Want change? What Self-Image Are You Offering?

After decades of training, and years of making daily life-saving decisions, doctors may have developed a self-image which does not include checklists. Like the rest of us, doctors may not want to be reminded of their limitations. In the world of process improvement where I come from—and that’s what we are talking about here—the hard part is seldom designing a better procedure (aka: checklist), but how you will get people to use it. As evidenced by Dr. Pronovost’s resignation that checklists may never be accepted in US Medicine, he is recognizing the greater challenge: changing doctor’s behavior.

As practical and apparently effective as Dr. Pronovost’s checklists are, his strategy for adoption is, apparently, ineffective. Process improvement consultants today include a “buy-in plan” as part of any initiative. Many companies today have “change management” managers responsible for stewarding new ways of doing things. Like we ask our change-initiative clients to consider, what self-image are you asking people to accept when you ask them to change? Are you asking people to accept a story that they have failed, that they are incompetent, forgetful? Given that medicine has—as Robin Moroney of the Wall Street Journal aptly points out—gone the route of specialization over process, it was predictable that Medicine would chafe at a procedural cure.

Furthermore, the protestations of some doctor’s groups that one can’t possibly make a procedure for everything, grotesquely distorts the truth that codification of a few important and simple procedures can make a big difference. Dr. Pronovost has proven that, as have many others in scientific, technical and business disciplines.

But what successful change-agents do that apparently Dr. Pronovost has not done is offer an alternative self-image for doctors as attractive as the one that he seeks to replace. If you are going to challenge doctor’s self-image of expertise, then you must replace it, for example, with one of selfless service to patients, and leadership by example.

Can we find an effective counter-story, a countervailing machismo for the hyper-competent, cool and collected doctor? A culturally-shared story that occurs to me is that scene in the movie Apollo 13 where the engineers at Houston Control have to design a procedure—a checklist—for the astronauts to use to assemble improvised filters to remove toxic levels of CO2 gas from the cabin air. Later mission control boss played by Ed Harris commands “failure is not an option.” And with that, the men of Mission Control get busy making their lists and savings astronauts. Ed Harris’ character Gene Kranz challenged one self-image and offered another: He challenged mission engineers’ by-the-book thinking with throw-the-book-out and-improvise-a-new-book thinking. Kranz offered an equally appealing self-image for his engineers. What is Dr. Pronovost offering doctors?

Dr. Pronovost writes about Medicine lacking a discipline of medicine-delivery. He may be right. But that will take years—probably decades—to change. But immediately with each proposal he can borrow from the business-improvement playbook: Every change needs a change-management plan. Every self-image that you will challenge needs an appealing replacement. Every storyline that you want to re-write needs a new story. Dr. Pronovost, what is your story for doctors?