Morale, adaptive reserve and innovation

I have another blog post on the CCIO website – the contents of which may remind readers here of this and this and also this – so here is the Greatest Hits version:

 

POSTED BY SEAMUS MACSUIBHNE ON 8TH MARCH 2017 POSTED IN INNOVATION

On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan recently wrote a post called Happy Organisations and Happy Workers – a key factor in implementing digital health.

In the opening paragraph, Dr Quinlan invokes Anna Karenina:

 

To paraphrase Tolstoy, “all happy organisations are alike; each unhappy organisation is unhappy in its own way.” The ability for healthcare organisations to innovate is a fundamental requirement for adopting and sustainably scaling digital health solutions.  If an organisation is unhappy, for example if it is failing to communicate openly and honestly, if staff feel overworked and that their opinion isn’t valued, it stands to reason that it will have trouble innovating and handling major complex transitions.

The whole post is a fascinating read, with implications for team functioning beyond the implementation of digital health and indeed beyond healthcare itself. Dr Quinlan cites research on what makes a happy worker;

What these factors combine to achieve is happy, engaged workers – and happy workers are more effective, compassionate, and less likely to suffer burnout. Clear objectives, praise, a sense that your voice matters – these can seem like fluffy ‘soft’ concepts and yet they are found over and over to be central to providing the right context within which new digital health innovations can flourish. Classic ‘high involvement’ management techniques – for example empowering team members to make decisions and not punishing them for every misstep are found to be key.  As Don Berwick of the Institute of Healthcare Improvement (IHI) says, people who feel joy in work are “not scared of data”, rather “joy is a resource for excellence” 

Dr Quinlan goes on to describe the high rates of burnout and emotional exhaustion among healthcare workers. Unfortunately this is a phenomenon that has been consistent in survey after survey. Not only does poor morale compromise the introduction of innovation, it also causes direct human suffering and compromises what an organisation is trying to achieve.

The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:

Adaptive reserve is an internal capability for change which includes being agile; capable of continuous learning; and being adept at self-assessment, reflection and improvisation. The Adaptive Reserve questionnaire asks staff to rate their organisation according to a variety of statements which include statements such as; ‘we regularly take time to consider ways to improve how we do things’ and ‘this organisation is a place of joy and hope’.

There is sometimes an urge to reform or innovate our way out of the situation healthcare finds itself in, and yet the concept of Adaptive Reserve suggests that this is inverting how reform and innovation work; there needs to be not just systematic space and infrastructure for it to happen, but psychological space among staff.

A related blog post on the ARCH website by Dr Marcella McGovern on the blame culturethat exists within many organisations, and particularly in the Irish health care context is worth reading. Dr McGovern uses Melvin Dubnick’s framework of “prejudicial blame culture” to describe how systems focused on blame stifle initiative and responsibility.

Google recently completed Project Aristotle, a study of what makes a successful team. Far and away the most important factor is “psychological safety” – “Can we take risks on this team without feeling insecure or embarrassed?”  Focusing on technological fixes in the absence of a sense of psychological safety is a recipe for innovations to fail and for morale to decrease further. Can technology, in and of itself, foster psychological safety? My inclination is to say no, that psychological safety is much more about interpersonal relationships within a team and a system. What technology may be able to do – in a positive sense – is help facilitate team communication.

Of course, this also has to be carefully thought through. Evgeny Morozov’s “To Solve Everything, Click Here”  is a fascinating and at times rather frustrating book which takes a searching look at technology in the modern world. Morozov is against both the excessive hype of technological utopians and the excessive gloom of technological pessimists. He strongly decries what he calls “solutionism”:

“solutionism.” … has come to refer to an unhealthy preoccupation with sexy, monumental and narrow-minded solutions – the kind of stuff that wows audiences at TED Conferences – to problems that are extremely complex, fluid and contentious. These are the kind of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” How problems are composed matters every bit as much as how problems are resolved.

The problems of healthcare are truly “extremely complex, fluid and contentious” and any honest attempt to solve them must engage with this complexity.  Can judicious innovation help foster psychological safety within a team, and thereby not only create happiness among health workers but also help them achieve the organisational goals they are engaged in meeting?

