When appropriate, patients can bring issues to light that could otherwise be missed. They offer a different, and often very important perspectives that can be easily overlooked.

Another important aspect of including patients in the planning process is response bias. Patients may be less willing to provide criticism or might answer questions in a manner that they think is favorable. This shouldn’t necessarily deter a practice from asking patients for their feedback, but it does mean the method in which this is done needs to be thoughtfully planned.

Very rightfully said. Around the world, many patients are becoming more informed about, and more empowered to make, healthcare decisions. In some countries, rising education and literacy levels are fueling this change; almost everywhere,growing use of digital devices have fundamentally altered the information available to patients. As a result, many providers see an opportunity to become more patient-centric. Patients should ideally be the center-piece of the entire value chain. We as members of health care organisations have the responsibility to involve patient feedback as early as possible and at every interval as possible in the entire patient journey. Instead of passively receiving treatment, patients now often ask for more information and expect to be involved when treatment choices are made. It is in the interest of every stakeholder in the healthcare industry to practice innovation
in a way that improves patient care in general along with other missions to reduce health care costs and in turn providing care to a larger group of patients.

One of the processes we are actively working on innovating are bedside rounds. There is immense variability in time spent during rounds, which is understandable and at time warranted given there is varying patient complexity. Unfortunately this may occasionally lead to an imbalance of available resources due to teams being tied up on rounds. In an effort to
1) understand and 2) affect physician behavior and practice, we conducted a multi-disciplinary think tank via IGNITE which shed light on barriers and opportunities to change, and led to a team-designed Innovation process. Integral to tracking this one example’s impact is continuous monitoring and iteration, while sustaining key stakeholder engagement.

Great answer. One side of the coin is what Marcelo mentioned, the imbalance due to team being tied up on rounds. However, the other side of this is that bedside rounds have changed drastically in the recent times.Historically, bedside rounds was the place where residents learnt to master physical exam skills with the mentors at the bedside. These days, the emphasis has shifted to the new electronic devices that help in diagnosis and the emphasis on physical diagnosis has diminished to a point, where I think residents are at a huge loss. Recent study had suggested that intern spend only 12% at bedside as compared to 40% on computer screen which may be a reason for their burnout. More and more younger physicians as residents and fellows seem exhausted, just from doing work that they never really bargained.
I am currently a part of an initiative called "Assessment of Physical Exam and Clinical Skills" (APECS) started by the JHU medicine training program to improve the bedside clinical skills of the residents. It is based on the framework of PACES conducted by Royal College of Physicians and tests residents one on one at the bedside for the clinical skills with teaching and feedback at the end, trying to bring back the fun of medicine for the residents along with mastering of clinical skills. This indeed is a process that soon will fix the growing physician burnout and patient dissatisfaction we are seeing now.

One of my favorite innovations was a complete overhaul of supply management. We found that supplies were difficult to find, not stored in intuitive locations, products on the shelf/ cabinet were expired, etc and it was a huge line item in the budget that just wasn’t working. This is one of my favorites because the issues were universal in both the hospital setting and ambulatory care and it the solution was low tech and easy to maintain. It also had a huge impact on physician and staff satisfaction, safety, and financials.

An innovative practice is one that is able to think beyond traditional ways of serving patients. However, it begins, first and foremost, with building and fostering a strong team culture. In order to innovate a practice must have a supportive and trusting team environment that encourages all members of the practice to contribute ideas and solutions. By building a strong team culture, communication among all practice members improves leading to sharing creative solutions and true innovation.

The only failure in innovation is refraining from even trying. An innovative practice may not have "cracked the code" or fully bent trend, but they've shown an appetite to at least try to break the mold. Maybe this is a new welcoming protocol at the front desk, followed by a follow up survey. Maybe it's having the first 5-mins of every visit be focused on eye contact between provider and patient. Maybe it's sending a "3-things we can do differently" email from your staff to your C-Suite leadership every Friday. Regardless, it's the desire to innovate (and the demonstration of that desire in some way) that marks innovation. Keep being noisy!

