The art of stopping

Most people understand innovation as starting something new. After all, Oxford Dictionaries defines the word as making changes to the established, "especially by introducing new methods, ideas or products."

The lesser discussed side of innovation is when you stop something.

There has been no shortage of stopping, halting, quitting, banning and barring in the United States recently. The Confederate battle flag was lowered from the South Carolina state capital, CVS stopped selling tobacco products and Ringling Brothers and Barnum & Bailey Circus decided to retire its traveling elephants.

In healthcare specifically, Cleveland Clinic cut ties with McDonald's in its cafeteria, three prominent academic medical centers took steps to ban low-volume surgeries, New York City hospitals agreed to ban reality TV filming without patient approval and Mayo Clinic stopped requiring an outmoded dress code for women.

Stopping one thing doesn't just have to be an effect of starting something else. Rather, the deliberate departure from existing approaches, systems and norms should be given equal consideration as healthcare organizations look for ways to innovate and improve the care they provide. Stopping something might be the best innovation for a hospital, even if it is uncomfortable to break from the norm.

Stopping requires bold leadership

Change via stopping requires leaders to exercise a different muscle, and organizations to be flexible. First and foremost, deciding to stop something major or ingrained requires the willingness to take risks.

"Leaders need to have the ability to look at the systems and processes that have been part of an organization historically and assess the value they truly bring to the organization today," says David Jarrard, president and CEO of Jarrard, Phillips, Cate & Hancock, a healthcare strategic communications and public affairs firm.

There are a few other muscles leaders need before stopping or quitting something. One: A board that understands risk and is willing to accept failure, learn quickly and move on without penalty, according to Mr. Jarrard. This is critical to innovation efforts, which by definition imply risk. While Mr. Jarrard says "there is an important difference between smart risk and crazy risk," a leader who fears failure and a board that is overly punishing could not possibly innovate.

Executives also need internal support before stopping something. All change efforts — whether starting or stopping — demand a relatively high level of cultural alignment. It is the leader's responsibility to demonstrate why taking the risk will yield value and how abandoning something reflects the health system's greater mission.

Stopping something often means breaking from the past

"Change requires that you break from habit," says Manuel Hernandez, MD, MBA, practicing emergency physician and leader of CannonDesign's Health Advisory Services. "Many of the steps and processes people are engaged in — in any industry — can become almost automatic and oppressive."

Ditching a common practice requires as much observation, thought and planning as starting an initiative. Just look at two health systems that recently backed way from practices that, over the years, became ingrained in their culture.

In early June, Rochester, Minn.-based Mayo Clinic revised its dress code for women. After many years of requiring women to wear nylon stockings, as of June 12, nylons are optional.

"You would not believe how excited people are," senior web production specialist, Danielle Teal, told NBC affiliate KTTC. "I mean, it's definitely a reference to the Braveheart 'Freedom!' you know? You want to yell it out, run around and throw your pantyhose out the window."

Mayo Clinic's decision to give its female employees a leg up on their dress code may seem like a trivial change, but as Ms. Teal's enthusiastic comment conveys, ending the hosiery requirement is actually a big step toward making women more comfortable, which could positively impact performance.

Cleveland Clinic also made a decision this summer to stop something that was commonplace, though increasingly counterintuitive. After allowing fast-food-chain McDonald's to operate in its food court for 20 years, Cleveland Clinic decided in August to close down the restaurant in mid-September.

"We want to demonstrate that we can walk the talk by being a healthier organization," said Cleveland Clinic spokeswoman Eileen Sheil, adding that removing McDonald's is part of a much broader wellness campaign at the hospital.    

The point of no return

Sometimes the stakes of an innovation effort are higher. When CVS decided to stop selling tobacco products in stores in February 2014, the franchise took a huge financial risk. None of its competitors indicated intention of following suit.

At a certain stage of CVS' plan to remove tobacco products from its shelves, the company's leadership reached a point of no return; if there were financial repercussions from the decision, CVS could not simply return to selling tobacco without completely compromising commitment to its mission, and the mission itself.

How certain do you need to be that halting is the right choice?

According to David Crosswhite, senior vice president of Kaufman Hall and co-author of The Innovator's Field Guide, leaders will be confident with the decision to stop something when they believe that the outcome expresses the organization's goals and values in a more effective way.

