I am haunted by the question, “Are there any other work force innovations at SETMA of which you are particularly proud?”   When I first looked at the Robert Wood Johnson Foundation project, I was concerned as to whether SETMA’s work would be valuable because we have not adopted some of the “new ideas” which have become very popular in the age of healthcare reform.  We wondered if imposing new structures on existing organizations would essentially change those organizations or would they simply make them appear to be different.  We came to believe that existing structures and organizations need a metamorphosis which would radically, dynamically and continually change the organization where the changes were not superficial but fundamental.

In fact, we have rejected reform as a method for the improvements which are necessary in healthcare.  “Reform” by its nature results in only imposing upon existing organizations different structures without fundamentally changing those organizations’ raison d'être.  The national healthcare policy debate has been cast in terms of reforming of the system. I would argue that reforming is an inadequate goal, doomed to failure, and even if should succeed; reformation of the healthcare system will not produce the positive results which are legitimately desired by all participants in the debate. I would argue that if healthcare change is going to improve care, improve the quality of life, cover all Americans, and address the rising cost of care, we must have transformation of the healthcare system and not simple reformation.

Does the distinction between reformation and transformation of the system really make a difference? In order to examine this question, we must define our terms. The definition of "reformation" is "improvement (or an intended improvement) in the existing form or condition of institutions or practices etc.; intended to make a striking change for the better in social or political or religious affairs." Synonyms for "reformation" are "melioration" and "improvement." Another definition states, "The act of reforming, or the state of being reformed; change from worse to better."

On the other hand, "transformation" is defined as, "a marked change in appearance or character, especially for the better." "Metamorphosis," a synonym for "transformation," is the transliteration of a Greek word which is formed by the combination of the word "morphe" which means "form," and "meta" which means "change." "Metamorphosis" conveys the idea of a "noticeable change in character, appearance, function or condition." Metamorphosis is what happens when a caterpillar morphs into a butterfly.  It does not simply impose a new structure upon an old form; it fundamentally changes the nature of the organism which rather than crawling around now can fly!

The Function of Reformation and of Transformation Radically Different

In function, the distinction between these two concepts as applied to healthcare is that "reformation" comes from pressure from the outside, while "transformation" comes from an essential change of motivation and dynamic from the inside." Anything can be reformed - reshaped, made to conform to an external dimension - if enough pressure is brought to bear. Unfortunately, reshaping under pressure can fracture the object being confined to a new space. And, it can do so in such a way as to permanently alter the structural integrity of that which is being reformed. Also, once the external pressure is eliminated, redirected or lessened, the object often returns to its previous shape as nothing has fundamentally changed in its nature.

Reforming Tools

Reforming tools are rules, regulations, and restrictions.   Reform is focused upon establishing limits and boundaries rather than realizing possibilities.   There is nothing generative (creative) about reformation.  The “lethal gene” of reform is the inclination of organizations to resist the tools of reformation.  Resistance requires more and newer tools, rules, regulations & restrictions with which to exert more pressure.

Reform does nothing to change the healthcare model of a patient going to a provider, expecting something to be done to or for the patient. In this model, the patient was and is passive.  There is little patient responsibility for their own care, as to content, cost, or appropriateness.  This model offers no patient/provider leverage for improvement of care, health or cost.

Transformation, on the  other hand changes the nature of the organization.  Transformation is generative (creative) producing the energy and power for sustainable improvement. Transformation is not dependent upon external pressure, but is energized by an internal drive which is the nature of a  “learning organization.   Transformation is fueled by personal passion; it is self-sustaining, requiring no reward or recognition to continue.

Mental Images Define a Future you Intend to Create

Transformation creates mental images of what the future can be.  These images are internalized by the individual and by the organization.  The images morph into a personal and organizational vision, which produces a passion for creating a remarkable future.  These mental images then create new images, which propel further innovation and transformation.  The healthcare provider is no longer a “constable” attempting to impose health upon a patient - the provider is a counselor, a consultant, a colleague, empowering the patient to achieve the health status he/she has determined to have.  The transformation is not sustain by external pressure but by internal passion.  The “coming into being’ of the structures and functions demanded by the mental images is the generative (creative) process “forced” by transformation.

Provider and patient, with many others, are active team members, working together to preserve or improve the patient's health.  All members of the team know and acknowledge that the “race of life is the patient's to run.”   The patient and the provider must rethink their common prejudice that technology - tests, procedures, and studies - are superior methods of maintaining health and avoiding illness than communication, vigilance and "watchful waiting."   Both provider and patient must be committed to evidence-based, patient-centered medicine, which has a proven scientific basis for medical-decision making.   This transformation will require a community of patients and providers who are committed to science and to personal relationships of mutual respect.

An Inconvenient Reality - without Humanity Science is Helpless

It may be an inconvenient reality but science is not the foundation of transformation.  The tension which exists between technology and humanity is why technology must always be subservient to humanity.  Yet. that subservience does not emasculate or eliminate the power of technology.  Through acknowledging truth, privately and publicly, we empower sustainable change, making analytics a critical aspect of healthcare transformation. But the balance which humanity brings to the equation  is that  in the midst of health information technology innovation, we must never forget that the foundations of healthcare change are ‘trust’ and ‘hope.’  Without these, science is helpless!

Transformation will require the reestablishment of the trust which once existed between provider and patient. That cannot be done by fiat.  Patients must be absolutely confident that they are the center of concern and of care.  Patients must also know that they are principally responsible for their own health.  These concepts are the genius behind Patient-Centered Medical Home and  this trust cannot be achieved by regulations, restrictions and rules.

Patient and provider must lose their fear of death and surrender their unspoken idea that death is the ultimate failure of healthcare.  Death is a part of life and it cannot forever be postponed.   While the foundation of healthcare is that we will do no harm, recognizing the limitations of our capabilities and the inevitability of death can lead us to more compassionate and rational end-of-life choices.  As primary care providers are the key to transformation of healthcare,  primary care providers must be  actively involved in the defining of public policy.  To be successful, they must be able to put their personal and pecuniary interests aside and support and promote policies which will create a sustainable future for healthcare.

Being from within, transformation results in change which is not simply reflected in shape, structure, dimension or appearance, but transformation results in a change which is part of the nature of the organization being transformed. The process itself creates a dynamic which is generative, i.e., it not only changes that which is being transformed but it creates within the object of transformation the energy, the will and the necessity of continued and constant change and improvement. Transformation is not dependent upon external pressure but is sustained by an internal drive which is energized by the evolving nature of the organization.

The tools of transformation may actually begin with the same ideals and goals as reformation, but now rather than attempting to impose the changes necessary to achieve those ideals and goals, a transformative process initiates behavioral changes which become self-sustaining, not because of rules, regulations and restrictions but because the images of the desired changes are internalized by the organization which then finds creative and novel ways of achieving those changes.