|By Susan Dentzer, MA, Senior Policy Adviser to the Robert Wood Johnson Foundation; Member, Innovations Exchange Expert Panel|
Efforts to promote health care innovation are more likely to succeed if they are based on an understanding of the forces that drive innovation as well as the adoption and spread of innovation. By considering the factors that stimulate new ideas and that motivate people and organizations to take them up to improve performance, we can better explain why a particular innovation achieves its goals and is emulated in other settings. Such a conceptual framework also provides the foundation for designing effective initiatives to encourage innovation and adoption of innovations, and thereby to achieve health system transformation.
Acceleration of innovation is a necessity if the U.S. health care system is to achieve what Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services, called the Triple Aim: better health, better health care, and lower health care costs. This set of goals remains the guiding principle of ongoing efforts to reform the health care payment and delivery system. The need for improvement is abundantly clear in light of the relatively poor health of the U.S. population,1 persistent deficiencies in the quality of care,2 and growth rates in health expenditures that, while slower than in recent years, continue to outpace the growth of the general economy.3
Given the formidable challenges involved in making progress toward the Triple Aim, where can we expect to find opportunities for innovation? In his influential book Innovation and Entrepreneurship,4 Peter F. Drucker described seven sources for innovative opportunity in the business sector, all of which are relevant to efforts to foster innovation in health care, as follows:
Drucker’s crucial insight was that change provides the opportunity for innovation, and systematic innovation is the purposeful and organized search for changes that can be exploited. Rather than thinking in terms of innovations driving change, we should keep in mind that successful innovations almost always exploit changes that are already under way. Therefore, efforts to promote health care innovation should aim to identify changes that can pave the way for new approaches.
- The unexpected success, failure, or outside event. A current example, either positive or negative, might involve the performance of new health insurance exchanges under the Affordable Care Act (ACA) or recent Federal appeals court rulings on the applicability of Federal subsidies to coverage purchased through the federally run “marketplaces,” or exchanges.
- Incongruity between reality as it actually is and reality as it is assumed to be. We can easily think of incongruities between our assumptions about high-quality health care and the actual care that patients receive—or, for that matter, between the assumption that high-cost care is necessarily high-quality care and the evidence that this is not always the case.
- Process need. A classic example involves U.S. auto manufacturers that were competing against Japanese firms in the 1980s and 1990s and that needed to adopt changes similar to those the Japanese firms had adopted to improve quality and reduce defects. Health care organizations today face comparable pressures to improve outcomes while curbing costs.
- Changes in industry or market structure. This phenomenon is a major concern for health insurers as they adapt to major changes in the insurance market structure driven in large part by the ACA.
- Demographics. For example, the United States is well on its way to becoming a majority minority population, and that trend is likely to necessitate, as well as prompt, a variety of health care innovations.
- Changes in perception, mood, and meaning. We might ask how health care delivery may change in response to the younger generation’s preference to obtain goods and services online, rather than visiting a brick-and-mortar setting.
- New knowledge—scientific and nonscientific. For example, it seems certain that breakthroughs in the application of genomics in medicine will drive further innovations in health care.
How can we incorporate these ideas into a conceptual framework for understanding the innovation process in health care? First, we can place Drucker’s list of changes that create opportunities for innovation along one dimension (the Y axis) of a matrix of factors that drive health care innovation. Next, across the other dimension of the innovation matrix (the X axis), we can place two other key factors: the internal and external motivators that determine the level of urgency for the adoption and spread of innovation in pursuit of the Triple Aim (see figure).
Figure 1. This diagram shows how opportunities (Drucker's categories) and motivators (external and internal) drive the innovation process in health care. Click the image to enlarge.
Internal motivators come into play when staff in a hospital unit or some other health care organization look at their performance and decide, “We could do a better job.” External motivators include policy changes, such as elements of the ACA that aim to achieve better health, better health care, and lower costs.
For an example of an extrinsic factor that is leading to innovation, consider how tax-exempt hospitals and health systems are engaging in population health activities in response to new requirements under the ACA. In order to retain their Federal tax exemption, these organizations must conduct a “community health needs assessment” at least every 3 years and must adopt an implementation strategy for meeting the community health needs that the assessment identifies. The penalty for not meeting these requirements is an excise tax of $50,000 per year. This mandate has led to a sharp increase in analysis of community health status, health factors, and health outcomes. As a consequence, this ACA requirement has fueled enormous growth in the use by health care systems of the Community Health Rankings and Roadmaps, an initiative that was funded by the Robert Wood Johnson Foundation prior to passage of the ACA and was developed in partnership with the University of Wisconsin Population Health Institute.
