Peering Into the Future: Pediatrics in a Changing World

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.

Reshaping Change

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.