How Micro-Moves Can Drive Major HealthCare Change: Walking the Patient’s Path

First published in Harvard Business Review

First published in Harvard Business Review

The complexity of today’s healthcare organizations makes it hard to change the way they do things. Conventional wisdom holds that real transformation requires bringing in consultants, undertaking large-scale and highly visible action, and jolting the organization into change.

But there’s another, far less disruptive approach: what I call “micro-moves.” These are small and often barely visible actions and interactions that my research and that of others has found to generate real and consequential change, rather than derailing it as sweeping organizational makeovers often do. By inviting collaboration in the change process from people across the organization, micro-moves tap collective energy and build enthusiasm that is essential for driving change.

One such collection of micro-moves is “discovery.”  These actions encourage people to notice their taken-for-granted assumptions regarding how things are done, reconsider them, and create alternatives.  For example, a team of managers and clinical leaders at a medium-size health system, Thedacare, in Appleton Wisconsin, gained invaluable insights about their own care delivery process simply by walking the “care path” with patients.

Early in her tenure, Kathryn Correia, an executive in this health system at the time, brought together managers and clinical leaders to figure out how they might change inpatient care delivery to improve quality and safety.  As they talked they soon realized that they had very little understanding of how patients moved through the system.  Although all participants knew how patients navigated within their own areas of treatment and their units, they had little idea of how patients travelled between admission and discharge, or what patients experienced on the journey. So, the group decided to walk the actual care path themselves, first as if they were patients, and then alongside the patients through real-time care delivery.

In a second session, the group explored how they could best learn about patients’ subjective experience as they navigated the system. They generated open-ended questions to ask patients when they accompanied them that would illuminate their experiences – questions such as, “Would you share with me what being a patient here is like?”  “What was it like just now when (describe situation concretely) happened?” “Could you describe some other experiences you have had here as a patient?” And they decided to leave behind their medical frocks and suit jackets in order to slip out of their “expert” roles. These gestures – leaving their “uniforms” behind, walking the care path, engaging patients with open-ended questions – are examples of micro-moves for discovery.

As they walked  with patients, the team was surprised to discover how difficult the route was for many patients and how truly arduous it was for the elderly and the very ill. This insight led the team to other discoveries about the burdens large and small patients face, such as having to return at a later time to complete diagnostic tests or having to repeatedly answer the same question as different providers come into the room.  Understanding these hardships and sources of anxiety prompted the organization to redesign the care delivery model around the patients and their experience rather than around provider convenience.

This new model is organized as a series of care phases occurring between patients’ admission and discharge that is similar for all patients.  The first phase involved a coordinated care team of a nurse, physician, pharmacist and discharge planner meeting in the patient’s room to conduct an admitting assessment and create a single plan of care.  Stopping points marking the end of each care phase are built into the plan to assess how the care is progressing. If all is going well, the nurse advances the patient to the next phase; if not, the nurse determines the reason and has the authority to resolve the matter, by, for instance, calling clinicians back to the bedside or following up with ancillary services to avoid delay and needless trips for patients.

Although walking the patients’ path is just one example of micro-moves for discovery, it powerfully conveys how groups can gain insight into previously invisible problems and foster momentum for change.  In this case, the team’s experience led to three positive individual and organizational outcomes:

• It moved leaders and clinicians out of their familiar roles, allowing them to better understand the patients’ perspective and the need for change.
• It allowed insiders to design and execute needed change that both aligned and stretched the organizational culture through infusion of new ideas. This allowed the organization to transform organically rather than being jolted into change by outside consultants.
• It cultivated insiders’ beliefs that their efforts can make a real difference in improving care. This in turn generated momentum and spurred dedicated effort to implement the change.

The insights gained led to the development of an innovative care model that has received widespread attention for its positive outcomes. Health Affairs highlighted the model in a series of profiles of key innovations in healthcare, reporting that in units where the model had been implemented, both cost and average length of stay had declined, nurse productivity had increased, and the percentage of patients satisfied with their care increased. The model was also detailed in arecent post by Leonard L. Berry and Jamie Dunham on HBR.org.  As word has spread about the success of this new care model, people have come from far and wide to visit ThedaCare to learn more about the model and the unique change management program that enabled it.

Engaging insiders in micro-moves may lack the dramatic flair of bringing in a S.W.A.T. team of consultants, but small moves, when many are taken together, can add up to big and lasting change that benefits patients, energizes staff and improves the healthcare system.

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