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How to Deal with Pushback and Other Large-Scale Change Lessons Learned

By Rebekah Gee | Friday, July 30, 2021
How to Deal with Pushback and Other Large Scale Change Lessons Learned

In 2010, Louisiana had some of the highest C-section rates in the country. Two years later, elective deliveries before 39 weeks dropped by 90 percent in the state. What made the difference?

Many credit the Louisiana Birth Outcomes Initiative, a statewide partnership with the Institute for Healthcare Improvement (IHI) led by Rebekah Gee, MD, MPH, when she was Chief Medical Officer for Louisiana Medicaid. In addition to reducing the C-section rates, the initiative also contributed to a 25 percent drop in infant mortality and a 10 percent reduction in NICU admissions. Gee, who is now the CEO of Health Care Services at Louisiana State University Health Sciences and a new IHI board member, talked in a recent interview about what she learned about using quality improvement to take on large-scale challenges and how her life experiences shape her dedication to partnering with patients and families.

On using data to evaluate the scope of a problem

When I was tasked by then Governor Bobby Jindal to improve birth outcomes in Louisiana in 2010, I wasn’t told what to improve or how much to improve outcomes by, it was a daunting request. As such, I started out by trying to understand the current state of the issue on hand. I found that infant mortality and prematurity rates were exceptionally high statewide. In fact, Louisiana had some of the highest C-section rates in the developed world. Some hospitals had C-section rates of over 40 percent. One hospital had the highest rate in the nation. I also saw tremendous disparities in care. People were being treated differently because of the color of their skin.

On learning from the right teachers

To start, I contacted the smartest people in the country who had done the most writing [on maternal and child health] to ask them to work with me. They were people like Elliott Main, Kay Johnson, and Michael Lu. I also came to IHI after I found that Woman’s Hospital in Baton Rouge was the hospital in Louisiana that was doing the best job controlling their C-section rates. Woman’s Hospital had brought in IHI and the maternal health care team, led by [former IHI director] Sue Gullo, to help them improve their culture and improve outcomes. Woman’s had seen some exciting initial results with decreasing C-section rates and improving the customer care experience.

On how good ideas aren’t enough to change the status quo

At first, the secretary of the Department of Health and Hospitals had misgivings about the collaborative approach to improvement. He said, “Why do we have to have all these meetings? Why don’t you just do it?" IHI helped teach me that the hardest part about improvement is not coming up with ideas or even solutions. Implementation of the right ideas are the key, and implementation happens when you have buy-in [from key stakeholders]. We had some ideas from the start about what we wanted to do, but having change ideas come organically from teams of physicians, nurses, quality improvement experts, hospital CEOs, the leadership of the hospital association, and patients was a powerful driver of change. It helped get everyone invested in the work.

On how to deal with pushback

There were many people, initially, that did not think there was a need for change. As we first traveled the state, people tried to ignore us or laugh at us. We had meetings where hospital leaders said, “You’re ridiculous. The data you’re showing us isn’t right. We don’t need to change.” Hospitals called up the governor. They complained to the health secretary saying, “This Dr. Gee lady and her team are nags, and we don’t have to change anything.” What I learned over time was that empathy and caring motivate people to change. If you can convince people that the changes you’re asking them to make will result in improving or saving someone’s life, it’s hard for them to fight it. You get the big pushback when people don’t understand what the work is about, and they just feel like you’re just making their job harder.

On drawing from life experience to make change

I’m a physician. I’ve seen patients throughout the course of my career since becoming a doctor. My patients teach me about the problems in health care that need to be solved. Also, I was hit by an SUV in 2008, and I spent three months in a wheelchair. I had 18 broken ribs and a paralyzed left arm. I spent a month in a rehab hospital. All this is to say that I understand what being a patient means in a way that most physicians don’t, and I hope they never do. I also learned so much watching my mother’s caregivers when she died of breast cancer. I’ve had twins. Having had a C-section myself, I deeply appreciate that they ought to be prevented if they’re not needed. I think so many of these experiences have informed the work that I do and my commitment to bringing patients to the table because their voices can be the most powerful.

On why improving maternal health care matters

I got one of the best Christmas presents of my life two years ago when I got a call from a hospital administrator who said, “We’re a rural hospital. We’re 90 miles away from a blood bank, and we used the [hemorrhage bundle] for one of our patients. We realized she was very high risk, and we ordered blood ahead of time. She ended up needing seven [units]. If we hadn’t [used the bundle and been prepared], she would have died.”

The problems women face — whether it’s our birthing experiences or our contraceptive needs — they are too often very low down on the list of policy priorities for those who have been in charge. For women’s health to change, we need people in charge who care about women, and about birth outcomes. We need people who care about Black women’s births and their birthing experiences because they are too often not respected and have poorer outcomes.

We’re far from where we need to be in Louisiana, but we were able to reduce hemorrhage and hypertension [during childbirth]. The preliminary numbers were 39 percent, but it’s looking we’ll get to about 60 percent within a few years. These improvements resulted from using simple interventions, like hemorrhage carts, team training, and checklists. But these changes need to happen on a broader scale. I think having more women in leadership will help. Improving birth outcomes has huge implications for health care costs and long-term outcomes.

On what IHI should be doing in the next 30 years as IHI celebrates 30 years as an organization

In recent years, IHI has done tremendous work internationally. We also have people here in the United States who need our help. I’m talking about people who live in the Mississippi Delta, for example, whose lives have not materially changed in 100 years. They live in abject poverty and don’t have access to clean water or adequate education or transportation. These folks have horrific outcomes compared to the rest of the developed world. I want IHI to lean in on [improving the health of] vulnerable populations here in the United States. I want to see IHI lean in more on health disparities. I’m excited to see more of IHI leading discussions on how to make the changes that will lead to improvement when we talk about disparities.

Editor’s note: This interview has been edited for length and clarity.

(Having difficulty watching this video? Watch on YouTube.)

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