For the most part, innovative companies in every field are more profitable and better positioned for growth. One way these companies ensure success is to create an innovation plan and hold people accountable to see this through. Therefore, one of the best ways a health system leader can support innovation is to add innovation to the overall strategy, set a budget to support it in practice, and assess/examine the effort toward meeting the innovation goal throughout the year. However, it will take more than this to be successful. They also need to lead by example - be willing to try new or modified procedures/processes, hire employees with a track record or interest in innovation or quality improvement, and praise groups/departments who are working to solve problems even if the new solution was less than optimal.

I agree with Jennie, and would add a caution that Innovation can sometimes take on it's own identity in terms of strategic goals. This can be a costly mis-step when it comes to scaling innovation successes down the road. As you lay out your initial innovation strategy, be mindful to align metrics and efforts to existing organization wide objectives, values and goals. When you've succeeded in a small scale, additional resources can be much easier to come by if your practice's efforts are a tailwind for the broader goals of your hospital, system, etc.

I would agree with Drew and Jennie, especially emphasizing the value in ensuring alignment with goals - both large and small. In my experience, ensuring that this alignment is bidirectional has become increasingly important - not only should the team(s) understand what the overarching organization strategic goals are, but Leadership should also be aware of what their teams' needs and objectives are. This can create a better awareness of where the gaps/barriers are to ensuring resources and support are in place for innovation efforts, and open communication.

Along the lines of strategy, innovative approaches and practices are best cultivated when there is open dialogue both on intent, progress, and "failures." While many of our organizations must take on a more conservative, risk-averse stance given the high-stakes "business" we are in, it is important to allow some flexibility to for those more innovative ideas and solutions which carry more creativity and risk. This can be done by modeling and/or rewarding those who embark on innovative projects, no matter the size, and celebrating the early failures with lessons learned.

Brilliant answers and I totally agree with the above. Along the same lines as Marcelo mentioned, one of the important things that I think the health system leaders can support innovation is by seeking out the reasons why the health care providers would be less likely to adopt the new innovation. As a health care provider, i would not be likely to adopt a new practice innovation if it clashes with my patient-care values or the values of my organization. Hence, as health system leaders, their responsibility is to be expressive of the rationale behind the innovation and bring forward the new innovation aligned with our long standing cultural values that we all are adherent to and respect as caregivers. This will motivate the providers to be more open to the adoption and then the focus could be on identifying the logistic barriers in the adoption of the new innovation .

All great comments above. Health system leaders play important roles in supporting the development of the innovation and, equally important, the spread of the innovation to all those who would benefit from adopting the innovation. Their advocacy role includes broadly communicating how the innovation aligns with the systems vision, mission, and values, recognizing those developing the innovation, ensuring a management system is in place that promotes spread, and celebrating those who adopt the innovation into their work.

One more key point - it is difficult, if not impossible, to demonstrate the value of an innovation, is the baseline workflow is highly variable. Leaders who want to maximize the value of investments in innovation would do well to first focus on developing consistency in care delivery in each service line. The vast majority of care delivery today is highly variable, resulting in significant waste, and making it difficult to realize the full potential of any innovation.

Some lessons learned: Leaders at every level can be evangelists of change, and leverage their influence in making innovation and change part of the culture. They can demonstrate the importance of this work by making tangible financial and non-financial investments (ideally allocating protected time for clinicians and staff to be involved in improvement efforts, and publicly celebrating the successes and energy of folks already doing great things who are champions for problems they see firsthand). Be crisp in helping defining metrics (and co-design these with folks at the front-lines as there may be many nuances to consider), and help set clear targets so everyone can agree on what success is. Support learning outcomes as much as clinical outcomes in the short term, since failures and iteration often help define long-term success!

One of the best things physicians can do here is to foster curiosity. Regardless of the size of the organization, or the size of the innovation ask, without curiosity, the value generated by the innovation process can be threatened. Cultivating staff - and each other - to "ask why" throughout the innovation process not only leads to more vibrant and creative solutions, but can help unearth missed opportunities and/or failures early. By being curious, leaders can better empathize with and be more supportive of those in the organization who are embarking on innovation. Alternatively, curiosity leads to "bottom-up" questioning of the status quo; organization members know that they are encouraged to "ask why" and stay creative, while also focusing on the core mission/vision set forth by an organization.

