Improvement Fatigue

Everyone is working hard to improve the healthcare system, but is the frontline running out of gas?

By Ian Morrison

The PowerPoint is easy: Healthcare needs to move from volume to value, we must improve patient safety and quality, reduce the cost of care and transform the entire patient care experience to be higher performing, by using modern information technology: all noble, necessary, and non-negotiable.

But, here’s the issue: we may be straining the ability of frontline caregivers to pull this all off. They don’t just do PowerPoint, they have a day job: they look after patients. And many are at their wit’s end.

In the past few months I have had many conversations and interactions with health system leaders and boards; professional clinical leaders (physicians, nurses, clinical pharmacists and others); medical directors of health plans, physician associations and health systems; and real live physicians and nurses who deliver care. Every one of these people, each in his or her own way, points to what I have come to term improvement fatigue.

As usual, my brilliant insight was not original. (There are no new ideas, basically all of us pundits are in the recycling business). It turns out that as long ago as 2007 a high profile group of medical leaders ( pointed out in a prestigious medical journal the rise of quality and improvement fatigue as a growing consequence of the increased pressures to measure and improve the quality of care. But in the last eight years the pace has intensified as bigger strategic commitments are being made to reach the lofty PowerPoint future of health improvement and transformation that is being pursued by government, purchasers, and health delivery systems themselves.

Don’t get me wrong, I support the PowerPoint… hell, I wrote a lot of it. But all of this change trickles down to the caregivers and they need help.

They want to understand better the “why of change” in a clear and coherent way, and they need help and support in changing how care is delivered while at the same time they are actually delivering care.

This is a key challenge for health system leaders: to learn to spot improvement fatigue and help frontline caregivers overcome it so that they can continue to do what they always wanted to do: care for their patients in the best possible way.


What is Driving Improvement Fatigue?

Obamacare Angst. Ironically, we celebrated the fifth anniversary of Obamacare (which reduced the uninsured by a third) with the 50th vote by the House of Representatives to repeal it. Our national sport is knocking Obamacare and using it as the whipping boy for all we hate about healthcare: high deductibles, financial gotchas, high prices, waiting times for appointments, bureaucratic impediments, government incompetence, private sector malfeasance etc, etc. You hear it from many clinicians: “this will all get better if we just get rid of Obamacare.” Well actually, no. The problems of cost, access, quality, value and security of benefits would, in my judgment, be aggravated by repeal, not helped. Valuable momentum would be lost, and politicians of every stripe would be loathe to make bold moves, taking the steam out of the promising progress we have already made and will make if we stay the course. But, it is true that Obamacare has been a significant accelerator, stimulator, and funder of change – and quite frankly at the same time a convenient excuse for health plans, health systems and purchasers to pressure caregivers to make necessary changes happen.

Need for Explanation of the Why of Change. Clinicians are smart, you can explain to them the why of change: the lack of affordability, the need for transparency, the moral necessity of coverage expansion, the desirability of moving from volume to value, and so forth. If you need help just look at recent columns from fellow columnists Joe Flower, Emily Friedman and Paul Keckley. Or turn to the rich resources of the AHA Health Forum.   But it is not enough for health system CEOs to just explain the why of change to their board, they have to explain it to everyone who delivers care. Harris surveys of hospital leaders we conduct try to identify who is on board with understanding the financial necessity to make changes. We find that the boards are on board, the CFOs are on board, the management team is on board. There are just three groups that are not on board: doctors, nurses, and patients!

Mixed Signals. To make matter worse, when leaders reach out to explain the why of change, (the volume to value journey, the path to population health, and so forth) they give the great talk and then follow it up with demands for RVU productivity, or referral management and patient flow capture, or, worse yet, growth targets for ancillaries. As Tonto said: “they speak with forked tongue.” (Full metaphor disclosure: Most of what I knew about Americans [until I became one] was from TV, I loved the Lone Ranger as a young boy in Scotland and would change out of my kilt after Sunday School to don my Lone Ranger outfit. There is no higher authority to me than Tonto.)

High Stakes. Improved patient experience, reduced readmissions, elimination of avoidable harm are all noble goals, but now there is money attached and it is only going to grow as a share of all health spending. A greater share of reimbursement will be at risk for performance as purchasers and providers alike, pledge to bold and ambitious targets. This is high stakes stuff.

Multi-Tasking. There are so many different improvement projects going in most clinical areas that there has to be confusion. Whether it is Lean overlayed with checklists, new quality metrics, patient satisfaction improvement projects, and the implementation of electronic health records, the effects must be bewildering to the front line. This is particularly true of complex inpatient care where the acuity levels continuously rise as more routine care is shifted to the ambulatory environment. A perfect example was a meeting I had with quality improvement specialists from a variety of leading institutions who were focused on implementing specialized clinical decision support software. I asked them if there was confusion and fatigue with all these improvement initiatives. One young lady pulled out her business card and showed her new title to the group: “Coordinator of Coordinators.” Enough said.

The Quality Police. I am a big fan of transparency, quality improvement, measurement and public reporting. I salute the pioneers from NCQA to NQF to Leapfrog to CMS to Healthgrades to Consumer Reports for putting their time, talents and resources into the infrastructure for quality and accountability. But, among the caregivers I talk to, many of them feel that the measures don’t measure what matters to them and don’t truly reflect quality as they see it. Even more worrisome, the measures are cumbersome to collect, and are duplicative and often inconsistent in their results. A terrific example of this was a recent careful academic study ( that found that there was remarkably little consistency in the results of the different hospital quality rating systems. This finally explains the old joke that there are 432 Top 100 Hospitals in America (is this a great country or what?) Many clinicians feel the quality police are watching them, yet don’t always know the transgressions they might commit, or even whether they can actually affect what is being measured.

