Rationality is a contested concept in the social sciences, but perhaps the most influential approach derives from the work of psychologists Tversky and Kahnemann, who specify rationality in terms of consistency and coherence.22 Defined in that sense, the paradoxes we have outlined help to explain why it makes little sense to think of rationality as the main driver of innovation in health systems.
Non-rational collective decisions should perhaps be considered the norm rather than the outlier: when health systems are faced with continual external and internal pressures for innovation combined with strong emotional, economic and political forces, the ability of those systems to engage in rational debate and planning is undermined. Yet the need to avoid unnecessary innovations and manage the transition for necessary innovations is among the most important challenges facing health systems today.
If a new technology or technique is being considered for use, health systems should consider the principles of quality improvement as they are introduced rather than waiting for the inevitable problems to occur (box 1). Thus, for a new surgical procedure, we might ask:
- What is the evidence that the procedure improves outcomes in other settings, while recognising the complexities of generalisation?23
- What support, training and systems will be needed before it can be introduced?
- How should we monitor the introduction?
Box 1
Innovation in healthcare: an agenda for action
- Recognise the risks and costs of innovation, including the disruptive effects even of beneficial innovation.
- Have more effective systems for controlling the diffusion of innovation, including better systems for accrediting use of technologies (not simply approval of the product/device).
- Study innovation at the same time as it is occurring, and collect data to link new interventions to outcomes (both intended and unintended).
- Run adoption and implementation studies using high-quality social science methods and theory alongside trials; do not wait until the trial is complete before working out what is needed to adopt and implement the intervention in real life.
- Clarify lines of authority in relation to innovation and use institutional authorities to mediate and adjudicate between the competing interests and demands of front-line actors, patients and their advocates, and manufacturers.
- Use the clinical trial model of Phase I studies to identify the potentially unwanted or unhelpful effects of innovations in systems, and the ways they are ‘metabolised’ by healthcare organisations, before proceeding to full-scale testing and implementation.
- Improve training of health professionals to deal with the challenges—both positive and negative—of innovation.
By asking the first question, we may avoid the many disruptive innovations that are fashions rather than true improvements. By asking the second and third questions, we will smooth the transition. By thinking carefully and critically about when we should regard health systems reforms as ‘clinical experiments’ (and thus requiring the same level of evidence and oversight as other clinical interventions24) and when we should regard reforms as a normal part of the continuous experiential learning required to improve healthcare, we remain alert to the possible impacts—both negative and positive—of innovation.
These are all difficult challenges and require courage in the face of uncertainty, in the face of vested interests, in the face of immense political, patient and provider-led appetites and pressures, and in the face of financial squeeze and organisational and institutional inertia. Perhaps most importantly, these challenges require the courage to fail and learn.25 In summary, quality improvement work needs to reconsider the role of innovation. In the long term, most elements in any medical system will be discarded and replaced. If we focus on making wise and courageous choices of innovations, introducing them with quality improvement principles in mind, then our future healthcare systems will better serve patients.
academicscores.com 