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Accelerating acceptance. (Positively Influencing Physicians).

THE CHRISTIANA CARE Health System is one of the largest in the United States, with 45,000 discharges, 7,000 employees, and 1,200 members of the medical staff. My ability to sustain consistent improvement has been limited, despite an enthusiastic administration and staff. Although we deliver consistently excellent care (passed JCAHO with commendation) and our benchmarks in mortality compare favorably to hospitals of similar size and scope of services, there is always room for improvement. Finally, in desperation, I began to explore the underlying sociologic and historical reasons for my perceived failure, I discovered I was not alone in this frustration.

Scurvy and soap

Everett M. Rogers (10 Diffusion of Innovations offers well-researched examples of innovations that were either accepted or rejected because of their implementation--sometimes without regard to improvements over existing techniques. (1)

In 1601, Captain James Lancaster sailed from England with four ships. In one, he daily administered three teaspoons of lemon juice. In the other three, the sailors received their customary diet--and 110 of 278 crewmen died. He reported his findings to his superiors. In 1747 (approximately 150 years later), James Lind, MD, applied six different regimens to a crew on the HMS Salisbury. Again citrus cured scurvy. The British Admiralty accepted his findings and changed policy for the British Navy in 1795. In 1865, the British Board of Trade made it a policy for all maritime travel to include citrus supplements for long sea voyages.

So in all, it only took 265 years for a known remedy to death in the most important industry in England to be adopted.

The acceptance of soap followed a similar pattern.

Soap was first produced in Babylon around 2800 BC to clean textiles. Phoenicians were also documented to use soap in 600 BC for this purpose. Pliny the Elder noted that soap bars were found in a factory in Pompeii. No one, including the Romans, used soap for humans, During the Renaissance, olive oil was substituted for animal fat in the production of soap. This had two effects. First, it created a demand by the affluent for soap. Second, it made Its production In Southern Europe a craft of guilders and not peasants. In Colonial America, animal fats were stored all year for soap production in the Spring. It was labor Intensive and, hence, provided a market for Tallow Chandlers who would collect the fat and make soap in large blocks and cut them into bars.

In 1806, William Colgate produced soap bars of uniform size and consistency. In 1837 Procter & Gamble entered the market and Ivory Flakes became available to consumers demanding fast dissolving soap in 1895. The path to everyday acceptance of soap was not linear. There were a number of retreats. Public bathing was thought to spread the Plague, Soap was taxed as a luxury and its use was economically restricted to the affluent. Soap production guilds formed and the secret to production was protected.

These examples share some common themes. Rogers has examined these and developed theories and techniques about the diffusion of innovation.

The rate of adoption

The rate of adoption has a long early phase, rapidly accelerates, and then plateaus (please see Figure 1). An innovation can be a new idea, technique, practice, procedure, or anything that is deemed new by the adopter.

Diffusion has a time dimension, which Rogers describes as the "innovation-decision" process. We are all vaguely familiar with this. Remember your first decision to purchase a VCR? The innovation-decision process has five components:

1. Knowledge of the innovation

2. Being persuaded to accept the change

3. Actively deciding

4. Implementing the innovation

5. Confirming your decision to adopt change

These steps provide the boundaries for the individual accepting a new process or method. The innovation may be rejected if the conditions are not right.

All adopters are not created equal. We all know gadget freaks who are compelled to own the latest electronic device. There are five categories of adopters: (1)

Who adopts changes?

1. Innovators (2.5 percent)

2. Early adopters (13.5 percent)

3. Early majority (34 percent)

4. Late majority (34 percent)

5. Laggards (16 percent)

These adopters each have specific personalities that can be identified and used to implement new policies and procedures.

Innovators

* Members of this group can understand and apply complex technical knowledge. Simply stated, they are geeks. They are able to think abstractly, but apply the information to real world problems. They are interested in how things work. Innovators cope with a high degree of uncertainty. They are not bothered by the edges of the data and intuitively understand that new ideas have many unknown limitations. They do not require complete information In order to act. They make decisions and base actions on preliminary data--this may be their most important personality trait.

Innovators:

* Are obsessively venturesome.

* Transfer knowledge into new applications.

* Are always involved in new ideas and practices. Some of their ideas seem "far out" or "kooky."

* Reach out of locale peers into "more cosmopolite social relationships." They are active members of their professional societies and other outside groups.

* Know the other innovators and hang out with them, even If their personalities seem to clash. They have broad and diverse networks.

* Are financially resourceful to absorb failures. Although it is counter-intuitive, they are successful financially. They take the hits and move on. By definition, failures are expensive.

