"All politics is local"

The late Thomas Phillip "Tip" O'Neill, Jr, 47th Speaker of the U.S. House of Representatives is often credited with saying, "All politics is local."  You can either agree or disagree with Speaker O'Neill's statement, but I think that the statement would apply to health care as well.  Jeff Goldsmith and Lawton Burns posted an article on the Health Affairs Blog that provides a number of examples of highly innovative, and in some cases, disruptive and transformational changes implemented by health care systems around the country that subsequently failed to take hold in other areas of the country.  Goldsmith and Burns referred to a concept in the winemaking world called "terroir" (I had to look it up).  The term is defined by Webster's dictionary as the natural environment (soil, climate, topography) in which a particular wine is produced (more technically, where the particular grape is grown).  "Terroir" explains why some of the finest champagne grapes come from a specific district in northeastern France and nowhere else.  The two authors then go on to list several examples of transformative health delivery systems that have failed to scale to other parts of the country, including the Kaiser Permanente system (a model of health care delivery that has been incredibly successful in Oregon and California, but not so much in other markets, including Colorado, Hawaii, and the District of Columbia).  In fact, attempts at replicating the Kaiser Permanente model in areas of the country outside of California and Oregon have been costly failures in the majority of cases.  They go on to say that, "Very little about the health system is actually national."  In other words, just as in politics, "all health care is local."

There is no question when it comes to transformational change, leaders who fail to take account of things like institutional culture and local attitudes and behavior do so at their own peril.  We, as a health care industry (and perhaps physicians most of all), have greatly contributed or even created the conditions that have led to the fragmentation and regionalization of care delivery practices - indeed, the way things are done in New Jersey don't look too much like the way things are done in Ohio.  We have to do better.  We, as a health care industry, need to be open to change, and now is the time to do so.  If we wait too much longer, these changes will be forced upon us.

Every time I hear a physician complain about some regulatory requirement, I can't help but wonder if we allowed this to happen simply because we refused to change.  Just the other day, I heard from a physician who wanted to know why the hospital leadership was suddenly becoming the "quality police" and requiring all of these things (medication reconciliation, closing open charts, signing verbal orders, etc, etc, etc) that made her life more difficult and contributed to professional dissatisfaction and burn-out.  I responded by saying that these were regulatory requirements (many of which do actually improve the quality of care, but admittedly some that don't really do so) that were being forced upon the hospital by regulatory bodies, such as the Joint Commission and the federal government.  It always, always goes back to a graph showing the dramatic (almost logarithmic) increase in the number of health care administrators compared to physicians over the last decade.  Again, we created this situation when we, as physicians, failed to change.  We failed to lead, and as a result, someone else took over.

Health care is not easy.  It's complex, and it's probably all local.  But we have to recognize that the time for change is now.  We have great issues that need to be addressed, and if we fail to do so, someone else is going to take over and try to address them in ways that we don't like (ways that don't necessarily place quality of care and value at the forefront).  If we accept change, and if we learn to adapt best practices from other health delivery systems to our own local environments, health care delivery will improve.  For the better.