovators are listening carefully to Helen Bevan, the director of service transformation at the English National Health Service (NHS), a single-payer system that provides comprehensive care for 57 million people and ranks well above the United States in almost every measure of quality and cost. Like systems in the United States, the NHS is facing significant challenges, including cost pressures, widening health inequities and a lack of public confidence.

But instead of recommending what she calls a linear, rational approach to improvement that relies upon large-scale implementation of traditional improvement models—an approach that has resulted in significant improvements in NHS wait times—Bevan suggests we change the way we think about change.

She counsels us to take risks and adopt the strategies and tactics of such social forces as the U.S. labor or civil rights movements, which tapped into values, spontaneity and emotion among their members to drive broad change with commitment, creativity and élan. Inspired change, if you will.

"Recapturing the soul of health care," Bevan and her co-authors call it in an unpublished paper called "The Power of One. The Power of Many."

Bevan recognizes that many improvement systems used by health care providers, such as Six Sigma, LEAN and IDEO, are borrowed from industrial improvement models and do not always account for variables that are rife in a system as complex as health care.

Variables like frontline staff, the ultimate providers of quality health care.

In their research, Bevan and her colleagues discovered a critical gap between the organizational agenda of the NHS and the values of frontline staff. They also found improvement efforts have faltered because of limited involvement by frontline staff.

Does this sound familiar to anyone? Some at Kaiser Permanente still favor a top-down management style—but Bevan's conclusions underscore the importance of the work being done in partnership at KP by unit-based teams, teams that engage frontline workers, managers and physicians in performance improvement as never before.

The NHS, Bevan says, made significant changes with 20 percent of the frontline involved—but she believes at least 80 percent need to be involved to make more critical change.

That is why she and her colleagues turned to social movement theory and practice. These days, NHS is celebrating the role of activists, identified as angry but certainly passionate individuals who identify with the larger cause of patient care and who are committed and willing to take risks to change themselves and the system they work within. We all could learn a thing or two from them.

As Helen Bevan puts it, with great enthusiasm: "Rock the boat while staying in it."