Early adopters

By contrast, early adopters are summarized by "respect" of their peers. They accept innovations and can then persuade others to do the same. They are an integrated part of the social system and easily identified as members of "the system." They have titles and positions of leadership. They seek out new and better ways of working. Early adopters:

* Are "localites." They belong to the local scene and can be found with the usual suspects." Their social network is among their community peers.

* Become opinion leaders. Change agents seek them out and immediately recognize them as the people who will accept the new drug or surgical instrument. Consultants ask them to participate in focus groups.

* Have a central position in the communication network and can convey their subjective evaluation to near-peers. They test new practices and spread the word among their peers.

Early majority

These are the workers who get the job done day-In and day-out, but are not quick to embrace innovations like the innovators and early adopters. Unfortunately, because of their solid reputations, they are often chosen to be the leaders In new processes. This leads to frustration by executives who do not understand why their loyal hard working lieutenants are not making changes in the organization. The "early majority" is not psychologically equipped to be first. Only the difficult and ostensibly rebellious innovators are suited for that task. The early majority:

* Form the consistent matrix of any organization (one third of the staff).

* Adopt just before the average member.

* Have a long innovation-decision period compared to innovators and early adopters.

* Are an important link in diffusion to the whole organization.

* Are the glue for the system.

Late majority

The "late majority' could be categorized as skeptical. They play an extremely important role by noting that the Emperor has no clothes. These are most of the physicians in 1999. They are under intense pressure to maintain practices under dire conditions. Literally, they cannot afford experimentation, which will both consume resources and may worsen their economic situation. Much of the problem in implementing practice guidelines lies with the late majority. Fully one-third of the organization, the late majority:

* Only adopt after others, when the innovation has been both adopted and adapted to local circumstances.

* May only adopt under economic pressure, when it is clear that this is the new standard.

* Are less financially secure and very conservative.

* Are dubious of innovation.

* Need peer pressure to motivate them to change.

Laggards

These traditionalists see no reason to alter their behavior or practices. They often express the sentiment that, "this has always worked before, why change?" They will resist change even when confronted with a transparently better approach. Underneath it all, they are struggling to make ends meet. They actually cannot afford to experiment or they will lose it all. They have condemned themselves to this lower rung. They round at odd hours. They are not found in the hospital cafeteria. They are the reason that the adoption curve never attains 100 percent. Laggards:

* Are near isolates in the social system.

* Talk about the good old days.

* Make decisions with regard to what has already been done: their point of reference is the past.

* Are suspicious of innovations and change agents.

* Are financially strapped.

Change agents and opinion leaders

"The most innovative member of a system is very often perceived as a deviant from the social system."' They are not well-suited to trying to influence others. However, opinion leaders are good candidates for swaying the majority toward a new idea. "Opinion leadership is the degree to which an individual is able to influence other individual's attitudes or overt behavior informally...This informal leadership is not a function of the individual's formal position...Opinion leadership is earned and maintained by the individual's technical competence, social accessibility, and conformity to the system's norms." (1)

The most common example of a change agent is a consultant. They move clients' innovation decisions forward and use opinion leaders as their lieutenants In diffusion campaigns. One of our department chairmen describes a consultant as someone who borrows your watch to tell you what time it Is. Although a somewhat cynical remark, it accurately describes the relationship between an opinion leader and a change agent. Often opinion leaders are prophets in their own land and change agents are necessary to externally validate the need for innovation.

Who talks to whom?

Even after staff are identified by their willingness to accept or reject innovations, the spread of new practices may not occur. For example, while I might buy a DVD In my next computer, I would be an unlikely advocate for a radiology digital archiving system, despite the obvious similarities in technology. Innovations diffuse through "homophilus" (near-peer) contacts. Heterophilus contacts are much less successful. Watch the body language and interaction between surgeons and internists. While they are mutually dependent, there is an inherent sense of mistrust between them. Even groups of seemingly homophilus individuals change very slowly. This may explain why Grand Rounds are not successful in altering practice patterns. More than 50 percent of most hospital medical staff are specialists. The audience at Grand Rounds is quite heterophilus, despite the fact that most attendees are members of only one department.

What are innovations?

The innovation themselves have traits that make them more or less likely to be accepted. The following characteristics need to be considered:

* Relative advantage: Does it have an advantage over current methods or approaches?

* Compatibility: How does it fit in with current processes and attitudes?

* Complexity: How difficult is it to use?

* Trialability: Can we try it out easily with little risk?

* Observability: Is it easy to see the beneficial results?

