Sir Winston Churchill, a great warrior, and leader of the British people during World War II, offered this statement as an indirect jab at the American way of getting things done. He completed his thought with, "… when they have tried everything else."

As a nation, as a people, as a model for the free and not-so-free world, this statement reflects what our closest relatives and allies believe about who we are. We have historically done many things to achieve a goal. When we failed, we learned from it, adjusted, and moved ahead. That is clearly the story of our several hundred-year journey in health services. It is only when we persist in doing ineffective things that the system bogs down. Improving patient adherence to their plan of care represents such a condition.

I watched "Gangs of New York" last week starring Leonardo DiCaprio as an Irish street thug during 1863 draft riots of the American Civil War. While all men are modern in their own time, the 1860’s, even in the Big Apple, was a gritty time. Self-taught trade school physicians delivered health services such as they were. A standardized system of quality control, infection control, patient centered care, and patient empowerment were a century away. Infection control, patient centered care, physician credentialing and licensing had also been around for almost two millennia in ancient Persia. Some things cultures need to discover on their own. We find ourselves today nearing the end of the second decade of the 21st Century and I wonder what clinicians in the year 2163 will think of our "gritty time."

Health services providers take a lot of process improvement from industry for several good reasons, it improves productivity, reduces costs and increases profit. Henry Ford stated, "We are charged with discovering the best way of doing everything." In discovery, there has been and will continue to be a lot of mistakes and learning along the way. That is the nature of discovery and that is the history of mankind. Ultimately, we will, as Thomas Edison admonished his contemporaries, "There is a better way… find it."

Health Services is more than Process Improvement

There are two realities in health services delivery that Ford, Edison, Demming, Juran, and other proponents of process improvement programs, didn’t have to consider: 1. Parts on an assembly line don’t have a choice to be there and 2. Most (non-human) products are not self-destructive.

People who enter our health care "assembly lines" have a choice. Many will choose to ignore their symptoms until those symptoms become overwhelming and can’t be ignored. This is the "rescue population" and the health care system does a pretty good job of rescuing people from their self-injurious choices. Others might jump on the "assembly line" and then choose to jump off because of cost, inconvenience, or side effects. These patients are in the "primary non-adherence" category. Others will have new parts installed but return to the very habits that initially threatened the life of the old parts. Finally, there are many who will follow their plan of care, at least for a while. What all these groups have in common is the behavior of choice and the consequences that follow that behavior.

When they have tried Everything Else…

Patient non-adherence is hardly new. It has been the bane of existence since Adam and Eve were told to eat every fruit of the garden except one. To be sure, many of the medicines and treatments, from years long gone, were likely worse than the disease itself. In the grand scheme of life, most of us are "patients" in title only and only when we use the health services system. Other than during those brief moments, patients are people. People do the things they do because of the consequences of their behavior. Those consequences, from the person’s perspective, are ignored when clinicians offer the standard "patient education packets" to their patients.

In the last several decades, what have we focused on in “trying everything else” to improve adherence? Systems improvement comes to mind. Change the word from compliance to adherence and improvement will follow. Add adjectives to the word patient. There is patient centered care, patient enabling, patient entitlements, patient [fill in the blank]. Population health is another way to define a process to improve adherence. Finally, we have taken the term “patient” out of the equation as we seek the holy grail of adherence. Once we have tried “everything else...”, will we turn to behavior and adherence management to improve outcomes?

Weaning myself off…

A couple of weeks ago, I was traveling through North Carolina. I was having breakfast with my wife and could not help but overhear a conversation between a lady in her 50's and her adult daughter. "My doctor says I have high blood pressure," the lady said. Her daughter, clearly concerned about her mom responded, "Well Momma, what’s the doctor want you to do?" Without hesitation Momma responded, "I started on this blood pressure pill. I think I’ll take it until my blood pressure gets back to normal and then I’m going to wean myself off it."

I wanted to have a conversation with her, but we had another 500 miles to drive that day. How many mommas and daddys are weaning themselves off a plan of care because the consequences of adherence today are negative, while the consequences of non-adherence are years away?

What non-behavior based techniques and processes, which have been used for the last 35 years without success, are going to suddenly become effective overnight and actually work this time at changing these patient behaviors, or are clinicians finally going to do the right thing? Stop focusing on non-behavior based processes. Identify your at-risk patients, figure out why they are at-risk, establish an Adherence Improvement Plan and work the plan with the patient and their families using positive reinforcement of the proper adherent behaviors until they become habits.

Adherence Management Coaching©… It’s the behavior based solution to true patient centered care!

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