Sean Safford gets it right on health care reform and, indeed, reform of just about any kind:
To work, both of those fixes have to be effectively implemented at an organizational level. They will require changing the way doctors, nurses and other medical care providers do their job. And that means changing the organizational rules by which hospitals and doctors offices operate. But what that organizational model will look like has not been specified. It might look like the Mayo or the Cleveland Clinics which use computerized records, pay doctors salaries and reward them for patient outcomes rather than per service. Yet as the New York Times points out, only one plan in Congress addresses the organizational model and that one is just a pilot program. Massachusetts is looking at ways of urging doctors to shift into salary-based provider networks. But there’s no discussion of a mandate or of anything with teeth that would move the medical industry in that direction.
How many reform movements have succeeded in winning legislation meant to change society, but then fail to actually change anything? Too many to count. Why? Because the devil in achieving real change is in the details of organizational implementation.
Safford goes on to discuss what many consider undiscussable:
Avoiding that fate requires recognizing that organizational change on an industrial scale is a highly contested political process. But those politics don’t unfold inside the halls of Congress. They happen inside and among the organizations charged with implementing reforms. And shaping those politics means recognizing where real organizational power lays.
Politics and power–not the kind on C-SPAN, but the up-close and personal dynamics that enable or doom efforts to change. One of the elementary concepts one learns in studying the brief history of planned organizational change is that change is more likely to be successful when points of resistance are eliminated rather than increasing pressure for that change. Put more simply, you have to make it easier to change than not to change.
I share Safford’s concern that history is about to repeat itself, and I would draw attention to three examples from very recent history that could be instructive: the 9/11 Commission, the Senate Committee on Prewar Intelligence, and the Columbia Accident Investigation Board.
In each case, there were clear, urgent pressures for change. In each, organizational issues were specifically emphasized. In each case, the necessary reforms fell short.
As David Hanna notes, “organizations are perfectly designed to get the results they get.” They tend to stay the way they are for a reason–the current state works well for the people who benefit from it. Real, meaningful, lasting change requires focus, consistency, clarity, persistence, and strong political support. Moving boxes on an org chart doesn’t cut it.
For health care reform to succeed in a way that improves what most agree to be a broken system, leaders at the organizational level must demonstrate the courage to address power and politics. It will likely be the toughest job they’ve ever had.