Achieving Large System Change in Health Care

When faced with big challenges, individuals or organizations are most likely to respond, “How can we?” One such challenge is large system change, ie, the holistic alteration in processes and behaviors across a system that leads to a step change in the outputs from that system. Meeting such challenges requires alternative framing of the question, and the contention is that several key principles assist in reframing the question from “how can we” to “why not?” In outlining these principles, this Commentary will describe lessons from my experiences with designing and delivering large system change across varying sectors (health, education, communities) in different countries.

Any analysis of recorded episodes in human activity that have made a leap change yields one clear conclusion. Whether it be the Romans constructing the self-supporting domed roof of the Pantheon 2000 years ago or a human mission to the moon's surface, there has been a common cause: pushing the boundaries of the current norm. Status quo was not an option for the scale of the vision, and simply tweaking the status quo would also have been unsuccessful.

Current health care is marked by a demographic crunch manifested by worse health at a younger age than the previous generation due to obesity, medical errors costing billions, and the majority of patients not receiving the best care possible. The response has largely been to tweak status quo. This is insufficient. A year in the life of an older person whose health care system does not improve can be a year too late. Pushing the boundaries is not an indulgence; it is an imperative.

It is inevitable that when pushing boundaries, obstacles such as vested interests, politics, structures, and finance will be in the path. Yet large system change in health care is achievable. Over 44 months, the Primary Care Collaborative of the UK National Health Service engaged 5500 primary care office practices covering 32 million individuals in England and gained measured improvement in access and secondary prevention of coronary heart disease.¹ This exercise was repeated using the same techniques across Scotland and the whole of Australia (Australian Primary Care Collaborative) and on a smaller scale in the Education Breakthrough program created with secondary schools in England,² with similar results.

In these and the other examples in history, unless leaders maintained and expressed optimism about overcoming obstacles, change would not have been achieved. However, leaders will not by themselves achieve the change that requires the hearts and minds of every individual involved in delivering services. Leaders can sometimes address the logistic challenges accompanying change, but the change goes nowhere without engaging a critical mass of those on the front line. This engagement in turn helps overcome the logistic challenges.

Most individuals in organizations will experience fear of change, along with the twin emotion of skepticism. Changing the mind-sets of affected individuals is one of the biggest obstacles faced in large system change. One construct that underpinned the success in the collaboratives named above was changing mind-sets. This process has 3 components. First, it is important to start addressing the objections to change with opposing facts (avoiding trench warfare) and instead create a clear vision of what the change would mean for individuals and for the organization. Second, it is equally important to illustrate practically, even in small ways, what the change would look like, preferably by outside example. Third, once the change process has commenced, it is effective to use those who have achieved success, and who were initially skeptical, as advocates for the change. This requires systematically taking everyone through a sequence of reducing anxiety about change.

Large system change is also an exercise in identifying opinion leaders and seeking either to suspend their opposition or gain their support. As change progresses across organizations, able enthusiasts are recognized and used as examples to others, thereby becoming the opinion leaders. They are tutored to ensure a consistency of message and vision. Leaders should seek to achieve an unstoppable momentum requiring a subtle combination of psychology, marketing, and campaigning using a delivery infrastructure.

For years, the holy grail of health care has been evidence-based medicine, and it is argued that making this knowledge widely available would ensure standards. The flaw in that thinking was exposed rapidly when it became evident that experiential knowledge of systems and processes enacting that evidence base were of equal importance.³ The implementation of this knowledge has led to considerable improvement. However, the missing element is human behaviors and addressing those behaviors. Why is it that even when nurses knew they were being observed and had to wash their hands between caring for successive patients, 20% did not,⁴ or that when templates are constructed from the evidence base on how to deliver care for a patient, those templates are not fully completed? Partly this is a systems problem, but pivotally it is about human factors. Health care is a person business. Understanding and shaping individuals is key to maximizing outcomes. The equation should be therefore be:

knowledge of evidence + knowledge of improvement methods + knowledge of human factors = outcomes.

An important aspect is understanding how to combine evidence, improvement methods, and human factors. It is known from other industries⁵ that human factors need not be taken for granted.Mechanisms exist for training in behaviors, eg, having early warning report systems and maximizing the involvement of individuals with relevant frontline expertise in solving problems and designing systems. Failure to address human factors is a central reason that outcomes are not optimized.

At its simplest level, this means teams function better than individuals. In health care, the makeup of those teams often takes on a traditional appearance. In large system change it is essential that team composition includes individuals from other parts of the organization or other organizations, but the key team members are the patients. This approach ensures that discussions are focused on actual needs and experience, that there is less “group think” among the professionals, and that their behaviors become modified. Interdepartmental or interorganizational petty rivalry is not played out in the presence of patients, who by their presence force attention to health care alone. It also ensures that professionals do not fall into the trap of designing services for themselves, thereby creating a service gap.⁶

The involvement of patients also makes a difference in outcomes.⁷ In the work I designed for Healthy Communities, the same was true.⁸ In this case the hypothesis was as follows: could getting residents of a deprived community to work on a particular topic using a breakthrough-style program gain improvement in that topic but also gain social capital that enabled residents to progress to another topic?

Initially, the members of the improvement teams were the residents of those areas; professionals from health, housing, and social care were a resource. After program initiation, falls among area residents declined (as measured by calls for ambulances).⁸ In addition, a “message in a bottle” scheme was initiated for placing health information in homes, an approach that has now spread throughout England. At the beginning of this program, the participants were in “victim” mode; that is, their repeated experience of failing to improve their circumstances had led to the view that nothing could be done. By applying the methods for large system change, the psychology was changed.⁸

The same is true for any large-scale change. Skeptics become enthusiasts. Achieving early wins and small changes encourages persistence. Knowing teams that were at the same stage at the beginning, and seeing those teams achieve improvement, acts as a stimulus to others. Enthusiasts become the advocates, and all successful participants become recruiters by default through positive conversations they have with nonparticipants in the same or other organizations. The enthusiasm and energy created by a well-constructed and well-delivered large-scale change program is difficult to describe, but it is the fuel that drives the scale of change. Engaging and driving change through the front line and allowing headroom for innovation (and ensuring that innovation is captured as part of a dynamic within the change), when combined with overall direction, incentive, and commitment from leaders, offers the best chance of sustainability. This does not occur by default but rather by design. Large system change needs to be planned from the outset; “pilot and spread” will not do.

Professional colleagues can be frightened by the notion of taking calculated risks. They incorrectly assume that the risk involves care of patients. However, the corollary is that not embarking on change to improve is itself a risk to patient care. The risk is not about testing evidence of what is best care or even about testing the systems. The risk in this context, predominantly one for leaders, is to convince important organizational stakeholders to embark on ambitious large-scale change without being certain of its end point. Reasonable projections can be made, but the variables are too extensive to be certain. Taking calculated risk is present in all projects mentioned above, including building the Pantheon and traveling to the moon.

What must be done to make the difference is known. Plenty of isolated examples exist to illustrate the improvements in care achieved by teams or organizations, and each week new evidence is published giving fulsome testimony to that fact. The challenges to health care will not disappear; “how can we” hesitancy needs to be replaced with “why not” energy. Only courage and properly constructed large-scale change will make the difference in changing health care.