Over the last decade, health care has experienced continuous, capricious, and ever-accelerating change. In response, the American Academy of Pediatrics convened the Vision of Pediatrics (VOP) 2020 Task Force in 2008. This task force was charged with identifying forces that affect child and adolescent health and the implications for the field of pediatrics. It determined that shifts in demographics, socioeconomics, health status, health care delivery, and scientific advances mandate creative responses to these current trends. Eight megatrends were identified as foci for the profession to address over the coming decade. Given the unpredictable speed and direction of change, the VOP 2020 Task Force concluded that our profession needs to adopt an ongoing process to prepare for and lead change. The task force proposed that pediatric clinicians, practices, organizations, and interest groups embark on a continual process of preparing, envisioning, engaging, and reshaping (PEER) change. This PEER cycle involves (1) preparing our capacity to actively participate in change efforts, (2) envisioning possible futures and potential strategies through ongoing conversations, (3) engaging change strategies to lead any prioritized changes, and (4) reshaping our futures on the basis of results of any change strategies and novel trends in the field. By illustrating this process as a cycle of inquiry and action, we deliberately capture the continuous aspects of successful change processes that attempt to peer into a multiplicity of futures to anticipate and lead change.
In January 2008, the American Academy of Pediatrics launched the Vision of Pediatrics (VOP) 2020 project. At the heart of this project was the explicit acknowledgment of the inevitability of change in a world of increasing complexity, unpredictability, and interconnectedness.
The VOP 2020 focus on change and its impact on child and adolescent (hereafter, “child”) health and the practice of pediatric health care was built on previous efforts. Shifts in US population demographics, family structure, income, educational levels, and cultural norms1,–,3 continue to directly affect the health and well-being of children, adolescents, and young adults (hereafter, “children”) as portrayed in the Future of Pediatric Education reports in 1978 and 2000.4 Modifying pediatric educational programs to adapt to change was the focus of the recent Residency Review and Redesign Project.5 Medical journals and the media flood practitioners and families with scientific advances, and health organizations, professional societies, federal agencies, health plans, and accrediting bodies have implemented tools to disseminate and translate new knowledge into pediatric practice.
However, the process of anticipating and leading change has not been a major focus for pediatrics. Koeck noted in a 1998 article in the British Medical Journal that a “student of management and organizational theory could only be stunned by how little the efforts to improve quality [in health] have learnt from the current thinking in management and from the experience of other industries.”6 The VOP 2020 Task Force deliberately sought to anticipate upcoming changes that may affect child health care and pediatric practice through a scenario process commonly used by businesses, the military, and policy makers.7,–,9 The task force brainstormed a range of possible future scenarios and identified 8 “megatrends” to address in preparing for plausible futures (see Table 1 and the accompanying article in this issue of Pediatrics10).
Despite its focus on scenario planning, the VOP 2020 Task Force also acknowledged that the timing and scope of change are not predictable. In addition to the 8 megatrends, several “wild-card” trends were identified as possible, but less probable, futures (see Table 2). Before we had finished the project, events relating to both the megatrends and the wild cards occurred on a national and international scale. The passage of health care reform in the United States in Spring 2010 has already affected pediatric health coverage. The unexpected emergence of the H1N1 influenza virus and its propensity to affect children surprised a public health community focused on the risks of avian flu and reminded us of our vulnerabilities to emerging diseases. Environmental disasters (eg, the Icelandic volcano eruption and the Gulf of Mexico oil spill) have had societal as well as health implications. The cataclysmic effects of the economic recession are still affecting families and the public and private systems that care for them. These recent events heightened the task force's awareness of the unpredictability of change.
In response, we modified our goals as a task force. Although a major focus was identifying next steps with respect to the 8 megatrends, we also prioritized promoting an ongoing process of reshaping a multiplicity of possible futures and choosing how we, as a field, want to lead those futures. Drawing on the business, sociology, psychology, organizational, and quality-improvement literature, we sought to delineate a relatively simple framework to visually represent this type of process.
THE PEER CYCLE AND IMPLICATIONS FOR PEDIATRICS
Our framework (see Fig 1), the PEER (preparing, envisioning, engaging, and reshaping) cycle, parallels the plan-do-study-act (PDSA) cycle used in quality-improvement initiatives to implement changes in health settings.11 The topmost position in the cycle is preparing by building our capacity to actively participate in change efforts. Simultaneously, we move clockwise to envisioning possible futures and potential strategies for leading change. Next is engaging in strategies to initiate, implement, and catalyze change. We then enter into a period of reshaping our vision and strategies on the basis of feedback from previous implemented changes, ongoing monitoring of trends in the field, and the creation of new scenarios that incorporate these data.
