Reflecting on 2020: COVID-19, Innovation, and (yes) Constipation

By Alexis Kirk, PhD, Director of Implementation Science, Centerstone’s Research Institute

With a new year upon us, it’s natural to spend time reflecting on the year behind us and our goals moving forward. 2020 was a year like no other, with the COVID-19 pandemic brining challenge and change. As an implementation scientist, my core mission is to help organizations create effective change. Whether implementing a new evidence-based practice or rolling out new technologies, I help teams identify, anticipate, and mitigate barriers to change, as well as take a systematic and strategic approach to change. In my opinion, one of the most underutilized tools in creating lasting change is reflection: taking time to sit down throughout the change process and not just look at the outcomes we’ve been able to achieve, but reflect on what we learned along the way – how and why we were able to achieve those outcomes.

Last month, I [virtually] attended an implementation science conference, and one of the talks focused on innovation in the context of COVID-19. Dr. David Asch spoke about the rapid innovation his Center, the Penn Medicine Center for Health Care Innovation, had been able to achieve during COVID-19. He remarked that his Center had innovated more in the past 8 months than they had in the past 8 years and posed the question: “why?” Was it a greater need for new services during COVID-19? That the urgency was greater? More collaboration as researchers rallied around a common cause? It was probably all of those, but his main hypothesis was that “organizational constipators” got out of the way (Dr. Asch is a gastroenterologist, by the way, hence his metaphor of choice.)

He noted that, in the past, organizational constipators clogged up the path, blocking the way forward and slowing down progress. He noted that organizational constipators can take many forms – people fearful of what change might bring (loss of power, status) or policies and systems of checks-and-balances (well-intended to create safeguards in decision-making, but not without their unintended consequences). He noted that since the start of the pandemic, many blockages were removed, allowing innovation to flow more freely. HIPAA requirements were loosened; payers began covering telehealth services; and hierarchies, power dynamics, and lines of authority were flattened as organizations called for “all hands on deck” to tackle urgent needs in this new landscape.

I agree whole-heartedly with Dr. Asch’s analogy, and I also add in my own reflection: COVID-19 didn’t just laxate rigid systems and policies, it completely upended the status quo. Even systems that weren’t conspitators were upended. Tried and true ways of operating efficiently and effectively went out the window. People and teams who, in the past, may have been cautious to move too quickly or depart too far from current systems, or fearful of failure, ultimately shifted their perspective. Caution and incremental change became less important when everything else was already in chaos. From my observation, teams were – in an odd way – empowered to try anything, even if it was risky, unprecedented, and a total departure from the status quo. Perceptions of risk and failure are just different when the world is already upside down.

In its transition to telemedicine, Centerstone underwent a similar period of rapid transformation. In March, Centerstone transitioned more than 3,000 employees to working from home and went from providing 500 telehealth services per day to over 6,200. Centerstone did in a week something that had been on the radar for years. How? What can organizational constipators and a changed perception of risk add to our understanding of how we made it happen?

Some policy and regulation constipators are obvious – shifts in federal policy from the Office of Civil Rights brought changes in requirements around email communications with clients and payers relaxed telehealth requirements and reimbursement policies. Internal processes changed, too. Normal procedures for executing change went out the window. Centerstone was challenged to make the transition to telehealth happen in a week…to train and support clinicians in learning how to use new telehealth platforms and help them translate their clinical skills to a remote environment. Rising to the challenge meant old ways of getting things done were relaxed and upended – review and approval processes were condensed, which led to quicker work.

Some early results show promise – a rapid evaluation found Centerstone clients were extremely satisfied with services and prefer to receive services via telehealth in the future. Clinicians reported benefits as well, including flexibility in scheduling and improved access to hard-to-reach clients. So where does this leave us? Are we to think that our old ways of doing business, including all of our constpiators, should be thrown out the window? That completely removing gatekeepers and relaxing processes can get work done faster and still provide good results? Probably not. Although organizational constipators can slow us down, many serve important functions, like ensuring compliance with regulations or adequate technical standards. However, I think we can find a place in the middle.

For myself, I’m left with some further questions to reflect on, that I encourage you and your teams to reflect on, too:

• What happened: What innovations have you been able to accomplish? What outcomes have you been able to achieve?
• How and why: How were you able to innovate? What organizational constipators may have moved out of your way to clear the path for innovation? How was your mindset approaching this change different than the past? How did you evaluate risk and failure differently? What did you learn?
• What were they really there for: Once you’ve identified your constipators, think about what function they really served. Were they there to ensure basic requirements, standards, or customer needs were met? Or were they really serving another function – using inclusion in the process as a way to protect egos, power, or turf? If it’s the latter, how can you build trust to ensure those needs are met in ways that don’t unnecessarily slow the process down?
• What’s next: Don’t let these reflections hang in the virtual air on your Zoom call. Carry them forward. What antidotes to organizational constipators can you carry forward into the future? How can you better manage checks and balances with the need for rapid innovation? How can you encourage risk-taking and normalize failure once the world is no longer upside down? (Necessity may be the mother of invention, but failure is the necessary and natural child of innovation.)

As we move into a year that will hopefully bring a positive shift to this pandemic, I encourage us to reflect – to resist the urge to snap the rubber band back to normal once we can, to take this opportunity to truly embrace transformation as we come out the other side of this pandemic. So take some time to identify what you’ve done, how you’ve been able to do it, and how we can carry these new ways of working together forward.

Alexis Kirk, PhD is the Director of Implementation Science at Centerstone’s Research Institute, where she focuses on building buy-in for change and creating supportive environments for implementing and creating change.

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