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Why is implementation in healthcare so hard?

I was in an executive meeting the other day and one of the vice presidents asked, Why do we struggle with implementation?

If you work in healthcare, this won't be the first time you've heard this. Timely and impactful execution is often juuuuuuust out of reach. Healthcare is brilliant at planning documents and we have rock solid best practice guidelines yet we struggle to implement and scale beyond a pilot phase.

I am sure this is true for most bureaucracies and large organizations. It's difficult to give flight to such large, cumbersome beasts. Innovation units like our Design Lab are commonly used to help teams dream up new business ideas and service models and we are pretty damn good at getting people to reach toward their most mind-blowing ideas and then - yep, you guessed it - those ideas come crashing down because they're not supported with a broad enough wing-span to push past those fire-breathing bureaucratic monsters.

Our lab launched 2.5 years ago and we've worked with dozens of teams to solve complex problems like How might we better support youth with mental health challenges? and How might we help rural patients at the end of life without building more bricks and mortar? While we've had projects that stalled quickly after an initial launch, we've also had projects and teams that have been able to push through the clouds of red tape and flocks of fixed mind-sets to reach a mind-boggling altitude of impactful change. In a nutshell, here are the qualities that we believe will carry your ideas over the horizon.


User engagement is still a fledgling concept in healthcare, occurring sporadically and mostly in a tokenistic manner. Very few healthcare organizations work with patients to create, test and implement a service or innovations. While patient advisors are being brought on in droves as volunteers, we quickly slot them into committees and other bureaucratic structures that tend to move in pontificating circles.

What we've seen is that active change will not come from committees and working groups. Insights come from truly understanding patient, family and community needs - through storytelling, observation and ethnographic interviews. A satisfaction survey is never going to get to the heart of the issue, and statistics aren't going to help you understand what really matters to patients and families.

Patient groups are starting to organize themselves (@pts4Change) but they are careful not to offend the establishment. They ask questions like Why do I need to physically go to the doctor's office to refill my prescription? and Why do we still use fax machines if they are known to be woefully unreliable due to user error? These are not absurd questions - but yet we can't seem to respond.

Teams that get shit done are the ones that are in the community, talking to patients and families, learning about what questions to ask and inviting them to co-design and test solutions. We've met with teams that don't even know who their end-users are, or haven't taken the time to speak to them directly about the problem. Those projects never even get off the ground.


At the Design Lab we have a little cheat sheet for how to spot bold leaders. In a large bureaucracy where protocols are plentiful, we have found that bold leadership is essential for successful execution. Here's what we look for:

  1. Comfortable sharing failures and encouraging experiments

  2. Willing to stick out their neck and challenge superiors or other leaders when necessary.

  3. Strong enough to bend or break rules + policies to make the right thing happen.

  4. Okay with not building consensus before proceeding (gasp!)

  5. Willing to learn from action vs. a thoughtful plan (placing more emphasis on people than ideas).

Bold mavericks. Go-getters. We all know who these trailblazers are. When faced with an idea that sounds interesting they say Let's try it! vs. Please write me a one-pager I can present to the steering committee.

I am convinced that 15% of healthcare leaders have this type of bold leadership, and those are the ones that drive meaningful change.


Oh yeah - that scary four letter word. Who in your network has grit? It is easy to spot. These people are frustrated with the status quo and have an insatiable drive to make an impact. They are undeterred by hurdles, they embrace the ugly, messy and dirty and have the courage to tackle the hard stuff. They bounce off bureaucracy and are allergic to mediocrity. These are the people that you want to work with.

I met a guy the other day who talked about a very transformative idea - I got all excited but then he said "but if it's too hard I won't push it". My heart sank. He does not have the four letter word.


Find people who have influence. These are the people who speak their mind and people follow them. They might not have the big title - in fact, most often they won't - but they have large networks. This type of person will provide the wind currents to lift big ideas to greater heights.

People with influence are usually engaging speakers that can connect with hearts and minds. They are not easily swayed by power or prestige or protocol and are adept at navigating the emotionally-charged thunderstorms that drive discontent. From John Kotter:

People change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings. (The Heart of Change).


If you are not surprised by this list - and if your project has a group of people who possess these traits - then you are golden. Off you fly!

But what if you suspect that none of these qualities are prevalent on your team or project? Step one is to talk about it. I openly ask new clients Are you willing to bend the rules to try something? Sometimes our team involves a higher level of sponsorship to make sure we have cover to do something different.

I also should mention that not only does our lab seek to work with people of these qualities, but we are consciously cultivating these traits in our very cores. We challenge each other to be bolder, to risk more, to dig deeper and reach higher. We have recently embraced radical candor and it has been wildly successful in keeping our collective heads out of our collective asses.

And sometimes, even with all these qualities apparent, we still fail. But our failures lift us higher into the air, they give us a higher cliff from which to launch the next time. Every failure brings us closer to success.

When it comes to executing those big ideas, it's always going to be a struggle. But if you populate your team and your projects with people that have these specific qualities, I think you'll find that impactful implementation is not so out of reach.

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