Gary Oftedahl: Mindset, change, and health care

For the past 3 ½ years, I’ve had the opportunity to participate as a catalyst and convener in the DIAMOND initiative in Minnesota.  Working through a large multi-stakeholder approach, a collaborative model for addressing the care of depression in primary care has been implemented in over 80 clinics.  Associated with this is an evolving effort to identify and develop a payment methodology redesign that would support the sustainability of this effort.  Needless to say, it’s been a tortuous, at times contentious, journey, but filled with breakthroughs, dramatic improvements in care, and individual patient stories which fill many of us with pride.

But as we’ve walked this journey, I’ve been struck by the variability seen within participating organizations in successfully advancing this concept internally.  Despite having access to identical training materials, ongoing networking support, and a common Midwestern environment, it is striking to see the differences in attitudes, efforts, and success from clinic to clinic.

I know there are likely many contributing factors that impact this, and we’re presently involved in an extensive evaluation of each clinic searching for key characteristics that identify success.  What we learn may have great impact on future efforts in advancing collaborative care.  Certainly the challenges of moving toward the nebulous patient-centered medical home will offer further opportunities to learn.

But I’ve recently become aware of a concept that while perhaps self evident to some, resonated with me as an intriguing possibility for why some succeed, and some don’t, or at least struggle.  Understand, I’m not attributing everything to this as a causal effect, but I think there is an interesting consideration—mindset—as a factor.

Let me explain.  I just finished reading Switch by Dan Heath.  First, it’s a must read if you want to understand the challenges of successfully creating sustainable change.  But in the book he references the work of Carol Dweck from Stanford, on the concept of “mindset”.  While it applies to us as individuals, I believe it’s a powerful metaphor for organizational change.

Dr. Dweck believes that the ability of people to grow in their individual careers traces back to their fundamental mindsets.  People with the “growth mindset” who believe they can improve their abilities and accomplishments through purposeful effort, excel.  People with the “fixed” mindset, who believe their intrinsic worth is cast in stone, stagnate.  It is important to recognize the pervasive effect this has.  If we have a fixed mindset that we’re highly talented, and skilled (I know many like this, as I’m sure you do), we believe that things should come “easy” to us, and thus don’t feel compelled to put forth much effort.  The implicit feeling is that they’re already successful, talented, so why put hard, intensive effort, often times poorly initially, to improve.  After all, I’m already as talented as I need.

By contrast, people with a “growth” mindset, believe they can improve and expand their skills through intensive effort, taking risks, failing initially on occasion, but view mistakes, initial struggles as an opportunity to learn, and improve.

In her work with individuals, Dweck describes a fear of those with fixed mindsets to not appear smart, competent, and skilled, thus limiting their willingness to make concerted efforts to improve.  Students taking courses that are easy for them to demonstrate their excellence, and support their self-image and mindset would manifest this.

How does this apply to our clinical effort, what might this have to do with DIAMOND?  What planet is he from?  As I’ve viewed our efforts in DIAMOND, without naming specific clinics,  I now think about how an “organizational mindset” might impact involvement in this innovative approach.  First, this is hard work.  It’s a new way of delivering care, requiring new roles, new skills, new processes, new thinking—all dramatically different than the traditional.  Because of that, it’s almost certain that as you move forward in implementing DIAMOND (or substitute your own quality initiative) there will be struggles, failures, mistakes, steps backward, renewed efforts, and frustration.

From a mindset perspective, let’s consider this.  There are some health care organizations who pride themselves on having developed the skills and having the structure to succeed—a fixed mindset.  With that framework, or even a slight variation of that, the implication is that putting a new program into effect should come easily.   When the initial efforts don’t come comfortably, aren’t easily incorporated, these will be inclined to blame the program, the concepts, and proclaim that there’s nothing they can do to improve—and gradually or rapidly back away from the effort.  Organizations that have the growth mindset will understand that this will be difficult, fraught with frustration and perhaps initial failure, but believe that with continued effort, practice, commitment, they can and will develop the skills and abilities to succeed, and improve as individuals and as an organization.

While simplistic, and not totally able to explain all the variation, isn’t an organizational mindset a potentially powerful determinant for anticipating the success or failure of a new venture?   I’ve been profoundly affected by this different way of looking at change—beginning to understand the power of mindset, both in identifying those who will succeed, but recognizing those who will struggle.  As we move health care transformation forward, the growth mindset will be critically important in creating the change we need to see.  Where do you see yourself, and your organization?  Are you  “fixed” or are you in the “growth” space?  I think it’s worth considering, don’t you?

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