Happy Dogs in a Pile of Sticks (Spreading Improvement in Chronic Disease Care)

The California HealthCare Foundation’s Chronic Disease Care conference was so packed with great panels that I needed help choosing my targets. Here is the first in a series of posts about this event.

Spreading Improvement: After the Innovators/Early Adopters

Hunter Gatewood of the Safety Net Institute led off with a plea to change the word “spread” (which he said doesn’t pack a punch) to “transformation.” To move from the mad-scientist/play phase of system transformation, he advises engaging people who do not want to change.  His group also tapped traditional clinical champions and community leaders to be “Spread Leaders.” They were empowered by the title and the charge to look across clinics for best practices, which in turn helped them get recognition at the CEO level.

The best take-away for me was Gatewood’s adoption curve illustration which is the visual for his wonderful observation that early adopters are like  “happy dogs in a pile of sticks. Late adopters are more like a hesitant cat, waiting to see what works, what blows up in dogs’ faces.” Who hasn’t been there? For the full set, see: Spreading Better Care Across California: Principles and Practicalities.

Lisa Johnson, MD, Medical Director of Quality Improvement Programs, Community Primary Care – SF Dept of Public Health, said that data brings issues down to a concrete level. Add all patients to the registry and sort it out later instead of picking & choosing at the outset. Also: mandate use of an innovation, make it useful & attractive, showcase people who use it well. Early adopters floated up and became change agents, but work flow change takes a LOT of support. The by-product of all this hard work is an excellent panel resource for other clinicians studying other conditions.

Diane Stewart, Director, CA Quality Collaborative: Recruit change leaders from the group of people who never raise their hands. Present what is proven to improve customer satisfaction – do not bill meetings as “come discover” events, but evidence-based sessions. Have one on one conversations with resisters and address what they need to make a change — do not discount the power of pride to make someone hesitant about trying new technologies.

Christy Mokrohisky, St. Joseph Heritage Medical Group: Their patient satisfaction rating on getting phone calls returned was their “best opportunity for improvement” (meaning: it was abysmal). They assembled a physician and staff advisory group to develop a standard of care: all calls must be returned by the end of a “session” (a call that comes in during the morning session must be returned by lunch, for example).  A Perfect Care Dashboard displays complete transparency data so everyone can monitor progress relative to their colleagues (meaning: it turns out that shame works.) Those who reached 90% patient satisfaction ratings also received a monetary reward (meaning: cash works, too).

I am not a hospital administrator so you might think these lessons weren’t for me. But I spend quite a bit of time thinking about technology adoption and how systems are transformed, either from the top (banks’ creation of online services transformed the consumer side of that industry) or from the bottom (peer-to-peer transformed the music industry).

Also, I was in a good frame of mind after hearing Mark Smith, MD, president and CEO of CHCF, who opened the conference with a homily on transformation. He said that we need to transform care within the box that is the current finance structure — think inside the box, don’t make wish lists for other people, think about what we can do. That is certainly what each of the panelists did at their organization and what each of us can do in our work.

I have a feeling that a lot of people commenting on this blog are “happy dogs in a pile of sticks.” Maybe the cats are watching though!

8 thoughts on “Happy Dogs in a Pile of Sticks (Spreading Improvement in Chronic Disease Care)

  1. Susannah,

    What an inspiring summary! Some of us trying to promote change/transformation will need to adapt these lessons and recruit the cats in our bailiwicks. Our experience is that a large hospital system has a LOT of inertia, and I’m eager to learn about all the ways in which patient-friendly change can be encouraged by those of us who are not CEOs.

  2. Fabulous write-up, Susannah! I particularly like Gatewood’s adoption curve. That’s a new perspective on the dynamics of a paradigm shift – I’m lifting it for use at work.

    So great to hear these reports from the frontier.

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