Nearly 1/5th of US GDP is dedicated to healthcare expenditures.
Healthcare spending, and its long-term affordability, drives public policy debate, with academics and government agencies annually proposing new plans as part of an agenda to control costs and improve health outcomes. The proposals fit nicely within concepts that seem to promote advantages for patients. An example is the upcoming event, Patient- and Family-Centered Care for Adults with Chronic Conditions, by the U.S. Agency of Healthcare Research and Quality.
Among the many events that seek to address the health care debate, the AHRQ is particularly promising as it examines real examples of patient experiences. However, AHRQ’s efforts could be significantly enhanced if the format and outcomes include direct conversations with healthcare executives – the officials who manage the designs of operations and organizations that affect patients.
At heart, healthcare executives have a unique role in society. They shape the organizational behavior of a diverse industry, including doctors, nurses, pharmacists, technicians, and other that we contact through our medical lives. It is an organizational behavior that informs us, the patients, what we can expect and control in clinical and overall health experiences.
That expectation and control is our “patient agency,” the ability of a patient to evaluate, decide, and act on healthcare matters according to personal preferences. It includes control over (1) visible and understandable information, (2) flexible and efficacious processes, and (3) effective and authoritative decision-making.
Patient agency is critical to the success of healthcare outcomes – and quality healthcare overall, given its direct influence on successful treatment and prevention of the most prevalent health problems, namely chronic diseases and behavior-driven conditions.
And healthcare executives can directly affect patient agency. In fact, that might be where our public policy and plans should begin—where health is foundational to an individual experience—patient agency and the healthcare executive.
What is the scientific research supporting this conversation?
There are numerous examples, some noted below, that demonstrate how the patient is the legitimate leader of her or his health and medical interactions. There is substantial evidence demonstrating the value of patient agency both in the demand for healthcare and the outcomes of treatment.
Patient agency drives healthcare outcomes:
- Greater sense of control enhances patient’s resiliency (Diesnstbier, 1989; Herbert and Cohen, 1993; Sieber et al., 1992; Wiedenfeld et al., 1990).
- Disengaged cancer patients tend to have unfavorable outcomes (DiClemente and Temoshok, 1985; Greer, Morris, and Pettingale, 1979; Pettingale et al., 1985).
- Pain control training produces better dosage schedules and less pain at follow-up (Rimer, Levy, and Keintz, 1987).
- Cardiac patients who can control visits and their timing demonstrated lower mean heart rate and diastolic blood pressure (Lazure and Baun, 1995).
Patient agency is useful in managing service utilization:
- Preparatory information is associated with shorter hospital stays, reduced morbidity, and reduced need for analgesics (Eisendrath, 1987).
- Video presentations on back surgery improved patients’ knowledge about options and reduced the demand for surgery (Deyo et al., 2000; Phelan, 2001).
- Under severe conditions (ovarian cancer), greater understanding of information is a strong determinant of treatment choices (Elit, Levine, and Gafni, 1996).
- Patient-controlled analgesia devices maintain effective concentrations (Hull and Sibbald, 1981) while keeping constant rates (Austin, Stapleton, and Mather, 1980).
Patient agency is reinforced by thoughtful clinical communications:
- Patients’ medical comprehension is dependent on clarity and specificity of the content (Hall, Roter, and Katz, 1988), and manner of delivery (Larsen and Smith, 1981).
- Patient’s medical objectivity is appropriate, given age (Stiggelbout et al., 1996; Yellen, Cella, and Leslie, 1994) and responsibilities (Yellen and Cella, 1995).
- Patients are consistent in medical decisions (Cassileth, Seidman, and Soloway, 1989; Danis et al., 1994; Everhart and Pearlman, 1990; Slevin, Stubbs, and Plat, 1990).
- Patient’s can communicate preferences when multiple trade-offs characterize complicated treatment decisions (Brundage et al., 1998).
A classic study on patient agency was completed at the U.S. Department of Veterans Affairs. VA researchers experimented with how they could affect patient agency through innovative techniques (Greenfield et al., 1985). They found that both veterans and programs could benefit significantly from designs that reinforce patient agency development. The examination was of a 20-minute pre-visit coaching program. The study demonstrated sustained and significant benefits in patient agency and physical health, without additional clinical time. In their conclusions, they contended that without well-developed patient agency, veterans “may not acquire the knowledge, skill, and more importantly the confidence and sense of control they need in the management of chronic disease” (p. 456). The study also illustrated that reinforced patient agency could help manage unnecessary use of healthcare services and improve veterans’ ability to prevent acute health problems.
Patient agency is developed in a person, and reinforced by local experiences. It is the foundational aspect of health outcomes, and largely shaped by the experiences designed by local healthcare executives.
