In the book, For Whom the Bell Tolls, Ernest Hemingway gives an account of the Spanish Civil War through the eyes, and the experiences of, Robert Jordan an American expatriate fighting on the Republican side against the Fascists.
At one point, Jordan is told a story about the taking of a town by the Republicans early in the conflict, and the forced “gauntlet” that the Fascists in the town are forced to walk as a result. The gauntlet is a practice dating back to native peoples worldwide, whereby someone is forced to walk or run between two lines of individuals that inflict some form of punishment as they pass by, often resulting in death at or near the end of the process.
In Hemingway’s story, two lines of drunken Republican rebels are formed, close abreast, and stretched between the Ayunamiento, or City Hall, and a high cliff. As the Fascist sympathizers leave the Ayunamiento, where they were praying, they walk between the two lines, and encounter men wielding…
“flails such as are used to beat out the grain and they were a good flail’s length apart. All did not have flails, as enough flails could not be obtained… And those who did not have flails had heavy herdsman’s clubs, or ox-goads, and some had wooden pitchforks; those with wooden tines that are used to fork the chaff and straw into the air after the flailing. Some had sickles and reaping hooks…”
As the Fascists leave the Ayunamiento, they are clubbed either to death, or nearly so, and thrown over the cliff once they either walk or are carried to the end of the gauntlet.
What does this terrible story have to do with innovation?
At times, those that are sponsoring and promoting innovative change of care delivery feel as if their efforts are forced to run a similar type of gauntlet – one where the end result is too often predictable.
A good example is the adoption, implementation and use of new, innovative technology-enabled solutions. There are several places at which a solution can stall, or actually be killed, regardless of its potential to actually add significant value – preparing it for the figurative toss off the cliff, into oblivion.
The individual or team, charged with evaluating a technology-enabled solution company’s offering may be faced with what I like to call the “three levels of uncertainty” – what does the company’s product actually do?… can the company deliver the solution at scale or with fidelity?… and, finally, will this company be around in a few years (how is it financed, what is the track record of the entrepreneurs, etc…). If these three questions cannot be answered clearly, the innovative solution may not even be tried.
In the 2014 State of Healthcare Innovation Survey, co-administered by HIMSS and AVIA, three significant barriers a bit further down the gauntlet were identified: limited personnel to vet and implement innovation, limited capital to invest, and the most dreaded of all, cultural or management challenges.
If an innovative solution can make it past the “three levels of uncertainty”, and a sponsor or accountable executive attempts to “sell” the idea to the central administration – he or she might find a lack of interest in the idea (cultural or management challenges), or a lack of funding (limited capital to invest).
"If fortunate enough to actually procure the innovative solution – the next place where the idea can be clubbed to the ground is insufficient manpower to implement"
If fortunate enough to actually procure the innovative solution – the next place where the idea can be clubbed to the ground is insufficient manpower to implement (limited personnel).
Finally, in For Whom the Bell Tolls, the American expatriate is told that it was important that there were placed a “concentration of the hardest men at the end of the lines by the edge of the cliff,” and that these men were provided with the most deadly weapons – sickles and reaping hooks. The reason for this was to prevent hesitation for inflicting the most egregious damage to those that were unfortunate enough to make it to the end of the gauntlet, and to ensure a willingness to toss them to a certain death over the cliff’s edge.
In the case of the health system “innovative solutions gauntlet,” the providers themselves (physicians and others) are positioned near the cliff. It is a well-known fact that even when solutions are understood both technically and accepted culturally by leadership, procured with adequate funding and implemented with appropriate manpower, there still is the danger that the provider – with the final power of life and death over the actual use and potential value creation associated with innovative solutions – may simply say “no” and toss it into the abyss.
Appropriate perhaps for this discussion, Hemingway takes the title of the book from John Donne’s Devotion Upon Emergent Occasions – a meditation on health and sickness. He quotes Donne in the epigraph, where Donne says that:
“No man is an Iland, intire of it selfe; every man is a peece of the Continent, a part of the maine… any mans death diminishes me, because I am involved in Mankinde; And therefore never send to know for whom the bell tolls; It tolls for thee.”
When it comes to the adoption, implementation and actual value-added use of innovative solutions, no health system is an island – none are exempt from the need to do more and do better – and to move the delivery model from volume to value. To force most solutions down the gauntlet, where many find their way over the cliff into oblivion, is to risk hearing the bell toll – louder and louder – for the value proposition of American health care.
This was originally posted on the HIMSS Blog