Preparing by Building Our Capacity to Lead Change
In the business world, the development and dissemination of innovations are critical for success. Yet, experts have estimated that, despite novel ideas and ample resources, there is a 70% to 75% failure rate for enacting effective change.12,–,14 Successful organizations, on the other hand, prepare by building their capacity to engage in change. Components of capacity-building described in the literature include (1) training leaders at all levels of an organization, (2) promoting a culture that supports learning and innovation, (3) emphasizing effective team development, (4) using information technology (IT), and (5) investing adequate fiscal and time resources.15,16
In pediatrics, many of these components deserve our attention. Although a number of outstanding individuals hold pediatric leadership roles, leadership training and development have only been marginally addressed. The American Academy of Pediatrics Pediatric Leadership Alliance17 and the Academic Pediatric Association leadership training series1 are examples of programs that make the requisite commitment of developing leaders. Second, our medical culture is primarily hierarchical and individualistic in nature; in contrast, more integrated, dynamic, and flexible environments foster successful change across other industries.18,–,22 Third, our training continues to be physician focused, apprenticeship based, and top-down, rather than modeling and explicitly teaching effective team strategies and “servant leadership” principles for both providing care and implementing change.23,24 Fourth, the use of IT also mandates attention and, we hope, will be catalyzed by the current federal administration's efforts to promote the use of IT in health care.25
Envisioning Possible Futures and Strategies for Leading Change
Many writers on change have commented that the types of problems we are facing as a society are increasingly complex and should be considered “wicked problems.”26 Wicked problems are messy, multifaceted, and multisystem; lack clear-cut solutions; and are insoluble by conventional means. Hence, discussions about these types of problems and possible solutions are often challenging, convoluted, and conflict-ridden. Thus, thought leaders in change theory promote the use of ongoing, in-depth dialogues or “permanent strategic conversations” that delve into the murkiness of these wicked problems, confront status-quo assumptions, acknowledge the inherent tensions of addressing them, and specifically seek to build off of these tensions to envision creative solutions.7,27,–,29
Each of the megatrends and wild cards presented in the accompanying article10 represents wicked problems that deserve this type of strategic discussion. Although the content of these conversations could and should evolve over time, the VOP 2020 Task Force proposes that we begin by discussing the megatrends and/or wild cards identified through the VOP 2020, using the questions provided in Table 3 as a starting point. These discussions will need to build on systems perspectives that draw attention to the interconnectedness of systems in initially creating problems and in promoting or hindering change.13 Discussions should include members of a particular system (eg, practice setting, team unit, health plan, subspecialty group) but also stakeholder groups outside the system that may overlap in function or interest area and have the potential to facilitate change.28,30 Identifying stakeholders with political, social, and monetary capital will also prove essential for having sufficient resources to implement change in pediatric health care. Children's needs have routinely had limited political voice, and this is not anticipated to change with the aging of the baby-boom population and the increasing numbers of children who live in poverty.2,31
Engaging in Strategies to Initiate and Implement Change
The success of plan-do-study-act cycles in quality-improvement work partially reflects their commitment to small, “safe-fail” experiments with real-time data collected, analyzed, and applied.18 Similarly, we in pediatrics need to commit to experimentation with new models of care. Our protocol-based, guideline-driven profession may, at times, naturally resist these types of experiments. Comprehensive multilevel approaches also are increasingly lauded in business as more effective than single interventions but have been less likely to be adopted in medicine, perhaps because of our training in single-intervention randomized clinical trials and the silo nature of medical systems.15
Writers on change processes acknowledge that change is difficult to initiate, implement, and sustain whether at the individual, organizational, or systems level.12,13,18 Pediatric leaders can help by creating a sense of urgency that combats people's inherent resistance to change; establishing a strong, trustworthy, guiding coalition; and clearly stating and restating a vision for the future, including its benefits and potential challenges. Additional steps for promoting change described in the literature include enabling others to act, publicizing successful change efforts, and institutionalizing change.32,33 Thought leaders in medicine also have suggested several mechanisms for promoting change, including providing time and resources to innovators and designating roles in an organization as “improvement fellows.”34
Both the megatrends and the wild-card trends demonstrate potential opportunities for experimentation. For example, the passage of health care reform and the extension of health care benefits into early adulthood could stimulate creative solutions regarding the transition of youth with chronic disorders into adult systems of care. These experiments do not have to be large but do need sufficient visibility and support. Table 4 provides some potential innovation strategies that the VOP 2020 Task Force identified. We acknowledge that our strategies may be bounded by our own assumptions as a task force; however, they may provide a starting point for discussions.
