Nancy mentioned a few weeks ago that the staff in clinic offices first reaction to a call for improvement will be to see it as a condemnation of their current performance. She cautioned that we must stress that quite the opposite is true. Providers and staff are working as hard as they can and that the systems have not been provided to help them reach their aspirations.

I think we really need to get some concrete stories and examples to make this point. Otherwise good people will feel threatened by what is meant to help.

I just had a conversation with a friend and colleague on Friday. I wanted to test the belief that we, as a medical community, need radically improved communication.
 I chose the three key learnings I have had to date from the Pursuing Perfection project.
  1. Systemness as the key insight.
  2. Patient centeredness as the key design principle.
  3. Cooperation as the key barrier and as the appropriate frontier for improvement in health care.

 What I found was that each of these topics brought up strong negative sentiments.
  -The word systems brought up the belief that those using it were blaming providers for the current situation in health care.
  -The word patient-centered brought up the belief that there was a plan to displace the provider from their current care giving role with patients.
  -The word cooperation bought up stories of failed attempts to cooperate and deep feelings of sabotage and betrayal.
 I don't know where to begin. One thought I had as we talked was that everything that has happened to health care in Whatcom county would likely have happened no matter who the people were. What I mean is that with our current organizational structures and behavioral norms including communication patterns, combined with our common ways of seeing the world, and with the economic pressures from the "environment" --with all of that being pretty much a given, people would do the same things and we would be where we are.
 My point is two fold.
  1. Blame is not getting at the root of the problem--blame indicts a person or a group. And I think for all intents normal people in the same situations would do the same things. In other words, the things that they did made sense from their position in the system.  The structure of the system, the things listed above and more, determine the outcomes. Blame diverts us from solutions.
  2. Outcome in systems has more to do with structure than it has to do with the players or the parts. You may wonder what I mean. I am not good at explaining it.
   -If we are playing basket ball the score is unlikely to be between 0-10 or greater than 150.
   -If we are competing against each other it is less likely that we will cooperate together, even when our best interests would be served.
   -When we blame people it is less likely that we will look for explanations beyond individuals.
   -The time and way that we meet to talk together, the ways we see the world and how aware we are of it and how openly we share our world views are all part of what I mean by structure. There are both internal and external forces that guide the outcomes, these unexplored or habitual structures create the results we live in.

  Systems thinking is needed to understand what is caused by the structure. Systems thinking is more about the structure than about the parts.
   Our only hope to change the outcomes is to first realize that the structure is more the determinant of outcomes than the individuals. We could then stop diverting or truncating our effort and energy by individual blame and begin to focus on the structure "system". My own belief is that without focusing on the system, the structure, the ways the parts interact things will just get worse.
   Working on understanding systems in place of blaming individuals is difficult and uncertain work. Why would anyone devote time and hope to it. My reason is simple and frightening: I see no alternative. The current way seems to be leading to insurmountable obstacles for many of us. The unintended consequences of our individual choices are continually coming back to plague us. We accept it. That is the way the world is. I agree it is inevitable unless we take a large step toward understanding the system that determines our thinking and our actions. We can better understand what is happening if we move beyond blame into systems thinking. We will need time and help but mostly we will need hope and faith in one another and some days I am afraid we are beyond hope and faith, we really believe in blame. What are we to do?

Three key insights so far in this journey to pursue perfect health care in Whatcom County.

First--A paradigm change in our thinking is required: from blame in people or parts to conceptualizing systems and relationships. This is also the key message of the IOM's Chasm Report.

Second--Patient-centricity, radical, literal patient-centricity is the design principle for improving the system of care. We have learned that having patients present in involved in conversations about system problems and plans for change is key. Our assumptions about what they want or what they feel that they need often are out of sync with reality. It saves a lot of waste and it is inspiring to work with patients in this way.

Third--Cooperation among clinicians is essential and it is the area of least experience and least knowledge. I think that this is the true frontier, the true area for highly leveraged innovation, perhaps more important to the future of healthcare than advances in technology or payment reform. Without significant advances in our ability to cooperate, even collaborate, we will not be successful in creating a dramatically improved system designed to meet patients' needs.