When I was a health system CEO, we had a committee that would agree on the national formulary of medications physicians and others could prescribe. Most of these experts were academic clinicians. Some were industry representatives.
A few members of the committee expressed misgivings about including a patient in our discussions. They doubted that patients would understand the complexities of our decision-making process. Their concerns proved to be unfounded. The introduction of the patient representative to the process changed the dynamics of the group and the conversation itself.
Traditional experts often come to best practice discussions with predetermined views. They have a seat at the table because they’re representing a position. Patients, on the other hand, often come with only their lived experience and the best interests of patients in mind.
For many years, I’ve been wondering how health care can close the gap between what we know and what we do. I’m not the only one. In 2003, Beth McGlynn and her colleagues shared in an article in the New England Journal of Medicine that only 55 percent of the thousands of adults in the US they studied received recommended care.
Why is there a gap between our understanding of quality care and what patients receive? It’s not because the experts who define best practice aren’t knowledgeable or that their recommendations are incorrect. One reason is because we too often forget the patient and the practitioner whose job is to implement those practices.
It’s easy to overlook these key constituents when they’re not part of the discussion. Currently, best practice is too often determined by the few (a select group of people who are not representative of society) for the many. The “few” are almost always older, white, and male, and that exclusivity is doing all of us a disservice.
How Conventional Thinking Holds Us Back
Please don’t misunderstand me. Expertise is essential. Scientific evidence is possibly more important now than ever before — and ought to be central to all our best practice discussions — but it’s not enough. Here are some of the other ways in which conventional thinking about who determines best practice holds us back:
- It forces us into a closed mindset rather than a growth mindset — As humans, we tend to think of “best” as final. What if, instead, we always used the term current best practice? That could help us remember that best practice is transient and always improvable.
- It makes our view too narrow — Current best practice needs to be created by the many for the many. We ought to make sure we equity-proof every set of guidelines or standards. In other words, are we sure a set of practices is going to close disparities rather than widen them? How are we going to know? We’re much more likely to improve practice equitably if we’re more inclusive.
- It takes too long for best practice to reach patients — There’s often a misapprehension that involving more people in developing best practice will slow things down. I would argue that opening the process to a diversity of views and experiences will help us get to a better result for more people more quickly. With patients in the room, for example, we’ll get a better sense of whether new ideas will work in real life with people who may not have medical degrees or PhDs. In almost every clinical design process in which I’ve been involved, patients were the ones who brought refreshing candor. They question traditional assumptions. It’s very often the patient who asks some of the most important questions: “Why is that necessary?” “Do we have to do it this way?” “Is there a way to make it easier for patients?” “What’s the downside to doing it this way?”
So, what can we do? How can we undo our conventional thinking about best practice?
- Incorporate improvement knowledge into the development of current best practice — I fundamentally believe that the collective expertise of clinical subject matter experts, improvement and implementation experts, and patients is far greater than the contributions of any of these groups separately. The creation of current best practice should be an open, cooperative endeavor and not allocated or assigned to just one these groups.
- Broaden who is considered an expert — If you’re a clinical subject matter expert, think about how your contribution to the creation of current best practice can work alongside the expertise of others, particularly patients and families.
- Ask what we might learn from other industries — In technology, for example, nothing is ever “best practice.” Everything is always in development, and often the people they rely on most to help them get to the next best version of a product are its users. We do it every time we use our smart phones. How we use our phones tells technology companies, for example, what functions we use, how often we use them, and what we might find useful in the future. They call this process of constantly testing and reiterating “perpetual beta,” and it’s an approach — and mindset — that could help us solve seemingly intractable problems by viewing them in new and creative ways.
While it’s true that we should do a better job of learning from the successes and failures of others, I’d like to challenge the notion that we shouldn’t “reinvent the wheel.” Sometimes we have to reinvent the wheel. If we didn’t, we’d have what they put on Medieval carts on our cars instead of 19-inch alloy wheels!
Let’s accept the idea that we need to keep reinventing the wheel and let’s not just do it in a laboratory. Let’s partner with the people who are going to implement or receive that new treatment, process, or procedure. Let’s get their perspectives on what they need and what matters most to them. Dedicating ourselves to quality improvement means never settling for anything other than the best. Continuously redefining what that means is one way for us to get there.
Editor’s note: Look for more from IHI President and CEO Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health and health care in the “Line of Sight” series on the IHI blog.
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