Surgical instruments, such as lasers, fit these characteristics. Which surgeons and techniques will most likely be advantaged by introducing a laser? Does it have a relative advantage over a knife or bovey? How complex is it to use? Can the surgeon try it out for awhile with little risk to the patient, her reputation, or her time? Is it easy for almost anyone to see the advantages? All of these questions inform the debate about diffusion of an innovation. As Sophocles said in 400 BC, "One must learn by doing the thing, for though you think you know it, you have no certainty until you try."

From the individual to the organization

Innovation decisions in organizations differ from individuals' adopting new processes or methods. This is because organizations have predetermined explicit goals, prescribed roles for staff, authority structures, written rules and regulations, and informal, but stable and recognizable, relationships making up the culture. Drivers for organizational innovativeness include: a positive attitude toward change; highly complex and interconnected structure with room for organizational slack; low centralization and formalization but large in size.

The very attributes that make an institution strong and from which it derives its unique identity are exactly those traits that inhibit its ability to adopt new processes. Conversely, the attributes that make an organization agile-low centralization and formalization and high complexity-make it less cohesive. Compare, for example, a Silicon Valley start-up to an established East Coast health system. Formalized and centralized structures inhibit process change.

While most of the organization traits are self-explanatory, "organizational slack" deserves special mention and means that there are sufficient personnel in the institution at any time so that some are free to experiment with unproven techniques. Compare this to the lean and cost-efficient deal in vogue among health care systems. The intense reduction in staff and the full utilization of every minute of the workforce works directly against the adoption of innovative practices.

The more we focus on doing what we have always done, but faster and better, the less we are able to try new practices. Inherent to the new practices is an intrinsic failure rate. Medical schools are the model of inefficiency and hence, the seat of many innovations. Most first-time experiments fail. Consequently, any institution that intends to be in the forefront of medical care must allow some "organizational slack." It must encourage its "early adopters" by allowing them the freedom to try new techniques of care delivery.

Organizational stages

There are six stages of innovation that are specific to organizations:

1. Agenda setting - Organizations ordinarily set agendas according to community needs. An agenda is one of the defining attributes of an organization.

2. Match the innovation - An organization needs to match the innovation to its particular circumstances and Immediate needs. Innovations chosen for staff model health systems are different than those selected for hospitals with large volunteer medical staffs.

3. Fit the problem to an innovation Each organization must fit the problem to the requisite innovation.

4. Redefine the innovation to suit local needs - Innovations are not adopted in whole; they must be tailored to the local habits and experiences of the institution.

5. Clarify - The institution must clarify for its members both the problem and the innovation or solution.

6. Routinize - Most importantly, the institution must make the innovation a matter of routine. The administration needs to demystify the innovation and lower thresholds for adoption. By definition, innovations are foreign and will be resisted by all but early adopters who are obsessively seeking new ideas.

Making change happen

How does an institution efficiently make changes in practices and processes? Diffusion networks are necessary to change the prevailing practices. If these networks can be identified and routinized, the change can be implemented consistently for the advance of the system. The importance of interpersonal network influences cannot be overemphasized-this Is where change happens. And these relationships must be homophilus. As we have lately come to realize, newsletters, memoranda, and lectures do not Influence behavior in any profound way. Opinion leaders informally move processes. Culture change is necessary for organizational change. The behavior of opinion leaders can change the slope of the S-curve (please see Figure 1), and, thereby, accelerate adoption of new practices.

The institution must create a critical mass of adopters by identifying the innovators and early adopters. They must be accorded appropriate respect for their role and given space in which to fail--ultimately they will bring a new richness to the culture. If these two groups are left out of the loop, then the implementation is doomed--they will find their own innovations and their energies will be expended at cross-purposes with the health system.

By recruiting the early majority, an institution can leverage local talent to effect its agenda. Social modeling affects change. Interpersonal communication drives the diffusion process--this requires one-on-one interactions, not mass media campaigns, which are an illusion at best and provoke cynicism at worst.

Contrary to perceived wisdom, there is little direct change from mass media to the majority, except through opinion leaders. The entire medical system is built on didactic presentations, from Graund Rounds to xeroxed journal articles that are circulated. In fact, new processes are adopted when opinion leaders initiate them, whose results can be tangibly discerned by the majority of adopters. Pharmaceutical firms understand this concept. What may seem like a wasteful practice of sending "detail reps" to physicians' offices is still effective in convincing physicians to change prescribing habits.

Conclusion

James Lancaster and James Lind failed as change agents for the British Admiralty. They were not opinion leaders and, consequently, were not in a position to change a group of the majority of admirals. They were outsiders.

Organizations need to create a critical mass of innovators and early adopters, and give them room to innovate. The health system should develop issue-specific opinion leaders with expertise, acceptance, and familiarity, so that the audience will empathize with them.