Although it’s important to focus on the factors that create opportunities and motivations for innovation, we should not lose sight of the fact that a lot of worthwhile innovation has already taken place, as is evident in the hundreds of innovation profiles on the Health Care Innovations Exchange. With that in mind, it is crucial to consider how to promote the scale up and spread of innovations that have been shown to be effective.
Robert K. Ross, President and Chief Executive Officer for the California Endowment, aptly captured this challenge for society as a whole: “When it comes to addressing today’s urgent social problems, from education and public health to civil and human rights, innovation is overrated. The greatest impediment to solving these problems is not a lack of innovation. Rather, it is our inability to scale up solutions that we know work.”5
If, as I believe, the biggest challenge we face is a shortage of adoption of innovation, rather than a shortage of innovation per se, how can we best encourage the dissemination and take-up of effective innovations? The spread of innovation depends mainly on knowledge sharing through social networks, according to Paul Plsek, of Paul E. Plsek & Associates (and a former member of the Innovations Exchange Editorial Board). At a conference on the diffusion of innovations, he offered this recommendation: “Devote considerably more attention and effort to social networking in health care as being essential to the goal of spread of innovation.”6
Mr. Plsek’s perspective on innovation adoption reflects in part his experience in helping Virginia Mason Medical Center in Seattle to apply lean manufacturing principles to health care delivery, thereby eliminating unnecessary treatment, reduce costs, and improve quality.7 The initiative had its origins at least in part in social interactions: After learning about the use of lean manufacturing by locally based companies with global operations, such as Boeing, staff at Virginia Mason went to Japan, observed the Toyota production system, and set out to translate the core principles into their health care organization. Extrinsic motivation also played a role, because stakeholders were telling Virginia Mason that its costs were too high and that patients were facing long waits to get care. The result was a collaborative effort to apply innovative approaches to make care more cost effective.
Mr. Plsek also highlighted the importance of describing the organizational context of a successful innovation. Moreover, he pointed out that the basic medical precept, “First, do no harm,” tends to foster a conservative attitude toward change in health care. He recommended asking, “Realistically, what is the worst thing that can happen?” when contemplating adoption of any innovation, and then discussing how to manage potential risks. By anticipating and addressing the potential objections to an innovation, health care organizations can help ensure that valuable new approaches are applied in new settings for the benefit of patients.
Full implementation of the ACA promises to create a new wave of incentives for health care organizations to improve health care delivery, reduce costs, and achieve better population health. The insights into the development and spread of innovative solutions described here can help overcome barriers to achieving the Triple Aim.
About Susan Dentzer, MA
Susan Dentzer, MA, is senior policy adviser to the Robert Wood Johnson
Foundation and an on-air analyst on health issues on the "PBS NewsHour."
From 2008 to April 2013, she was the editor-in-chief of Health Affairs.
From 1998 to 2008, she led the health unit of the "PBS NewsHour" as on-air
health correspondent and was the recipient of numerous honors and
awards. Ms. Dentzer is an elected member of the Institute of Medicine
and the Council on Foreign Relations. She graduated from Dartmouth and
chaired the Dartmouth Board of Trustees from 2001 to 2004. She is a
member of the Board of Overseers of Dartmouth Medical School and a
member of the Boards of Directors of the American Board of Medical
Specialties, the Public Health Institute, Research!America, and the
International Rescue Committee.
Disclosure Statement: Ms. Dentzer reported having no financial
interests or business/professional affiliations relevant to the work
described in this article.
Dentzer S. Still crossing the quality chasm—or suspended over it? Health Aff (Millwood). 2011;30(4):554-5. [PubMed]
Cuckler GA, Sisko AM, Keehan SP, et al. National health expenditure projections, 2012–22: slow growth until coverage expands and economy improves. Health Aff (Millwood). 2013;32(10):1820-31. [PubMed]
4 Drucker PF. Innovation and entrepreneurship: practice and principles. New York: Harper & Row; 1985.
Plsek P. Complexity and the adoption of innovation in health care. Paper prepared for Conference on Accelerating Quality Improvement in Health Care: Strategies To Speed the Diffusion of Evidence-Based Innovations; 2003 Jan. 27-28; Washington, DC. Available at: http://www.nihcm.org/pdf/Plsek.pdf
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7 Plsek P. Accelerating health care transformation with lean and innovation: the Virginia Mason experience. New York: Productivity Press; 2013.