With the increased workloads and responsibilities physicians face today, the need for innovation is even more pressing, not only for physicians but by physicians. Supporting each other with toolkits and resources to think creatively is integral; if an organization is not yet primed to offer resources or tangible support for physicians to innovate (or receive innovative solutions), fostering a culture of curiosity is a low-cost, and critical, step to setting the groundwork for an environment that encourages ideation, ultimately leading to the undeniable need to implement; this is still equally as important for those who have organization structure around innovation. Stay curious...

Physicians play an important role in healthcare innovation. They can lead the charge or stop the movement before it reaches solid ground. The have the ability to impact change in ways that no other role/position in health care can accomplish. Not only are they often the gatekeeper to new ideas, but they can also be a champion of an innovation.

They have a unique vantage point working with clinical staff, administration, and patients and have the ability to listen and observe day-to-day struggles from all parties. Therefore, their encouragement to try to ideas can be invaluable as is their openness to assist in a pilot test. Many times physicians are asked to champion an innovation and lead a practice during implementation. Physicians can also play a role in adding innovation to the overall strategy which would place a larger spotlight on its importance and need in today’s challenging environment.

I think it also should be said that physicians can’t innovate in a silo. They must built a team/support system of willing and curious members who are interested in working toward a better solution.

On any given day, physicians can engage in innovating and shaping the practice by:
1. Identifying and defining problems and areas for focus based on their experience on any given day. Pain points are a great place to start. Another place to begin is focusing on activities that require their or their staff’s time and attention, yet produce little added value.
2. Approaching key stakeholders/owners – practice leadership (medical director/practice administrator) – and engage/discuss their observations providing insight into the problem(s) at hand. Also, should they have solutions, explain those solutions and what those solutions if implemented would be accomplished, and
3. Determine if a group forum exists where this could be discussed. In my experience most practices have ‘operations committees’ that are ideal to discuss and determine next steps; ask that practice leadership bring this to the committee and/or attend the committee to introduce the discussion.

Lead by example! Be open to new ideas.

Physicians can be critical observers on behalf of the system. I think the best thing they can do today is ask the question of "Who 'owns' innovation at our organization?" With that answer, open the dialogue- tell them how many opportunities you see, tell them about the cool things happening in your med-school friend's practices across the country, let them know about the innovations you've been reading about. Finally, remind them that ALL of the innovators in the market need one critical thing to catalyze their innovations; access to patients/providers, and proof points. This is an asset that you have for free at your fingertips. From here, the innovation owners should be in a position to facilitate business conversations with innovators that can help the practice.

Physicians play a key role in the adoption and implementation of innovation in health care. Being at the forefront due to their unique understanding and direct interaction with the patient, they are the primary mediators to add momentum to the adoption and implementation of the innovation. When we see the traditional means of medical information transmission,it typically take years to change physician behavior, with one review concluding that the lag time between research publication and change in practice is 17 years. Hence, in this 21st century, when innovation has transformed almost all the fields, our responsibility as health care providers is helping in faster diffusion of innovative practices that help to improve the health care practice.
A great example of similar physician led-care redesign is the High Value Practice Academic Alliance (HVPAA) . The HVPAA participants are practicing physicians in various specialties from across the globe (US, Canada, Japan, Norway) which have a pledge to implement at least one value improvement initiative each year.
hvpaa.org/

Great question. My opinion is that we should begin with “what does this patient want?” And it’s different for different age groups. Mobile technology is great for our younger patients. My older patients want to get a person on the phone when they call, preferably somebody they know, and to get answers from a “real human”. My younger patients just want to go online and access us that way. Harnessing both technology and soft people skills works the best. I have a receptionist as well as one MA who are amazing - they remember the patient even after months or years and ask about their families. It’s the little details that count. So I would counter that we need both new ways with technology as well as old ways of comforting to confront the problems within healthcare.