Messages from both opinion and executive leaders should be clear, concrete, and easily understood. It is already sufficiently difficult to introduce a new concept: try to use words that are derived from current practices and make as many analogies as possible. Keep in mind that only early adopters understand abstract concepts, so reserve conceptual discussions for them. If you can follow these principles, then acceptance by the late majority and laggard adopters will be accelerated.

Granted, this is a radically new way of thinking about implementing change. All of us have struggled with changing how we practice medicine and the delivery of care. For many of us, we have been swimming upstream. Remember that when the salmon make it there, they die. Even though you will have to move rocks Out of the way on a downstream course, at least you are swimming with the current.

[FIGURE 1 OMITTED]

Acknowledgements

This article would not have been possible without the direction and support of my chief executive, Dr. Charles M Smith. While struggling with the same problem, he allowed me the opportunity to explore what was known elsewhere. ft took time away from my other duties, clinical and administrative. He intuitively knew that I needed some organizational slack to move us along.

Most of the work described in this article derives either directly or in part from Professor Everett M Rogers and his book Diffusions of Innovations. I was also greatly assisted in thinking through these issues by Professor Rogers' protege, Professor Thomas Valente of Johns Hopkins University School of Public Health. Tom was willing to spend hours on the phone, email back and forth, and finally, meet with me to discuss these concepts.

Donald Berwick, MD, MPP, recommended this book at his keynote address at the American Quality Conference two years ago. On the way home, I purchased a copy. I read it in a long night. f awoke a new man. If you are trying to change any system larger than your best friend, this book is requisite reading.

Reference

(1.) Rogers. Everett M. Diffusion of Innovations. New York. New York: Free Press, 1995.

RELATED ARTICLE: WHO ADOPTS CHANGES?

All adopters are not created equal. There are five categories of adopters, each with specific personalities that can be identified and used to implement new policies and procedures: (1)

1. Innovators (2.5 percent)

2. Early adopters (13.5 percent)

3. Early majority (34 percent)

4. Late majority (34 percent)

5. Laggards (16 percent)

WHAT ARE INNOVATIONS?

Innovations have traits that make them more or less likely to be accepted:

* Relative advantage: Does it have an advantage over current methods or approaches?

* Compatibility: How does it fit in with current processes and attitudes?

* Complexity: How difficult is it to use?

* Trialability: Can we try it out easily with little risk?

* Observability: Is it easy to see the beneficial results?

GAINING CRITICAL MASS

Organizations can accelerate the adoption of innovations by following these steps.

* Executives must both lead and visibly practice the change. It is insufficient that executives issue dictums about new policies.

* Change the institutional system to reward desired behavior. All too often, institutions have, at best, taken a wait-and-see attitude toward innovation. Instead, organizations must reward a limited amount of risk-taking behavior.

* Identify, support, and reward innovators and early adopters and pair them with opinion leaders to accelerate the pace of change.

* Find groups who will adopt all at once. In the best circumstances, executives will occasionally identify whole groups who, for whatever reason, are ready to change.

Organizational stages of adopting innovations.

There are six stages of innovation that are specific to organizations:

1. Agenda setting - Organizations ordinarily set agendas according to community needs. An agenda is one of the defining attributes of an organization.

2. Match the innovation - An organization needs to match the innovation to its particular circumstances and immediate needs. Innovations chosen for staff model health systems are different than those selected for hospitals with large volunteer medical staffs.

3. Fit the problem to an innovation - Each organization must fit the problem to the requisite innovation.

4. Redefine the innovation to suit local needs - Innovations are not adopted in whole; they must be tailored to the local habits and experiences of the institution.

5. Clarify the problem and the innovation - The institution must clarify for its members both the problem and the innovation or solution.

6. Routinize the use of the innovation - Most importantly, the institution must make the innovation a matter of routine. The administration needs to demystify the innovation and lower thresholds for adoption. By definition, innovations are foreign and will be resisted by all but early adopters who are obsessively seeking new ideas.

G.Stephen DeCherney, MD, MPH, is Chief of Endocrinology and Chief of Clinical Pharmacology at the Christiana Care Health System in Delaware. He chairs the Technology Management Committee for the system. Additionally, he is a national leader in health care quality improvement and Is on the executive committee of the Health Care Division of the American Society for Quality. He can be reached by calling 302/733-4186 or via email at sdecherney@christianacare.org.

* Rogers, Everett M. Diffusion of Innovations. New York, New York: Free Press, 1995.
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Author:DeCherney, G. Stephen
Publication:Physician Executive
Geographic Code:1USA
Date:Nov 1, 1999
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