 

“Huge ($$), broken, and therefore easily fixed” : re-reading Neil Versel’s Feb 2013 column “Rewards for watching TV vs rewards for healthy behavior”

Ok, it may seem somewhat arbitrary to bring up a column on MobiHealthNews, a website which promises the latest in digital health news direct to your inbox. However this particular column, and also some of the responses which Versel provoked (collected here), struck a chord with me at the time and indeed largely inspired my presentation at this workshop at the 2013 eChallenges conference.

In 2012 I had beta tested a couple of apps in the general health field (I won’t go into any more specifics) – none of which seemed clinically useful. My interest in healthcare technology had flowed largely from my interest in technology in medical education. Versel’s column, and the comments attributed to “Cynical” in the follow up column by Brian Dolan, struck a chord. I also found they transcended the often labyrinthine structures of US Healthcare.

The key paragraph of Versel’s original column was this

What those projects all have in common is that they never figured out some of the basic realities of healthcare. Fitness and healthcare are distinct markets. The vast majority of healthcare spending comes not from workout freaks and the worried well, but from chronic diseases and acute care. Sure, you can prevent a lot of future ailments by promoting active lifestyles today, but you might not see a return on investment for decades.

..but an awful lot of it is worth quoting:

Pardon my skepticism, but hasn’t everyone peddling a DTC health tool focused on user engagement? Isn’t that the point of all the gamification apps, widgets and gizmos?

I never was able to find anything unique about Massive Health, other than its Massive Hype. It had a high-minded business name, a Silicon Valley rock star on board — namely former Mozilla Firefox creative lead Asa Raskin — and a lot of buzz. But no real breakthroughs or much in the way of actual products.

….

Another problem is that Massive Health, Google Health, Revolution Health and Keas never came to grips with the fact that healthcare is unlike any other industry.

In the case of Google and every other “untethered” personal health record out there, it didn’t fit physician workflow. That’s why I was disheartened to learn this week that one of the first twodevelopment partners for Walgreens’ new API for prescription refills is a PHR startup called Healthspek. I hate to say it, but that is bound to fail unless Walgreens finds a way to populate Healthspek records with pharmacy and Take Care Health System clinic data.

Predictably enough, there was a strong response to Versel’s column. Here is Dr Betsy Bennet:

As a health psychologist with a lot of years in pharma and healthcare, I am continually frustrated with the hype that accompanies most “health apps”. Not everyone enjoys computer games, not everyone wants to “share” the issues they’re ashamed of with their “social network”, not everyone is interested in being a “quantified self”. This is not to say that digital health is futile or a bad idea. But if we took the time to understand why so many doctors hate EHRs and patients are not interested in paying to “manage their health information” (What does that mean, anyway?) we would come a long way towards finding digital interventions that people actually want to use.

 

The most trenchant (particularly point 1) comment was from “Cynical”

Well written. This is one of the few columns (or rants) that actually understands the reality of healthcare and digital health (attending any health care conference will also highlight this divide). What I am finding is two fold:

1. The vast majority of these DTC products are created by people who have had success in other areas of “digital” – and therefore they build what they know – consumer facing apps / websites that just happen to be focused in health. They think that healthcare is huge ($$), broken, and therefore easily fixed using the same principals applied to music, banking, or finding a movie. But they have zero understanding of the “business of healthcare”, and as a result have no ability to actually sell their products into the health care industry – one of the slowest moving, convoluted, and cumbersome industries in the world.

2. Almost none of these products have any clinical knowledge closely integrated — many have a doctor (entrepreneur) on the “advisory board”, but in most cases there are no actual practicing physicians involved (physician founders are often still in med school, only practiced for a limited time, or never at all). This results in two problems – one of which the author notes – no understanding of workflow; the other being no real clinical efficacy for the product — meaning, they do not actually improve health, improve efficiency, or lower cost. Any physician will be able to lament the issues of self-reported data…

Instead of hanging out at gyms or restaurants building apps for diets or food I would recommend digital health entrepreneurs hang out in any casino in America around 1pm any day of the week – that is your audience. And until your product tests well with that group, you have no real shot.

