At the Crossroad of Innovation and Operations

Even though contracts that reward value rather than volume are spreading, changing incentives is only the first step. Fixing the healthcare business is up to innovators on the front lines, points out Chris Trimble, a Dartmouth adjunct professor of business administration and national expert on healthcare innovation, and author of How Physicians Can Fix Health Care: One Innovation at a Time and five additional books.

Trimble recently spoke at the IHI’s National Forum about ways to fix healthcare through leadership and innovation. He spoke exclusively with IHE about resource allocation, key steps to take, opportunities to seek, pitfalls to avoid and why full-time change teams are needed.

Taking a clue from your book, what are the major aspects of healthcare that need fixing?

So many. We focus on care redesign, changing the care model and innovation initiatives that take the form of small but full-time teams that redesign care for a particular patient population.

For senior executives in particular, innovation resources are being allocated in a way that overlooks a huge area of opportunity. I’d like to describe that a little bit, because there’s a pretty solid history of investment in quality improvement work in healthcare systems. That’s all very good, but quality improvement work tends to constitute initiatives that can be squeezed into people’s slack time on the job, and also into their existing job descriptions.

And then on the other end of the spectrum, if you will, we’re investing in high-tech stuff: game-changing types of innovations, new cell phone apps to help get people healthy, new wearable devices, that sort of thing. And it’s fun to be on the cutting edge, but there’s a whole category that’s sort of in the middle. And in the middle, what we’re typically working with are commonsense, very straightforward ideas, like doing a better job of coordinating care, or keeping high-risk patients, or helping patients consider consequential medical decisions very carefully. That’s stuff we know needs to get done but is best done beyond the reach of quality improvement programs and specifically by commissioning small but full-time teams of 3–4 people to improve care for a particular patient population. That full-time piece is so critical.

Businesses are designed for ongoing operations, not necessarily innovation, which exposes deep, fundamental conflicts between the two. Tell us about the complexities of originating and managing these teams inside established organizations.

It’s difficult, because those teams are inevitably going to experience conflict with existing ways of doing business. And yet, to get anything done, they can’t really isolate themselves. They have to engage. There are always people involved in the initiative part-time, with supporting roles. There must be a healthy relationship between those working on the initiative full-time and the supporting cast. It’s a delicate balance that’s tricky and counterintuitive. The core of the book is really a step-by-step guide for the physician leaders of these initiatives so they may avoid mistakes their peers made in other organizations.

Have you come across any sort of formula that gives a good ratio of number of people needed on a full-time team to the number of patients the organization has?

It depends so heavily on the type of patient population. For example, what about children with complex medical conditions, their families and families’ needs? In that case, it was a full-time team of four that served 600 families.

On the other end of the spectrum, we have examples of initiatives to maximize throughput and the time of providers delivering the services. The best example is the high-volume joint replacement center, where the idea again is just the opposite: to spend as little time on each patient as possible, in a way consistent with high quality.

Physicians seem to have been taken out of the equation for providing input into these decisions. What is their place in innovating these teams and innovating organizations?

The physician’s role is so crucial. In the past, under fee-for-service, it’s been nearly impossible to do, with a pitiful few exceptions where the incentives just happen to work for a variety of quirky reasons. But by and large, the fee-for-service stands in the way of the kind of work we’re discussing.

The most powerful reason to feel optimistic about the future of healthcare in the United States is the steady transition we’re seeing to accountable care and value-based payments. There’s no going back. While physicians initially may be anxious about the fee-for-service transition to accountable care, they’ll find it’s also extremely liberating. Once fully implemented under accountable care, fee-for-service payers won’t be telling physicians what they can and cannot do, or how much time they may spend with each patient, or what they can and cannot bill for. Instead payers are saying, “Send us the results. If they’re good and costs are low, we’ll reward you financially.” That’s the way it should be.

What sort of culture is needed for accountable care to work best?

One, the organization has to be pushing the envelope on accountable care.

Two, they’ve got to make the right types of innovation investments. The biggest risk is that the type of investment I’m talking about is overlooked entirely in favor of those [more] high-tech, in favor of quality improvement, and in favor of…let’s call them innovation labs or innovation centers, which are really just think tanks that come up with proposals or often don’t have the resources or right staffing to take those proposals all the way to fruition. 

Third is to engage with those teams and help them in a variety of ways. One is to help them navigate the tensions that are going to be inevitable with the rest of the organization. Another is to expedite some of the hiring changes that may be necessary and some of the HR policies necessary to build a very different kind of team. A third is probably to help these small teams gather needed data—financial and outcome—to prove what they’re doing is working. Many times small teams get started just doing their data collection on a spreadsheet, but the more help they get in this area, the better the results are going to be over the long run.

What are the obstacles common to innovation?

All the excitement, all the pizzazz, is in the trip up the mountain, coming up with that big idea. By and large, people give way too little thought and attention to the great difficulty of executing an innovation initiative in an established organization.

The four straightforward principles are standardization, coordination, prevention and improved medical decisions. Those probably cover 95% of the examples of innovations in healthcare delivery that I’ve seen.  

Sidebar: By Chris Trimble

• Ten Rules for Strategic Innovators: From Idea to Execution (with Vijay Govindarajan), Harvard Business School Publishing, 2005
• The Other Side of Innovation: Solving the Execution Challenge (with Vijay Govindarajan), Harvard Business School Publishing, 2010
• Reverse Innovation: Create Far From Home, Win Everywhere (with Vijay Govindarajan), Harvard Business School Publishing, 2012
• Beyond the Idea: How to Execute Innovation in Any Organization (with Vijay Govindarajan), St. Martin’s Press, 2013
• How Stella Saved the Farm: A Tale About Making Innovation Happen (with Vijay Govindarajan), St. Martin’s Press, 2013
• How Physicians Can Fix Health Care: One Innovation at a Time, American Association for Physician Leadership, 2015