"Deciding to stop something can be a very hard choice to make," says Mr. Crosswhite. "However, even if tobacco was a profitable product for CVS, somewhere in their calculations was the business case that CVS would be better off in the long run being a healthcare company. If that means it has to stop selling a particular profitable product to achieve that goal, it's the right choice, both from a financial and a social responsibility standpoint."

Although the decision to stop selling tobacco products was risky, CVS essentially had no alternative if they were serious about being a healthcare company, as opposed to just a pharmacy or convenience store.

When innovation is a moral obligation

Peter Pronovost, MD, PhD, a critical care physician, senior vice president for patient safety and quality and director of the Armstrong Institute for Patient Safety and Quality at Baltimore-based Johns Hopkins Medicine, felt morally compelled to stop something at Johns Hopkins.

He read about the number of patients who die during low-volume surgeries, which U.S. News & World Report published in May. According to the report, as many as 11,000 U.S. deaths may have been prevented from 2010 through 2012 if patients who went to the fifth of hospitals with the lowest volume had gone to the fifth with the highest volume.

Although the data supporting the association between high-volume surgeries and better outcomes has existed since 1979, the latest findings struck a new chord with Dr. Pronovost. He and his colleagues had to act. "It was a moral moment for me, and we knew we had to do something about it," says Dr. Pronovost.

Soon after the report came out, Dr. Pronovost connected with two other physician leaders: surgeon John Birkmeyer, MD, chief academic officer at Lebanon, N.H.-based Dartmouth-Hitchcock Medical Center, and Michael Mulholland, MD, PhD, chairman of surgery at Ann Arbor-based University of Michigan Health System.

Together, the three systems consulted with surgeons to identify 10 high-risk procedures with the strongest correlation between volume and mortality. They agreed to bar them if their hospitals and surgeons fell into the lowest fifth by volume of procedures. Analysis by Dr. Birkmeyer found doing so could save 1,300 lives a year, according to U.S. News & World Report.

"Other health systems and professional associations have expressed an interest in moving in this direction as well and maturing the idea," says Dr. Pronovost. "I think it's an enormous and important shift for patient safety. Too often we think safety relies on the individual clinician — people think if you have a medical degree you're qualified to do anything, but that's not always in your best interest or the patient's."

Understanding resistance to change

Hospital executives, industry observers and even physicians say medical providers are generally resistant to change. Some resistance stems from physicians' concern for patients.

"Healthcare is a very evidence-based industry," says Dr. Hernandez. "Many healthcare professionals want to see the data to demonstrate that the changes being proposed will have the impact promised to them. They're concerned about making changes at the risk of negatively impacting quality."

When physicians affiliate or become employees of hospitals and health systems, they worry about compromising the "art of medicine," or their ability to maintain independence in their practice style and clinical decision-making. In some healthcare organizations, physicians see monitoring as punishment opposed to facilitating collaboration and learning, according to Dr. Hernandez. Fear of litigation also contributes to resistance to change.

When it comes to stopping, the feeling of absence can translate to loss, which can lead to resistance. Stopping is not an easy decision — it will be disruptive and upsetting to some people. A high level of trust in leadership mitigates such turbulence.

"Much of perceived loss is around stature, power and prestige, and this fear can grow like cancer if you don't have a way to communicate why you are making the change," says Dr. Pronovost. "What we've found in our own change work is we need to improve our skills at leading change. We approach it like a technical solution, but peoples' feelings about it can pose a huge barrier."

Strategy execution is more important than ever, and at the same time, healthcare organizations must zero in on a narrower set of goals. This often means pulling the plug on systems and products that are resource intensive and no longer create value. Stopping also sends a clear message to hospitals with competing demands and multiple priorities.

"Imagine everyone in the organization walking around with backpacks, and the leaders keep filling them up with new ideas. Everyone eventually becomes too burdened with every new initiative and rule until they can barely walk," says Mr. Jarrard. "This has historically been the case in healthcare. Now lighten the load. This makes the organization faster and leaner in clarifying what it is and what it's about."

Stopping can turn strategy into action just as effectively as starting. It requires a different perspective and acceptance of risk and even failure, but it is a critical capability for healthcare leaders.


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