The Innovation Revolution

By Roger Coleman

The first article in this series, Can You Be Too Lean?, drew the following response from one reader:

“This is so applicable to us because our administration is on a mission to get many people trained in Six Sigma, and I think it's such a terrible waste of time and money!  I talk to people getting trained as "Black Belts" and all I hear is how they are crunching numbers and figuring out statistical formulas, but when I talk to them about the process problems, they are clueless!  These guys are basically going to spend most of their time in an office, far away from where the processes occur. I've sent your article to everyone because you hit so many great points!”

To summarize, my objections to the current herd-mentality trend toward carb-heavy improvement methodologies are as follows:

• Using Lean and Six Sigma approaches to solve most problems is like using a shotgun to kill flies. There are simpler, faster, and cheaper ways to get the job done.
• Complex improvement methodologies (i.e., rocket science) limit participation to 5% of our organizational citizens—those with the time and support for the very lengthy (“black belt”) and expensive training: senior managers. Our line folks—physicians, nurses, and frontliners—are expected to continue to toil away endlessly within dysfunctional processes. This excludes way too many brains for my comfort.

(However, we understand that some of you are engaged neck-deep in these methodologies. We are not suggesting you abandon your work, but that you don’t rely solely on these tools to dramatically improve quality. We had a New York City client that wanted to do Patient Visit Redesign, but then had to delay for two years while a Six Sigma initiative rolled out. After two years, he finally got the support to proceed with redesign because Six Sigma had failed to make an impact. Patient Visit Redesign was, to him, like surgery. It went to the heart of a particular problem and solved it within nine months.)

So, what to do, what to do? Well, if we can run our incredibly complex, 300 million plus person country based on democratic principles, why don’t we apply some of the same philosophy to our institutions? Let’s create Innovation Democracies. Impossible? Let’s look at the evidence: Successful innovation companies like IDEO (the Palo Alto design company), Apple, and 3M understand that ideas can come from anywhere and anyone. It’s simply not possible to predict who’s got the best idea for any given challenge. So they create innovation cultures to encourage robust participation across the organization.

Innovation companies depend upon a steady stream of ideas to survive in a competitive environment. Not only is the healthcare environment non-competitive, but it is virtually isolated from the country’s economy. As we suffer an historic recession, healthcare (and government) expand while all other industries contract. This economic isolation leads to bureaucracy, a dearth of innovation (stagnation), and a glacial pace of change.

In this regard, we have much in common with American auto makers who are now discovering that institutional and industry isolationism always exacts a price at some point. But the first victim of isolation is always innovation, defined as “A new way of doing something—incremental, radical, and revolutionary changes in thinking, products, processes, or organizations. Not an insignificant change. The goal of innovation is positive change, to make something better. Innovation leading to increased productivity is the fundamental source of increasing wealth in an economy.” [Wikipedia]

Before true, deep, and widespread innovation can occur within a community health center, hospital, or public health department, all our organizational citizens must be oriented, trained (briefly), and coached to contribute heartily to innovation. And the keystone of this effort is management’s authentic belief that every human resource within your walls is capable of making such a contribution. It may sound idealistic, even unreal to some, but it is an astonishingly effective business strategy. We call this “Diving Into Your Talent Pool”. This strategy is based on the stark realization that the problems we need to solve are too numerous, too complicated, and too dynamic to leave their resolution to a mere handful of managers.

Here’s a few key steps to help you get started on establishing an Innovation Democracy that will pay big dividends:

• Set the stage by introducing this concept—face-to-face—with everyone in your institution. A memo is not going to do the trick here.
• Understand that all problems are solvable. We created them, and therefore we can solve them. It’s natural to think that problems that have haunted us for decades (infections, wait times, high costs, etc.) are necessary evils, but that’s not true. These problems exist because we tolerate their existence.
• Focus on your patients in solving problems so that you continue to build your patient impact steadily and solidly. Invite all ideas that benefit patients: comprehensible billing statements, minimal wait times, minimal barriers to access, evidence-based medicine, medical homes, live answering of phones, reduced medical errors, honest airing of patient care errors, etc. There’s so much to do! With this kind of focus, you can innovate and improve care and outcomes while improving financial performance (the better you are at something, the less it costs—as a mountain of evidence indicates). But make the mistake of focusing primarily on financial performance and a funny thing happens: patient care/outcomes deteriorate while improved financial performance continues to be elusive.
• Try every reasonable idea, even the half-reasonable idea. I am constantly surprised which ideas work in practice and which don’t. Sometimes the winning innovation is counter-intuitive, and sometimes an idea does not work well yet opens one’s eyes to some other innovation that turns out to be amazingly effective.
• Find your experimenters. Though almost everyone can be an idea person, evidence reveals that not everyone is good at experimenting—testing the new idea, collecting data, and distinguishing what works from what doesn’t work (so you don’t throw the baby out with the bathwater). You need small teams of experimenters—people who are thoroughly open minded but utterly operationally competent. And you need to discover, find, and recruit these natural experimenters. These are not six people sitting in a meeting who are appointed “experimenters” by a senior manager. You’re looking for talent, not fodder.
• Shock your experimenters with totally “unrealistic” and ambitious outcome goals. This helps focus the experimenters—and gives them the liberty to get wild, crazy, and radical. It gives you a fighting chance to achieve dramatic results. Reduce no-shows to 5%. Achieve average patient visit times of 30 minutes. Increase revenue collections by 50%. Increase productivity by 33%. We have consistently found that teams respond much better to ambitious goals than to those deliberately engineered to be “achievable”, like “a 5% increase in outcomes”.
• Experiment and prove on a small scale. Don’t turn this into rocket science, but rather run rapid testing sessions over a brief, time-boxed period (from weeks to a few months at most). Once you have a solution you know works well on a small-scale, then implement it (diligently!) on a large scale and tailor it if need be. It’s much easier to deal with resistance when you know something works. This allows you to proceed with confidence.
• Create huge momentum. It’s like a presidential campaign: whoever can sustain the most momentum wins! The current way of doing things—your organization’s culture—has tremendous momentum. To innovate, you need enough momentum to overcome this. As a hospital CEO once said: “People change when the pain of staying the same is greater than the pain of changing.” Never allow a worthy innovation to be derailed or delayed for any reason. We’ve had clients say: “This redesign work is great, but we have Joint Commission coming up and we’re implementing a computerized medical record system, so we’re just going to suspend this project and return to it after those two things settle down.” In every case, the client was unable to reestablish momentum and succeed at redesign.
• Celebrate successes, both big and small. And do it publicly. Innovators—whether the innovator be the CFO, a nurse, a medical assistant or tech, a physician, a receptionist, a maintenance staffer, or a custodian—need to be clear winners when they successfully help move the organization forward.

These are some key steps in tearing down the caste system culture that dominates our institutions and impedes our migration to vibrant, innovative cultures. The quality produced by our healthcare system is dying a death of a thousand cuts and we need a broad-based response that is equal to the challenge. Our problems are not going to be solved by the single “silver bullet” approach debated daily in the news. There are many, many things we need to do at all levels to make this system produce results worthy of two trillion dollars.

There is so much we can get done by using an Innovation Democracy, on one hand, and remembering, on the other, that “simple” is good—as in “simple” ideas and solutions. “Simple” should never, ever be confused with “stupid”. So let it rain ideas, let structured experimentation flourish and let your organization become a leading Innovation Democracy.

Roger Coleman
Editor-in-Chief