That's a great question and my opinion is that there are several issues in the health care currently.Though health care is a right, our nation is only a few among the developed countries that is unable to guarantee universal health coverage despite spending the highest in health care. A new Gallup poll suggested that almost 70% Americans felt that the U.S. healthcare system is in "a state of crisis". hence we as a part of health care organisation, hold the responsibility to improve this situation. To me by far, technology seems to be an asset along with workflow changes in order to appropriately address this.
For example, we are in the digital world where EMR has mostly replaced the human interaction of physician with the patient.
The average clinic visit in the United States lasts only 7 minutes for an established patient or 12 minutes for a new patient. During that very limited time, there is little eye-to-eye contact because the doctor is preoccupied entering data at a keyboard. This has led to unnecessary lab tests and scans, leading to vast waste, along with patient dissatisfaction and poor outcomes. Similalry, physicians feel rushed, unable to execute their charge of caring for their patients which is why they entered the profession, leading to increased physician burnout. Hence, our new way of thinking should focus on how to utilize the technology in a fashion that it reduces workload and make appropriate changes in our workflow so that both patients and physicians are more involved in the interaction leading to improved healthcare outcomes.

I think one of the largest problems in health care that needs to be addressed is the patient/clinician relationship. Patients spend very little time in the exam room with a physician, during which the physician needs to review all new information (labs, scans, etc), current symptoms, etc., make a diagnosis, and chart. We all know this situation isn’t satisfying for the physician nor the patient. There are a few EHR tools that can help with reviewing new labs or scans as well as software to assist with charting. Even with all the technology available, I’m not sure the current way of a physician cares for a patient completely solves the problem.

If a physician must see X number of patients a day to be able to cover operating expenses, throwing all the solutions we have at this problem will not solve the larger issue. I think in order to address this means we need to fundamentally change how insurance pays for a visit and we do have better options than fee-for-service. But until those (capitation/value-based payments) are more universal, I don't think there will be any major changes in the patient/provider relationship.

I’m not sure the implementation process looks very different at a smaller clinic vs. a large hospital. The goals of implementation are the same for both types of organizations and the method to reach the goal doesn’t change much. What does change is the scale of the implementation operation.

For example, training is among the first steps in the implementation process no matter the size of the organization. The end users of the innovation need to fully understand the solution and the impact it may have on their day-to-day environment. All end users might be able to attend one training session together at a small clinic. There may need to be many different training sessions scheduled at multiple times throughout the day to account for the different staffing levels at a large hospital.

Another example is the use of a 'champion' to assist with the implementation process. A smaller clinic might have 1 champion while a large hospital has 1 champion per department impacted by the solution. Again, the process doesn't change, it's the scale of the operation that needs to be adjusted.

The difference is in available resources. Smaller practices are generally non hospital based and paid significantly less under Part B for the E&M and also procedure fees. Larger practices are generally hospital based where costs of IT and other innovation or marketing are spread over larger departments. Owning a small practice is like owning an individual stock while owning a large practice (generally hospital based or large multi-specialty) is like owning a diversified mutual fund. Medicare’s annual OPPS or PFS updates are generally not as devastating for diversified larger groups. So the incentive to invest in transformative processes or to take risk is generally higher within larger systems, especially hospital based, which are somewhat buffered against adverse regulatory changes within healthcare. That being said, I believe the ability of an younger individual to make a difference is higher in smaller practices. Within hospital systems it takes time to get to the top which is when one can effect substantial changes.

Thoughtful question. Though I partially agree with Jennie regarding the goal and methods being the same for implementation of innovation in a small practice as well as a large hospital, I believe there are differences in the actual implementation of a new innovation. For example, the very first decision of adopting the innovation by a small practice would be relatively faster in a small practice as compared to the large hospital where there are multiple bureaucratic levels to pass decision before the initiation of adoption. Similarly, adoption of every new innovation big or small, carries with it the risk of failure to succeed. Hence, the attitude of an organisation towards the risk associated with adoption plays a very important role. Small practices may embrace the risk as they are more amenable to change and risk is small while large hospitals who have been steady for decades are relatively resistant to the new innovation and the risks associated with its adoption.

Practice Innovation, to me, is applying a toolkit of design-thinking and entrepreneurial frameworks and techniques that help address a specific business challenge. For providers, hospitals and health systems, for example, an important strategic challenge is: "In a competitive environment that is stressing higher quality care, better patient outcomes beyond the hospital walls, and a push to lower costs, how might hospitals and health systems re-think their business models to deliver value in a fundamentally different way than they have before?"