This fourth step in the PEER cycle moves beyond conventional evaluation purposes and, instead, focuses on lessons from previous actions, novel trends, and implications for future PEER cycles. Pediatrics can support efforts to reshape change by embracing the role of learning organizations, health care breakthrough collaboratives, social networks, and innovation networks in implementing and assessing specific care processes.34,–,37 In addition, futurists and business leaders alike have commented on the importance of monitoring trends for radical innovations that may herald the future.38 Monitoring in a spirit of creative inquiry may provide opportunities for pediatrics to lead change rather than simply respond. For example, consumers increasingly use “minute clinics”39 and on-line health information tools such as Zipnosis,40 which assist in identifying disorders and medical treatment. These trends should prompt conversations regarding why consumers are seeking these types of options and how pediatric care can creatively address these unmet needs. Ultimately, this fourth step in the PEER cycle leads to identifying new areas of capacity to develop, unanswered questions for dialogue, and novel innovations to implement.
APPLYING THE PEER CYCLE
We live in an age in which the speed of change, decision-making, and opportunity are palpable. The lessons of the last decade, coupled with significant recent events, point to the need of respecting both the quickness and unpredictability of change. Without embracing possibilities, the potential to become obsolete is high.
On an individual level, each of us can choose to commit to self-development as leaders, team members, and change agents and examine our own resistance to change, our particular passions with respect to future trends, any assumptions that we harbor about the types of problems we face now and potentially in the future, and possible strategies we could use to create innovative solutions. We also can identify current successes on which we can build to support future tasks within our spheres of influence.
Service settings and systems (eg, practices, public health agencies, hospitals, plans, industries, professional organizations, committees and/or task forces within organizations, and advocacy groups) can also embark on PEER cycles by determining what capacity needs to be built, identifying topics and participants for strategic conversations, and recognizing future innovations to implement. The American Academy of Pediatrics has committed to embarking on a PEER cycle across the organization, and several chapters already plan on hosting planning meetings. We also hope to stimulate similar types of activities across the field. An example of the type of activities on which a group practice might embark for 1 of the megatrends is provided in Table 5. We invite you to peer into the future and engage in a process that will help create and reshape the future of pediatrics and the future of the children and families for whom we care.
Dr Leslie's work on this article was provided by the William T. Grant Foundation (9443) and the Tufts Clinical and Translational Science Institute (UL1 RR025752); funding for the VOP 2020 Task Force was provided by the American Academy of Pediatrics.
Members of the VOP 2020 Task Force included John Duby, MD, FAAP (chair), Jeff Kaczorowski, MD, FAAP (vice-chair), Maria Britto, MD, FAAP, Christoph Diasio, MD, FAAP, Anne Edwards, MD, FAAP, Amy J. Starmer, MD, MPH, FAAP, Renee Jenkins, MD, FAAP, Robert Kliegman, MD, FAAP, Danielle Laraque, MD, FAAP, Laurel K. Leslie MD, MPH, FAAP, Martin Michaels, MD, FAAP, and Marleta Reynolds, MD, FAAP. The task force acknowledges the contributions of task force consultants Thomas Boat, MD, FAAP, David Bergman, MD, FAAP, Edward Schor, MD, FAAP, Bonita Stanton, MD, FAAP, Robert Walker, MD, FAAP, and Paul Wise, MD, FAAP. The task force also acknowledges the outstanding contributions to this work by AAP staff. Kenneth M. Slaw, PhD, designed the process and facilitated the VOP 2020 sessions, and Anne Gramiak, MPH, and Susan Flinn, MA, provided superb facilitation and staff support. Last, we thank Tully Saunders for editorial assistance. To learn more about the Vision of Pediatrics 2020 project, please visit www.aap.org/visionofpeds.
- Accepted August 16, 2010.
- Address correspondence to Laurel K. Leslie, MD, MPH, FAAP, Tufts Medical Center/Floating Hospital for Children, 800 Washington St, No. 345, Boston, MA 02111. E-mail:
The opinions expressed in this article are those of the authors and do not necessarily represent American Academy of Pediatrics policy.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- VOP =
- Vision of Pediatrics •
- PEER =
- preparing, envisioning, engaging, reshaping •
- IT =
- information technology
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- Copyright © 2010 by the American Academy of Pediatrics