As we have indicated in some previous blogs, significant change in the U.S. health care system will be required to correct the quality inefficiencies and rising costs that we are experiencing today. The redesign must be part of any successful health system’s future in order to address the three major voices demanding change. They are 1. Government, 2. Business owners/employers, and now 3. Patients and their families.
With change - whether it be in the clinical arena, where treatments are being modified constantly, or in the administrative area where processes and procedures must be updated to address these redesign requirements – toxic side effects are inevitable. It is prudent for health care leaders to predict these toxic side effects in advance so that when they occur, they will not have to face the dreaded question, “Have we made a mistake?”.
An example of an expected toxic side effect in the clinical setting is the hair loss that occurs in a cancer patient while they are undergoing what everyone hopes will be curative chemotherapy, After two weeks of treatment, when the physician walks into the patient’s exam room and finds him or her bald, the practitioner does not say, “Oh no, what have we done?”. Because he knows this is a positive toxic side effect, he is instead able to respond with, “Oh, the treatment is working.” In fact the toxic side effect proves that the treatment goals are being achieved and hopefully the patient’s tumors are shrinking .
The same logic needs to be applied to leadership/administrative decision-making processes undertaken each day to facilitate the changes necessary for creating excellence. By doing so, when we observe the expected toxic side effects, we can say, “Yes, our strategies for change are making a positive difference.”
One illustrative example of this important process was demonstrated when a health system decided that as part of their future strategic plans , driven by changes they saw occurring in their market, they would open convenient health clinics in association with Walmart. In advance of these openings, the leadership team predicted that a side effect of doing this would be pushback from some of the physicians because the doctors believed – inappropriately so – that these clinics would be providing poor quality of care and stealing patients from their practices. Numerous studies have been done by several unbiased organizations which clearly have shown that these concerns are not valid and in fact, the opposite is true. These clinics, staffed by nurse practitioners, are providing access to care for a limited number of illnesses, carefully managed by evidenced-based treatment protocols which has been designed with strong input from physicians. Quality has been in no way reduced. In fact, the quality of care has been enhanced because the patient can get access to care more quickly, often in the evening and on weekends when physicians’ offices are usually not open. It could be possible that more serious consequences of delayed treatments may be avoided.
Although physicians could opt to work in these clinics, they usually do not choose to do so, understandably, because of the lower salaries which are offered. But these salary structures, that are appropriate for nurse practitioners, are one of the reasons why these clinics are more cost effective, allowing these clinics to operate and succeed on lower reimbursement from patients. It is these innovative care access models that will be required to improve primary care availability which is sorely needed in the US delivery system today.
However, the expansion of these models will undoubtedly cause additional toxic side effects from practicing physicians and administrators of hospital-owned clinics. In a recent article, the author reported that a large percentage of services provided by primary physicians in their offices could be provided by nurse practitioners and that 40% of the visits handled in face-to-face visits by nurse practitioners could be handled on the phone. Yet, a significant number of primary care physicians, even knowing they are in short supply, are not supportive of nurse practitioners taking a bigger role in addressing the increasing demands for primary care and accessibility.
So, as is often the case when changes are made, a toxic side effect quickly rears its head, usually representing opposition that is not valid nor data driven. Knowing this, we should encourage debriefing sessions after implementing change processes and procedures to assure ourselves what is and what is not working as we expected. By identifying the most likely toxic side effects as early in the transformational process as possible, we may prevent the “Monday morning quarterbacking process of second-guessing ourselves”. Spending sufficient time reflecting on the toxic side effects of change will keep us from scrambling to cater to opposing, oft times inappropriate, uninformed and unmotivated, voices.