Practice innovation, then, is about first understanding and building a picture of what a “future state” of patient care and delivery looks like. Then, it’s implementing design-thinking to identify the elements requirements of new solutions that will help build this future state, and then thinking through the product, business model, and delivery innovations that will then execute on this future state.

To me, practice innovation denotes the multi-dimensional “motivation” for innovation - something that is unique to the 1) industry and 2) audience. In our industry, we have the valuable opportunity of having multiple audiences/consumers: physicians, nursing and other staff; patients; families; society, etc. The practical application of innovation is one that is designed to generate a value proposition for any or all of those audiences.

In fact, “practice,” as terminology, may be even more important than the end-product the innovation is designed to deliver. That practice may be strategically focused on a premier aim, such as novel development of therapeutics, or more broadly on quality/safety, operations, waste reductions, cost efficiency, etc. Regardless, the methodology of how a unique challenge is approached, iterated on, and more often than not pivoted upon, deserves more focus. Moving through the innovation process in an effort to ultimately design a novel patient therapeutic intervention, for example, can generate a multitude of lessons learned, unexpected gains and losses, unearthed opportunities, new synergies and relationships, and clarity — all unintended yet very real returns that reward motivation and the pursuit of fine-tuned practice, even if the sought after end-results is not achieved.

Asking “why” the problem needs innovating, and focusing in on the purpose of the individuals practicing that innovation, can yield more valuable, meaningful results (that in turn can lead to a larger “return”). There is methodology and process to targeted innovation, especially in large, layered organizations like the ones we share, where we may set out to innovate for a number of operational, strategic, and clinical reasons; but there is also a wealth of opportunity to better understand what motivates our unique needs to innovate - something, to me, that can never be practiced excessively and can only make innovation practice more valuable.

Practice innovation, in its simplest form, is creating a solution for an aspect of healthcare. I don’t think it means the new solution needs to be groundbreaking or create a societal difference to be considered innovative. Instead, I think that any solution that solves a problem or creates an efficiency within a practice can be considered innovative.

In my opinion, there are a few aspects of practice innovation that are nearly universal. The first is that the need or problem is identified and examined from various viewpoints. Asking the questions “Why?” or “Why not?” can provide eye-opening explanations of the problem. Sometimes practice innovation means trying multiple solutions to see what works best or creating an optimal solution through an iterative process. Either way, the people using the solution need to be able to provide feedback throughout the process. No matter which way the practice innovation is identified, it also needs to be sustainable in order to find its real value within the healthcare practice.

"Practice innovation" to me is all about "practicing to challenge
the status quo" . In today's world when the health care can be integrated with the technology at it's best, such as artificial intelligence (AI), precision medicine, genomics, tele-medicine, and much more, practicing innovation has become even more meaningful. Without any doubt, the health-care system is a dynamic organization with multiple stakeholders including patients; health care providers; health care organizations; federal, state, and local governments; health insurance companies; health care-related businesses; and academia with competing interests among the stakeholders that clash. However, the primary stakeholders are patients and in simpler terms, practicing innovation includes all those measures that help us achieve the target of improved patient outcomes with cost optimization and increased access to healthcare in the society.
Digital tools and innovative technology has brought profound changes in other fields and holds a potential in the field of healthcare which i believe would transform the way we practice healthcare now. So be it with simple tools like POCUS (point of care ultrasound) at the bedside or digital self-care tool kit CORRIE or complex predictive analytics of artificial intelligence, all this comes under practicing innovation ...and we as physicians who are at the forefront in understanding the needs of the patient need to challenge this status quo and innovate the way we serve the patients.

These are great thoughts. I will add that a key element of effective practice innovation requires designing for the physician and staff work experience as much as the operations of delivering care to patients. Early efforts are needed to make the work day sustainable and ensure top of scope efforts for the whole team, to enable any change or innovation to stick in the longer term, in this era of burnout. Some opportunities in this area include decompressing schedules to make room for high value visits, streamlining the day with support for documentation and note completion, and rethinking WHERE care is delivered (office, satellite sites, home), HOW (in-person, remote, automated hovering) and WHO (warm handoffs with the PCP or care management, APPs).