This perspective from Jim Bloedau is also worth quoting., given how much of the rhetoric on healthcare and technology is focused on the dysfunctionality of the current system:

Who likes consuming healthcare? Nobody. How many providers have you heard say they wish they could spend more time in the office? Never. Because of this, the industry’s growth has been predicated on the idea that somebody else will do it all for me – employers will provide insurance and pay for it, doctors will provide care. This is also the driver of the traditional business model for healthcare that many pundits label as a “dysfunctional healthcare system.” Actually, the business of healthcare has been optimized as it has been designed – as a volume based business and is working very well.

Coming up to four years on, and from my own point of viewing having had further immersion in the health IT world, how does it stack up? Well, for one thing I seem not to hear the word “gamification” quite that much. There seems to be a realisation that having “clinical knowledge closely integrated” is not a nice to have have but an absolute sine qua non. Within the CCIO group and from my experience of the CCIO Summer school, there certain isn’t a sense that healthcare is going to be “easily fixed” by technology. Bob Wachter’s book and report also seem to have tempered much hype.

Yet an awful lot of Versel’s original critique and the responses he provoked still rings true about the wider culture and discussion of healthcare and technology, not in CCIO circles in my experience but elsewhere. There is still often a rather  inchoate assumption that the likes of the FitBit will in some sense transform things. As Cynical states above, in the majority of cases self-reported data is something there are issues with, (there are exceptions such as mood and sleep diaries, and Early Warning Signals systems in bipolar disorder, but there too a simplicity and judiciousness is key)

Re-reading his blog post I am also struck by his  lede, which was that mobile tech has enabled what could be described as the Axis of Sedentary to a far greater degree than it has enable the forces of exercise and healthy eating. Versel graciously spent some time on the phone with me prior to the EuroChallenges workshop linked to above and provided me with very many further insights. I would be interested to know what he makes of the scene outlined in his column now.

Unintended consequences and Health IT

Last week along with other members of the Irish CCIO group I attended the UK CCIO Network Summer School. Among many thought provoking presentations and a wonderful sense of collegiality (and the scale of the challenges ahead), one which stood out was actually a video presentation by Dr Robert Wachter, whose review into IT in the NHS (in England) is due in the coming weeks and who is also the author of “The Digital Doctor: Hype, Hope and Harm at the Dawn of Medicine’s Computer Age”

Amongst many other things, Dr Wachter discussed the unintended consequences of Health IT. He discussed how, pretty much overnight, radiology imaging systems destroyed “radiology rounds” and a certain kind of discussion of cases. He discussed how hospital doctors using eHealth systems sit in computer suites with other doctors, rather than being on the wards. Perhaps most strikingly, he showed a child’s picture of her visit to the doctor. in which the doctor is turned away from the patient and her mother, hunched over a keyboard:

This reminded me a little of Cecil Helman’s vision of the emergence of a “technodoctor”, which I suspected was something of a straw man:

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

I still suspect this is overall a straw man, and Helman admits this “technodoctor” is “still only [part of] a minority” – but perhaps the picture above shows this is less of a straw man than we might be comfortable with.

Is there a way out of the trap of unintended consequences? On my other blog I have posted on Evgeny Morozov’s “To Solve Everything, Click Here.”  a book which, while I had many issue with Morozov’s style and approach (the post ended up being over 2000 words which is another unintended consequence), is extremely thought-provoking. Morozov positions himself against “epochalism” – the belief that because of technology (or other factors) we live in a unique era. He also decries “solutionism”, a more complex phenomenon, of which he writes:

I call the ideology that legitimizes and sanctions such aspirations “solutionism.” I borrow this unabashedly pejorative term from the world of architecture and urban planning – where it has come to refer to an unhealthy preoccupation with sexy, monumental and narrow-minded solutions – the kind of stuff that wows audiences at TED Conferences – to problems that are extremely complex, fluid and contentious. These are the kind of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” How problems are composed matters every bit as much as how problems are resolved.

As will be very clear from my other article, I don’t quite buy everything Morozov is selling (and definitely not the way he sells it!) , but in this passage I believe we are close to something that can help us avoid some of the traps that lead to unintended consequences. Of courses, these are by definition unintended, and so perhaps not that predictable, but by investigating rather than presuming the problems we are trying to solve, and not reaching for the answer before the questions have been fully asked, perhaps future children’s pictures of their trip to the hospital won’t feature a doctor turning their back on them to commune with the computer.