robertparker

“Everybody has to be on the bandwagon”

The story of one of the most famous quality measures -- percentage of patients with acute myocardial infarction who receive a prescription for beta-blockers within seven days of hospital discharge -- is an example of how people fit together. Beta-blockers are a class of drugs that block the effects of adrenaline and slow down the heart rate. In 1982, results from a randomized controlled trial found that administering beta-blockers after heart attacks cut patients’ death rate by an astounding 40 percent. The results were so conclusive for all types of patients that within two years, they had been written into medical textbooks and featured in both medical journals and mainstream news media. By the end of the decade, the medical profession at large had come to understand the importance of a veritable “silver bullet” for heart attack care.

And yet, by the mid-1990s, only 34 percent of patients received beta-blockers after heart attacks. The policy response was an expans

robertparker

“Look, doctor…”

The notion that local culture matters as much as any specific policy is not limited to health care. In fact, over the past few decades, organizational theorists have observed this phenomenon in companies across a range of high-reliability industries, from airlines to chemical plants to nuclear facilities. What is less clear is why or how this happens. After all, the academic and policy communities invest much effort researching the best interventions and piloting them across a variety of care sites. It is hardly apparent why shared values, in so many contexts, trumps carefully designed procedures; and even less clear how an abstract ideal is translated into tangible improvement.

The key may be in understanding industries whose work, like hospital medicine, naturally involves complex and unforeseen errors. In these environments, trial-and-error is not an available strategy for improvement: every trial is the consequence of a unique set of complications (think ER caseloads with a variety of

robertparker

“One community at a time”

That smaller cultural changes must accompany delivery system innovation is a truth already starting to take root among the largest institutions in health care. “All health care reform is local,” is a common saying among health care experts, and one of the key tenets in the mission statement for the Center for Medicare and Medicaid Innovation. In a speech on health system improvement given in early May, Kathleen Sebelius stated, “this transformation will happen one hospital and one community at a time. We can provide support and establish incentives, but you are the ones who will have to do the hard work of putting better systems into practice.”

In this way, the Partnership for Patients and the CMMI appear to be elegant solutions. The programs aim to encourage efficient, integrated care through a series of pilot programs and local interventions. Far from mandating top-down solutions, HHS is encouraging collaborations between hundreds of provider groups, hospitals, consumer groups,

robertparker

Online experience is fundamentally fragmented.

We managed broad areas of our life across different platforms, all of which have incentives to keep fencing us off from each other. As collateral damage, we seem to have become inured to poor experience in important areas on the web:

• task management.
• writing.

robertparker

Not all tech companies are startups.

We tend to equate them with tech companies, but fundamentally startups are businesses designed to grow quickly. To echo an oft-repeated truism: startup = growth.

Then why the free association between startups and tech? Over the past decade, the easiest way to grow quickly has been to acquire online users. The transitive equation has been: startup = growth = online users = tech.

In fact, we wrongfully equate startups with the tech industry. Startups are high-growth companies with large market potential. Tech reflects society's adaptation towards software automation tools, and spans culture, management, and technology.

robertparker

Want to fork your own gists? No fork button? No problem! Install this user script by clicking refork.user.js' "raw" link down below: ⇓