Complexity. At a recent meeting of leaders of academic medicine, a wise old dean asked me a really hard question: what can we do to eliminate the underlying complexity? He meant of course, not only the complexity of medical science and of care delivery, but also the administrative, economic, regulatory and financial complexity. America has the most complex health system in the world, and it’s being made more complex every day by everything from Obamacare regulations to personalized medicine. I didn’t have a very good answer, beyond: “ Make things simple.” As Apple has shown it requires genius to make things simple. It’s not easy, but it’s crucial.

The Electronic Health Record. If there is one source of improvement fatigue above all else it is the electronic health record. I have a slide I put together that shows old movie posters of Ben Hur and Lawrence of Arabia with the caption: “There is a reason they call it EPIC: it’s big, it goes on forever, and it costs a fortune.” Any time I use it with a provider audience it gets a dry laugh. AMA surveys and countless anecdotes reinforce the notion that the electronic health record is a major source of improvement fatigue. Clearly electronic health

records are a step in the right direction, but how do we help clinicians deal with the transformation, without losing their mind.


The Digital Doctor

Mercifully, we have a new resource in the form of my friend Bob Wachter’s brilliant new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. It helps us understand where we are and where we are headed with information technology in medicine and the appropriate role it should play in improving medical care. The Digital Doctor will be an invaluable resource in the battle to overcome improvement fatigue among clinicians attributable to the Electronic Health Record (and the other sources discussed above) because it explains the positive and the negatives of digital medicine in a thoughtful, nuanced, balanced, and engaging way.

Bob is always annoyingly excellent at everything from golf to Elton John impersonations, but his latest work is extraordinary. His book coherently explains the pitfalls and promise of digital medicine and provides a sober, smart and beautifully written review of our rocky recent history and our likely more promising future. Moreover, it is grounded in both deep scholarship on the subject and candid, contemporary conversations with nearly one hundred of the leading luminaries in the field, from venture capitalists to policy wonks to practitioners.  Bob has the advantage of being a distinguished academic and practicing physician at UCSF, as well as a leading health policy expert and pioneer in the quality and patient safety movements. He also coined the term “hospitalist,” and has been a leader in that specialty, the fastest growing in the history of medicine. Finally, he is one hell of a gifted writer.

I read the first half of his book and sent him an e-mail: “Unless you f-ed up the second half, it’s a tour de force.” Well, the second half is better than the first and will help leaders, clinicians and the public at large understand what’s at stake in moving medical care to the digital age. Bob’s book should be a must read for everyone in healthcare. It explains and inspires, and it will provide succor, support and solutions for individuals and organizations suffering from improvement fatigue.

Treating Improvement Fatigue

So what can health leaders do beyond reading and disseminating The Digital Doctor?:

Tell a Consistent, Coherent Story. Healthcare leaders must consistently and continuously explain the why of change to their organizations, particularly the front line caregivers. You cannot over-communicate. But, remember these are intelligent professionals who value authenticity, consistency, and scientific evidence. They are not easily persuaded by illogical PowerPoint exhortations that seem at odds with observed behavior and priorities.

Rethink Physician Leadership. The healthcare system has a problem. We need to redesign clinical care for higher performance and this is fundamentally work that must be led by and embraced by all clinicians, with physicians taking the lead. There is a woeful dearth of physicians capable of leading the transformation of multi-billion dollar clinical enterprises. Just because you have a medical degree (and even an MBA as well) doesn’t mean you have the stuff to lead massive change in complex organizations. (It is important to have both the degrees and the experience in managing large scale operations, but it’s a Catch 22 how do you build that leadership experience if you haven’t had a chance to lead clinical organizations?) Conversely, the current practice of systems co-opting a smart, committed and gifted physician, bestowing on him the title of CMO, and asking him to run interference with medical staff and shape up his clinical colleagues to get with the improvement program is not necessarily a recipe for success. Especially when these CMOs usually have no P and L responsibility, limited staff, and no real organizational power to hire and fire.

I hear it from CEOs all the time: where can we find, and how do we grow, Chief Medical Officers who have the skills and savvy of a big-time operations person and the clinical acumen, leadership skills and street cred of a brilliant clinician? And from CMOs and physician leaders I hear the other side of the coin: when are we be going to be given the power, the budget and the authority to make real and lasting change in the clinical enterprise? Some organizations may succeed by using diads of physicians and administrators (as Mayo has done for generations), or they will be lucky enough to find those exceptional physicians who can effectively manage large enterprises. But, a sustainable future requires the entire healthcare field to systematically find a way to attract, develop and give leadership learning opportunities to physicians who can build lifelong careers as leaders of massive clinical operations that will be in a constant state of change.

Provide Institutional Support. Progress is being made despite the difficulties. The field has shown that readmissions can be reduced, central line infections eliminated, inappropriate elective c-sections reduced. Many worthy improvement successes have happened seemingly without exhausting practitioners. Key lessons come from successful pioneers such as the Michigan Hospital Association’s Keystone Project: draw on the nation’s best experts and best practices, focus on a few actionable initiatives, and consistently provide support, training and infrastructure for making change happen. It is about capacity building, focus and perseverance.

Emphasize Noble Purpose. Even with great leadership and strong institutional support, clinical improvement will not occur without the active and enthusiastic support and participation of all front line caregivers. And here is the good news: If you can look clinicians in the eye and say that change and their help in change will be better for the patients, families and communities you serve, they will be with you.   Connecting to noble purpose will help overcome improvement fatigue.