It is astonishing how comfortable we can become with inadequacy. I often report the remarkable results from the first IHI-CICD Collaborative on Improving Care at the End of Life—teams that had 50% reductions in shortness of breath, or who doubled the rate of use of hospice. I show off the possibilities of really major, breakthrough level change—and participants dutifully nod approvingly before they go back to work and do nothing different. If only I could put it in a pill and sell it--everyone would want to buy it. But what we are learning to do is much more difficult than selling effective pills. We have to learn to change human behavior.
In contrast, consider just how astonishing society’s rate of change in the use of opioids has been: We now use nearly ten times the per capita dose in prescription drugs as we used two decades ago! What were we thinking then! How did we manage to keep walking away from people in terrible pain?
I remember standing by the stretchers of people being transferred to hospice who no longer bothered to cry out, and I remember giving them their first doses of morphine. How was it that I felt a little risky—as if someone might judge hospice harshly for this. Surely what I should have been feeling was abject outrage. We had these medicines for centuries, why were we not using them! How could we have learned to turn away from pain, and to assume that good care was being offered!
Yet, we did learn to improve things—not enough, surely, but improvements nonetheless. As a society, we have learned to do many things differently—how to let everyone vote, how to make major strides toward individual rights, how to enhance automobile reliability and safety. What elements are common to change? How can we accelerate the pace, and guide the direction?
Change is clearly easier when people tolerate error and celebrate diversity. Having visited a few dozen health care institutions each year for the last few, I believe I can now predict whether bright people get to do good things in that institution or not—from talking with wage workers or with leaders. Is there a climate of expecting new ideas to be tried out, or a climate of suspicion or arrogance?
Energetic innovation seems to depend upon a very clever combination of humility and enthusiasm! But it also depends upon tolerating error—some innovations are not going to work out as well as we expect. Even so, we must be careful not to make the price of failure too high, because each success is usually built upon a string of failures.
Change depends upon a vision of a better way of doing things. Some few creative folks—the visionaries in each community or organization—have to put together data, experience, stories, and persuasion in a way that allows others to "see" how their world could function differently.
And we all have to lend our enthusiasm, and share our humility, and keep on saying that change is necessary and good!
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