The curse of the quick fix

I’ve been reading Simon Garfield’s wonderful book Timekeepers: How The World Became Obsessed With Time. It is a fascinating set of narratives on the modern relationship with time. Towards the end, it slightly turns into a series of lists of conceptual art pieces that sound less Deeply Meaningful than Garfield makes out (oddly reminiscent of Evgeny Morozov’s To Solve Everything Click Here in this regard) and occasionally some of his more jokey passages grate, but most of the time (ho ho) it is a book that makes one see the taken-for-granted of the modern world for what it is. There are very funny passages on time management self-help books and on the world of haut horologie, and extremely thought-provoking ones on our time-poor age (or is it a perception? One of the time management gurus is actually wisest on this…)

Anyway a passage which struck me as especially germane to medicine, health care in general, and health IT in particular was the following – which is actually Garfield citing another author, but there you go:

And can any of these books really help us in these decisions? Can even the most cogently aligned bullet point and quadrant matrix transform a hard-wired mind? The notion of saving four hours every ten minutes is challenged by The Slow Fix: Why Quick Fixes Don’t Work by Carl Honoré. The book set its tone with an epigram from Othello: ‘How poor are they who have not patience! What wound did ever heal but by degrees?’6

The quick fix has its place, Honoré argues – the Heimlich manoeuvre, the duct tape and cardboard solution from Houston that gets the astronauts home in Apollo 13 – but the temporal management of one’s life is not one of them. He reasons that too much of our world runs on unrealistic ambitions and shabby behaviour: a bikini body within a fortnight, a TED talk that will change the world, the football manager sacked after two months of bad results. [<a href=”https://www.ted.com/talks/carl_honore_praises_slowness”>Honoré himself has nevertheless done a TED Talk – SS]

He cites examples of rushed and dismal failings from manufacturing (Toyota’s failure to deal with a problem with a proper solution that might have prevented the recall of 10 million cars) and from war and diplomacy (military involvement in Iraq). And then there is medicine and healthcare, and the mistaken belief – held too often by the media and initially the Bill and Melinda Gates foundation – that a magic bullet could cure the big diseases if only we worked faster and smarter and pumped in more cash. Honoré mentions malaria, and the vague but quaint story of a phalanx of IT wizards showing up at the Geneva headquarters of the World Health Organisation with a mission to eradicate malaria and other tropical diseases. When he visited he found the offices somewhat at odds with those of Palo Alto (ceiling fans and grey filing cabinets, no one on a Segway). ‘The tech guys arrived with their laptops and said, “Give us the data and the maps and we’ll fix this for you.”’ Honoré quotes one long-term WHO researcher, Pierre Boucher, saying. ‘And I just thought, “Will you now?” Tropical diseases are an immensely complex problem . . . Eventually they left and we never heard from them again.’”

As my own practice has developed over the years, I have come to a realisation that quick fixes tend to unfix themselves over time, and the quick fix mentality carries a huge cost over time.

Here is Honoré’s TED Talk. Garfield has a very entertaining passage in the book where he talks at a rival of TED’s, which has a 17 minute limit (TED has an 18 minute one)

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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:

 

Morale, adaptive reserve and innovation

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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” 

stressed-nurse

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.

download2Google 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?

 

“disrupting Health insurance” ≠ “improving the quality of healthcare

A few days ago I saw the following on my twitter feed:

I followed the link to the HIMSS website. What are the 4 ways in the Tweet? Well, they are:

  • The Use of Wearables in Wellness Plans
  • Three billion mHealth App Downloads and counting
  • Sensors and apps are everywhere
  • The Big Data Revolution

According to the blog post at least. I’ll leave it to the reader to make their own judgment.

I guess it may have been the trigger word “disrupting”, but I posted a rather grumpy tweet:

To which, shortly after, came a reply:

 

Perhaps I should have replied “solutions to what exactly?” (cf prior posting on solutionism) Anyhow, I replied and Stefan graciously replied and a rather civil exchange ensued.

Thinking about it again, perhaps I deviated from my original point too fast. Health insurers are in the business of selling a product to consumers. The product is coverage for access to healthcare – they are not providers of health care itself. Surveying the world of digital health, I sometimes wonder if the complexities and vagaries of the US healthcare sector – which represents the highest proportion of GNP of any developed country, and yet is notoriously complex, difficult to navigate, and all round obtuse – deforms how many players approach the sector. We often hear about engaging clinicians and “clinical workflows.” Insurers are clearly players in the game, and important players (especially in the US) but they are not clinicians or indeed service users.

I keep coming back to Neil Versel’s piece (and the comments following) from Feb 2013:

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.

And indeed, other factors may scupper your promotion of active lifestyles – all of this can be for naught with highly effective technologies encouraging consumption of calories and media (“binge culture” has several sides) at the same time.