'Insourcing' innovation may be best approach to transforming health care

In a Perspective piece published in the May 8 issue of the New England Journal of Medicine, the Penn authors -- David Asch, MD, MBA, professor of Medicine and executive director of the Penn Medicine Center for Health Care Innovation; Christian Terwiesch, PhD, professor of Operations and Information Management at Wharton; Kevin B. Mahoney, chief administrative officer of the University of Pennsylvania Health System; and Roy Rosin, chief innovation officer for Penn Medicine -- argue that too often organizations look to external consultants to create health care change. Lessons from other industries are often "translated into health care" as easily as if they were "translated… into French," the authors write, leading to misinformed recommendations.

"In order to identify and effectively solve a problem, you have to be willing to immerse yourself and try things out," said Asch, lead author on the piece. "Management gurus and experts from other industries can lend tremendously valuable expertise, but it's the physicians and nurses who combine the passion and the knowledge necessary to move ideas into implementation and testing, where the real value lies."

The Penn team argues that copy and paste solutions derived from other settings are not likely to work well in health care because health care is not one problem but thousands of problems. Instead, they urge hospitals and other health care institutions to consider adopting a four-stage design process for use in the specialized health care environment.

The four stages, which together help health care professionals to identify issues and create more effective solutions in a timely manner are: 1) contextual inquiry: understanding the way things currently work and seeing the nuances others have missed by immersion in the work; 2) problem definition: reexamining what the organization should be solving for in a way that avoids incremental improvement to a current process; 3) divergence: exploring alternatives to initial solutions; and 4) rapid validation: testing critical assumptions and proposed solutions quickly at low cost.

The authors write that each of the four stages of the design process can be applied by people already inside the health care setting. An advantage, they say, is that in contrast to many industries where the thought leaders are secluded in corporate headquarters, many of the thought leaders in health care organizations, including physicians and nurses, are right up front interacting with the "customers."

"Sometimes organizations think it's easier and more effective to spend a large sum of money on an outsourced shrink-wrapped solution when the expertise needed to identify and solve problems is already in the building," said co-author Roy Rosin, Penn Medicine's chief innovation officer. "Clinicians are mission driven to help their patients, and are constantly thinking of ways to improve health care delivery. If the focus were shifted toward creating and protecting time for staff to drive change from the inside, we could see the implementation of more successful solutions."

The authors have been working with teams across Penn Medicine to apply the four-step process to a range of health care delivery challenges, including new patient access and readmission rates. Working on one project that aimed to improve medication adherence among patients discharged after myocardial infarction, the team followed patients throughout their day, which allowed them to see how a long commute without bathroom access kept one patient from taking his diuretic. By immersing themselves in the patient experience, the team discovered the inadequacy of better reminders as a solution to the problem. Along with rapid validation techniques allowing in-house teams to test assumptions in hours or days, such insights enable internal innovators to drive change in health systems efficiently, instead of discovering months or years later that they invested in the wrong strategy.