To work in a Primary Healthcare clinic within my nation's healthcare industry that honors the Design Principles for Managing a Common Pool Resource. see dx.doi.org/10.1016/j.jebo.2012...

To work in a Primary Healthcare clinic within my nation's healthcare industry that is committed to reducing its cognitive dissonance by a willingness to agree on a unified epistemology for Caring Relationship, Cluster, Collective Action, Community, Dysruptive Processes, Family, HEALTH, Social Capital, Social Cohesion, Social Dilemma, and SURVIVAL COMMONS (aka safety net).

To work in a Primay Healthcare clinic that participates in my community's commitment to honor my nation's strategy to assure that Primary Healthcare is equitably available and ecologically accessible for each of my community's resident persons.

To work in a Primary Healthcare clinic where my associates and I participate in a nationally coordinated career long, self-mentoring strategy that is offered by my state's combined medical schools for my focused, continuing education needs that is locally tempered.

To work in a Primary Healthcare clinic where my associates and I can fine tune our encounter data sets and their coordination with our clinic's "medial Triage" algorithms.

To work in a Primary Healthcare clinic where the EHR maintains a comprehensive care plan based on a central problem list defined only by the patient's Primary Physician.

To work in a Primary Healthcare clinic where each of my Team members participate in an annually mentored Career Achievement Planning process. see HBR Febr 2006 "What executives should remember" by Peter Drucker

To work in a Primary Healthcare clinic where my associates and I participate monthly in a "chart audit" of our own design.

Innovation within the clinical practice is the offspring of necessity. Clinical practices (particularly physician ambulatory clinics) struggle to maintain balance in the face of consistent and increasing conditions of change – patient demographics and acuity, market dynamics and consumerism, payers and reimbursement, technology and electronic records, government regulation, therapeutics, labor markets, etc. All of these – complex in and of themselves – present daily in the clinical practice, patient by patient. And, unlike hospital reimbursement, professional fees are not structured to allow for developing the internal management capabilities/infrastructure to proactively account for future needs of the clinical practice. This leaves the clinical practice as the ground for which these changes manifest in real time.

Practice innovation means challenging current operating assumptions, redeploying resources, and allowing for change in dynamics to meet the health care needs of our communities. Importantly, practice innovation provides workforce and organizational sustainability over the near term, and develops the management infrastructure for meeting expected needs in the future.

Great question and one I thought about seriously as I founded my clinic during the recession. To me, practice innovation meant harnessing technology and people soft skills to make healthcare access and experience easier and flexible for patients. Banking is a regulated industry which has transformed. Why can’t we transform healthcare so it’s easy for patients? For our clinic, it began with transparency in appointment scheduling, accessing test results, and making patients become part of our clinic community. Mobile EMR tools for the doctors and staff helped. We invested heavily in IT technology. We pushed the envelope. Patients were invited to stop by the clinic which they did - and bonding experiences began. Past patients with cancer would talk to current patients in a separate waiting area clearly identified. We did walks for health, and patients started a non profit for the clinic. We had hand made gifts over the holidays for patients undergoing treatments. I treasure some handmade wooden Christmas ornaments and some stunning jewelry specially made for us and for new patients. Practice transformation is making the healthcare experience more enjoyable and if we could do that for cancer treatments then there is Hope! It take a village!

www.SheilaRegeMD.com

Practicing innovation in a clinical setting to me is about identifying and solving for the underlying problems that exist within healthcare delivery with technology. Innovation must extend past finding solutions to a surface level problem to understanding why that problem exists in the first place. For example, if the problem is "we don't have enough beds in the ER to service our patients", are we truly solving for the underlying issue? If we use the patient journey in this example to share what pain points patients experience throughout an entire ER visit, what else could we uncover? For example, a significant wait time for labs causing an overflow of patients in the ER might reveal the bed capacity issue is actually a symptom, rather than the underlying problem.

With this in mind, practicing innovation requires solving for challenges that exist across the healthcare journey (whether provider or patient driven), rather than focusing on pin point technology solutions. The startup landscape has responded to how healthcare stakeholders source for solutions, and historically this has been pin point driven. In order to solve for complex challenges that we face in healthcare delivery over the next 30 years, solutions must be scalable, holistic in nature, and focused on the healthcare experience.