We need to shift our attention away from the grand plans for healthcare and look to the value of the local leadership – leadership in personal health and healthcare services. Our common national objectives, lower cost, quality care, better outcomes begin with patients, not bureaucrats. We need to align our reform processes accordingly.
When we consider the nature of optimal work, almost everyone agrees on the one model to avoid – government.
The stories and experiences are part of our collective national legend. Scandalous layers of bureaucracy, soul-draining procedures, wasteful duplication and serial cost overruns, as well as mind-numbing regulations that are as dense as a triple canopy jungle. Work guided by process instead of purpose, seemingly impervious to improvement or reason, driven by the lowest common denominator.
It is no small wonder that Gallup consistently finds citizen trust in government at an all-time low, while a recent Harvard Institute of Politics finds particularly low trust levels among the newest generation of voters, Millennials.
Interestingly, the citizenry is not alone.
What is less apparent, but more meaningful, is that individual federal workers intuitively understand the need for innovation to improve the delivery of government services, and the vast majority are committed to do so. However those same workers do not believe that management encourages or rewards government workers for having this vital sense of initiative.
The Partnership for Public Service, in conjunction with private sector firms, examined the issue of innovation in government and the elements that foster and drive innovation in the public-sector space. According to the survey, 90 percent of government employees reported that they were always looking for better ways to do their jobs. However, only 55 percent felt that they were encouraged to be innovative, and only 33 percent believed that their agency would reward creativity and innovation.
Far removed from our common stereotype, federal workers are in fact motivated to improve the way they do their work, but simply do not feel that there is priority or benefit from management in doing so.
This represents a failure of executive vision; a lack of performance leadership by federal managers, writ large, which has left untapped the enormous “captive value” of the federal workforce. At a time of large-scale, public sector austerity, this value can serve as a “no cost” force multiplier across the federal government, liberating a wellspring of creativity and inspiration that has the power to transform outcomes.
The survey is a warning to the upper echelons of the federal government, and particularly to our political appointees, charged with charting a long-term course for effective, accountable government.
Program by program, the federal government must embrace performance engineering as a tool to foster performance leadership among executives, to connect management to employees through clear vision, goals and methods, and to embrace a culture of rigor as a cornerstone of program, process and practice evaluation so that organizations can constantly evolve, intelligently.
The raw talent and ambition exists. We need a concerted effort to “humanize” work, to un-cap that latent potential. This is necessary not simply to attract and retain the best and brightest in our federal workforce – which is essential - but more importantly as part of a concerted effort to restore citizen confidence in our public institutions.
Innovators don’t plan for obsolescence.
Self-evident, but paradoxical.
For no matter how disruptive an innovation is to the marketplace, the seeds of its obsolescence are already an integral component, embedded within the very processes that drive growth.
It is the dilemma of market acceptance.
Successful innovators first crack the market, and then own it. However, in the process, priorities necessarily change. The initial focus on market acceptance evolves into a sustained effort to protecting market share, clients and customers. Internally, a culture that had previously embraced risk, flexibility, dynamism, begins to atrophy through bureaucracy, inertia and risk-aversion.
Consider Kodak. Once globally synonymous with photography, Kodak’s comprehensive failure to adapt its business model as new technology fundamentally changed the market led to bankruptcy. Or Blackberry, which pioneered the market for the smartphone. Once ubiquitous, Blackberry’s determination to sustain its legacy business proved its undoing at the hands of innovative rivals.
For established innovators looking to maintain their edge, the risks of a failing performance culture have only gotten worse, as new technologies and shared service paradigms have driven the threshold costs of starting a credible business – and new competition – to unheard of lows. Collaborative communities, such as Odesk, allow new companies to outsource specialty work at competitive prices. Cloud computing offers the start up an entire data infrastructure that is scalable with the expansion of business. Communal work arrangements provide office space for incubators. And the explosion of VCs and variants, has made investment capital accessible to the individuals with good ideas.
The differentiator for successful innovators is an understanding of what can be controlled and changed. Maintaining a sustainable edge in this new and challenging business landscape requires matching the dynamic realities of the market with a rigorous organizational culture. To empower employees and unleash their captive value. To amplify the leadership of executives who can articulate a clear, concise and understandable message that engenders a culture of team work, best practices and problem-solving. To create an internal consciousness within the organization were individual initiative is collectively valued and recognized. Where the rigor of sustained performance improvement is the baseline for minimally acceptable conduct. Where the nature of work is humanized, not commoditized.
Google, Facebook, Amazon and Twitter – the popular innovators of our day, are all less than 15 years old. They displace other, well known firms that were once household names for decades, but who could not keep pace with the market. The trend will only continue, as the cycle of innovation becomes more compressed and the field of competition grows larger and more intense.
We cannot stop change, only adapt to it. A rigorous performance culture is the key to that success.