Training the Pathologist as a Driver of Institutional Change

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Training the Pathologist as a Driver of
Institutional Change

• Stephen S. Raab, M.D.
• Department of Pathology, University of
  Pittsburgh, Pittsburgh, PA
• July 29, 2005
• APC/PRODS/PDAS 2005 Annual Meeting

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Background

• IOM report Crossing the Quality Chasm stated,
  Between the health care we have and the care we
  could have lies not just a gap, but a chasm.
• Failure to use available science leads to overuse
  and unhelpful care, underuse of effective care,
  and errors in execution

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Background

• Serious medication errors in 7 of hospital
  admissions
• 80,000 unnecessary hysterectomies per year
• Errors in pulmonary anatomic pathology samples in
  up to 20 of patients leading to increased yearly
  healthcare costs of 415,000 in one hospital

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Innovation and Diffusion

• Invention is hard, dissemination is harder
  (Berwick).
• Example Randomized trials have shown that cheap
  antibiotics are best for first ear infections in
  children. In 12,000 children in Colorado
  Medicaid program, 30 received unnecessary,
  expensive, and hazardous antibiotics with an
  excess cost of 200,000 per year

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Diffusion and Innovation

• Everett Rogers Diffusion of Innovations
• Andrew Van der Ven Minnesota Innovation
  Research Program
• Rate of spread of change depends on
• Perceptions of innovation
• Characteristics of people who adopt (and dont)
• Contextual factors (leadership, communication,
  management, incentives)

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Perception of Innovation

• Perceived benefit of change
• Innovation must be compatible with current needs,
  values, past history, and beliefs
• Complexity of innovation
• Ability to try change on a small scale
• Ease in which others may watch the change first

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Individual Characteristics

• Adopter categorization
• Innovators (2.5 of population) tolerate risk
• Early adopters (13.5) opinion leaders
• Early majority (34) learn locally
• Late majority (34) adopt when status quo
• Traditionalists (16) use tried and true

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Contextual Factors

• Organizational culture for innovators
• Social interactions for early adopters
• Interface between early adopters and early
  majority
• Change acquires its own momentum after 15 to 20
  adoption
• Successful change depends on how a system
  embraces innovators and early adopters and how
  early adopters interact with the early majority

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Medical Culture

• Emphasis on perfection
• Role models stress infallibility
• Lack of communication
• Lessons shared privately
• Malpractice threat

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Medical Narcissism

• Valliant et al. Some psychological
  vulnerabilities of physicians. NEJM.
  1972287372-375
• Banja. Medical errors and medical narcissism
• Emotional disengagement
• Ideological rigidity
• Compulsiveness

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Medical Narcissism

• Intensely defensive toward anything that
  threatens self-image
• Loss of feeling for others
• Craving for success and achievement resulting in
  exploitation
• Disowning of the flawed and imperfect self

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Prescription to Change

• Find and embrace early adopters
• Search for innovations
• Let early adopters adopt
• Broadcast early adopter activity
• Enable re-invention
• Give people time (system on the margin of
  resources cant change well)
• Change yourself first

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Example 1

• Implementation of Toyota Production System
  process in clinical care and the laboratory
• Hypothesis relatively high errors frequencies
  detected by gynecologic cytologic-histologic may
  be reduced by changing processes

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Example 1

• Worked with early adopter gynecologist to
  redesign his practice of obtaining Pap tests
• Used metrics of evaluation that are easily
  understood (transformation zone sampling, ASC-US
  frequency)
• Encouraged early adopter to adopt
• Provided early adopter resources
• Invested in cytotechnology unit

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Example 1

• Improvement in sampling transformation zone (No
  T-zone decreased from 9.9 to 4.7 P .001)
• Decrease in ASC-US frequency (7.8 to 3.9 P
  .007)
• Increase in percentage of ASC-US women with CIN
  (8.1 to 60.0 P .002)
• Decrease in errors (9.5 to 7.8)

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Example 1

• Innovation is now being adopted by 5 other
  practitioners (early adopters)
• Why the success?
• Perceptions
• Individual characteristics
• Contextual factors

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Example 2

• Implementation of Toyota Production System
  process in clinical care and the laboratory
• Hypothesis overall care in patients who have
  lung lesions may be improved by using touch
  preparations of biopsy tissue

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Example 2

• Worked with early adopter pulmonologist to
  redesign service using touch preparations
• At first did not use metrics of evaluation that
  were easily understood, although eventually did
  use metrics
• Encouraged early adopter to adopt
• Invested in cytology unit

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Example 2

• Extremely high patient satisfaction with touch
  preparations (gt95 want service)
• Decreased costs (fewer biopsies per case)
• Increased sensitivity of core biopsy/touch
  preparation
• Decreased time to surgery (7 day decrease)

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Example 2

• Innovation not adopted by other parts of system
• Why the failure?
• Perceptions
• Individual characteristics
• Contextual factors

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Conclusions

• Training pathologists as leaders of institutional
  change must begin with top pathology leadership
• Department members must believe that they are
  part of the organizational change process
• Invest in innovators and early adopters