Cleaning the Graffiti in Health Care

I just left the most unusual conference I have ever attended. First, it was small – 25 people. Second, it was all women. Third, it was all senior healthcare leaders who have done amazing things…make that trail-blazing things. Moreover, I found myself surrounded by women who were journalists at major news outlets, retired military officers from the highest ranks, senior leaders (in some cases the senior most leader!) at major federal and state healthcare agencies, Fortune 500 companies, large health systems, healthcare foundations, national advocacy organizations. It’s no surprise the name “Amazon warrior” resonated with this group! Finally, the conference was all about identifying our “living legacy”. Legacy seems like a strange word when you are living…it’s even stranger when you feel like you haven’t don’t anything yet! So, how did I get invited you (and I) are wondering? After all, I was the youngest person in the room, which as an aside, is a very unusual context when you work with students and residents for big chunks of the day. So, believe it or not, I was invited by in large part due to my… social media presence! After reviewing the list of participants, the organizers realized something was missing, and that something was someone younger who also had a social media presence. And whoever said tweeting is a waste of time?

While there is much I could say, one of the group exercises on the last day of the conference is worth sharing and involving others in. We were asked to examine “broken windows” in healthcare. A broken window is a symbol of something smaller that is part of the context to a larger problem. As Malcolm Gladwell popularized in his book, the Tipping Point, New York made a dent in the big problem of crime by tackling smaller problems, such as cleaning off the graffiti from the train every night. By changing the context, people started to “own” the subway and report crime instead of expect it. An excellent video summary is here.

So, how does this apply to healthcare? While there are criticisms of the broken window theory, what a boon it would it be if we could locate something small in healthcare to fix the very large complex problems facing healthcare. So, our group only had a short amount of time to pursue identifying broken window in healthcare. While it sounds easy to come up with broken windows, it is much harder than it looks. Interestingly, the healthcare problems here are so large, that the broken window may not be as simple and elegant as the graffiti example, but represent an easier place to start. Here are three examples broken windows that we came up with.

• Media portrayal of healthcare, especially related to resuscitation – By correcting the media portrayal of resuscitation, the public might have fewer unrealistic expectations of life sustaining therapies at the end-of-life, which could result in fewer people opting for futile measures. By the way, researchers have even studies this (watching episodes of ER for research!) and have demonstrated the problem in a New England Journal article. Imagine tackling this problem with media tools to demonstrate to people what a “good death” is.
• Patient gown – While patient-centeredness is the new buzzword in our world, can we really say the system is patient centered? Take the simple example of the patient gown which represents a loss of control and source of embarrassment to patients. Could it be that when patients are in the gown, they feel to disempowered to engage in their own healthcare? Could changing the gown empower patients to take a larger role in their healthcare? In case you are wondering, there are many stories and efforts that have been undertaken to redesign the hospital gown – my favorite is the collaboration by Bridget Duffy, former Chief Patient Experience Officer at Cleveland Clinic, with fashion designer Donna Karan.
• The Word Healthcare – It is well accepted that our healthcare system focuses on “healthcare” and not “health”. Prevention and health promotion takes a back seat to intensive healthcare interventions. It’s easy to resign that this will never change due to the payment system, or that return on investments in prevention are only realized in the long-term. But, what if we could change the dialogue by using the word “health” instead of healthcare at every opportunity and juncture. By changing the dialogue, can we change the context enough to create a change in the system? I’m not sure, but at this point, I will say it is certainly worth a try.

There could be other examples of graffiti in healthcare. By continuing the dialogue, hopefully we can locate the most promising levers for change.–Vineet Arora MD

Special thanks to Dr. Joanne Conroy from the Association of American Medical Colleges for organizing the conference, our facilitators from the leadership consulting group Sunergos, and support from the Robert Wood Johnson Foundation to make it happen.