Why Good Ideas Aren’t Enough to Sustain Improvement

Michael Rose, MD, had a plan. An anesthesiologist at McLeod Regional Health Center in Florence, South Carolina, he was determined to help his organization use a new surgical safety checklist. Research indicated that it would help improve team communication and reduce complications and deaths associated with surgery. Surgeons around the globe were using it. Rose was confident he could convince the McLeod surgical units to adopt it.

First, he raised awareness of the checklist’s evidence-based outcomes. Then he trained staff to use an easy-to-implement method. He deployed sophisticated alerts to remind the surgical teams to use the checklist before going into the ORs.

Rose educated, communicated, persuaded, and cajoled. He used posters, conversations, and oversight. The CEO even issued a hospital-wide mandate.

After about 18 months, the adoption rate only hovered at around 30 percent.

Rose was discouraged. Patient safety was on the line. What else could he do?

The Psychology of Change

Doris Lessing, the famous British novelist, once wrote, “We know more about ourselves now than people did in the past, but very little of this knowledge has been put into effect.” Similarly, while there are examples of successful improvements in health care systems all over the world and countless evidence-based innovations, there is a gulf between what we know and what we do in practice.

Why not? Because we too often forget that change in health care won’t happen without people. If we want to make improvements, it helps to understand human beings and how we think and why we behave as we do. In other words, it helps to understand the psychology of change.

Some people become skeptical when they read or hear the word “psychology.” Maybe they roll their eyes. Let me be clear: This isn’t the “soft” stuff; this is the magic that makes improvement work.

Psychology is the science of how people think, feel, and behave. For our purposes, let’s consider the psychology of change a way to explore the thinking and behaviors that relate to improvement.

Understanding the psychology of change means learning how to activate people’s agency. In other words, how do we help people choose to improve? This isn’t about enforcing compliance. This is about tapping into people’s own belief that there’s inherent value in improvement. It means learning how to create the conditions that help patients, frontline staff, senior leaders, and others to work together to improve.

By applying the psychology of change to health care improvement, we build on our rich inheritance from W. Edwards Deming. His System of Profound Knowledge included psychology as one of its four key domains. The psychology of change expands upon Deming’s work by incorporating research on change management, behavioral economics, sociology, community organizing, design thinking, and scale up.

IHI Psychology of Change Framework

To help health care improvers, IHI has developed the Psychology of Change Framework (with a new IHI White Paper to be published in November), with five interrelated domains:

Unleash intrinsic motivation — Tap into the fundamental values that drive a health care provider and help them remember why they should make improvement a priority. Co-design people-driven change — Design improvement with those most affected by the changes you want to make. This can include patients and families. Co-produce in authentic relationship — Ask questions of those involved in and affected by improvement to understand and deeply value each person. Commit to the work together. Distribute power — Share decision making with leaders at various levels of an organization. No matter what position they hold in an organization, everyone has assets they can use to create change. Adapt in action — Recognize the value of learning about change by making change.

Applying the Psychology of Change

Michael Rose knew he needed a new approach to spread the surgical safety checklist. He decided to apply the principles of the psychology of change.

First, he distributed power. He recruited a leadership team made up of two socially influential nurses, a surgeon, a medical technician, an anesthesiologist, and a board member. Each of them had five to seven one-to-one meetings with those whom they felt they had some social influence.

To tap into the intrinsic motivation of the people they met with, they elicited stories about why they got into health care. They heard about people’s deepest values. They heard about their role models, their families, and injustices they had experienced. The storytelling helped all of them see beyond their own interests to recognize their common values and motivations.

As the leadership team had these meetings, they invited people to commit not only to use the checklist, but also to meet with five to seven others to have a similar discussion. They used a network cascade method to engage over 700 staff across the institution.

They co-designed people-driven change by testing new ways to make the checklist more workable. They continued storytelling during their daily OR debriefs. They talked about patients, families, and about how they were advancing change together as a care team.

Activating people’s agency brought results:

Surgical teams now use the checklist for 100 percent of their cases;

The surgical mortality rate decreased by 35 percent;

The hospital gained an annual economic return of 80,000 hours because they reduced hours per surgical case.

Surgical team members reported improved safety culture measures, increased job satisfaction, and decreased burnout.

Rose noted that surgical team members not only saved patients’ lives by adopting the checklist, but they also “saved” their own lives by renewing their spirit and improving staff well-being.

I’ve had the joy of working on the psychology of change with people at IHI and some of IHI’s partners for the past year. Seeing them put it into use is like teaching someone how to ride a bike. We don’t learn by reading a book on bike psychology. We have to get on the bike and practice. Once we figure out what works for us, we really take off!

Kate Hilton, JD, MTS, is a founding director and senior director at ReThink Health and lead faculty for IHI’s Change Agent Network.

Editor’s note: Kate Hilton is a presenter for Quick Course Q1 Psychology of Change: A Human-Centered QI Approach at the IHI National Forum (December 9–12, 2018 in Orlando, FL, USA).