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Leverage Points

August 22, 2018

By Bonnie J Horrigan

One way to make lasting change that advances the adoption of Integrative Healthcare is by identifying and addressing leverage points.

Leverage points are places within a complex system (a corporation, an economy, a living body, a city, an ecosystem) where a small shift in one thing can produce big changes throughout the system.

Consider the profound, widespread change that continues to this day after President Lincoln issued a preliminary Emancipation Proclamation, declaring that as of January 1, 1863, all slaves in the rebellious states “shall be then, thenceforward, and forever free.”  Or the effect of Roe vs. Wade, the 1973 landmark decision by the United States Supreme Court that reaffirmed a woman’s constitutional right to access safe, legal abortion.  Both of these “decisions” changed the rules.  And because of the adoption of these new rules, society itself began to change.

Dr. Donella H. Meadows, a Pew Scholar in Conservation and Environment and a MacArthur Fellow, founded the Sustainability Institute (now called Academy for Systems Change) with the mission of fostering transitions to sustainable systems at all levels of society, from local to global.  She spent years studying leverage points as they related to transitions.

In her list of the 12 places a person can intervene in a complex system to make change, the top four are:

  • The rules of the system (incentives, punishments, constraints).
  • The distribution of power over the rules of the system.
  • The goals of the system.
  • The mindset or paradigm out of which the system — its goals, power structure, rules, its culture — arises.

The leverage point that produces the greatest effect is changing the mindset or paradigm out of which the system arises.

Let’s look at these leverage points with health systems in mind.  Changing the rules could mean changing scope of practice or changing a credentialing process.  Once acupuncturists are approved to practice in a hospital, other dynamics begin to change.  Conventional practitioners have to learn about acupuncture and when its use is appropriate, something they would have not done on their own. They learn about the science that underlies acupuncture practice, and they see the results.  It should be noted that in this process, identifying common language is a crucial element in changing mindsets.  As the process moves forward, attitudes begin to change.

Changing goals is another way to gain leverage.  When value-based healthcare came on the scene and integrative medicine centers could show that integrative healthcare was helping to raise patient satisfaction and lower pain scores, the mindset about massage, Reiki and other integrative strategies began to shift from “a waste of time” to becoming a valued aspect of the care.  While there isn’t 100% acceptance by any means, it did open doors that were once closed.

Perhaps the hardest but also the most effective leverage point is changing the mindset from which the paradigm is emerging.

Changing the Paradigm’s Mindset

One of the best examples of using such a leverage point to make substantial change throughout the healthcare system comes from the work of The Bravewell Collaborative.

Early on, it became clear to the Bravewell philanthropists that no matter what else they accomplished, changing medical education and training was essential to sustain the movement toward integrative medicine. They understood that real change would take time because it would require reorientation of the organizational cultures of established institutions.  However, they also understood that wide-scale effects would be felt when the medical students who learned within the revised curricula were established in practice.  The only question was how such a feat could be accomplished.

At this same time, a group of eight academic leaders were forming a loose network with the goal of coming together to create change within medical education by including integrative medicine in the curriculum.  After learning of their efforts, Bravewell decided to support the in-person meetings of the fledging Academic Consortium so they could develop a plan and an organizational structure that would build the capacity to change the way physicians were educated.

This support would prove crucial.  The amount of money Bravewell gave them wasn’t that much — $1.5 million over ten years — but the academics had no funding to pay for meetings and without the meetings no real progress could be made. In the end, Bravewell’s support made all the difference in the world.

With Bravewell’s financial support, the academic leaders were able to focus on their work and widen their circles of influence.  Universities that might not have otherwise spent a few thousand dollars to send people to a meeting did not object to sending them if the meeting was funded.

The Academic Consortium quickly expanded, growing from eight members to twelve, then to twenty, thirty, and more.  In 2018, at the time of this writing, there are more than eighty members, representing more than one third of all US medical schools, several medical schools from Canada and Mexico, and some of the leading health systems in North America.

The mere existence of the Academic Consortium lent credibility to the field, especially with schools such as Harvard, Columbia, Duke and Yale joining the ranks.  The research the schools engaged in bolstered the evidence base, the curricula they created were picked up by many other medical schools, and the clinics they built served patients that would otherwise not have had access to integrative medicine.  Ripple effects continue to this day.

Consider the fact that Bravewell could have used the $1.5 million to build a new clinic. The effect that might have had on the entire field would have been very small and localized.

Supporting the meetings of the Academic Consortium was a perfect leverage point.

Identifying and Activating Leverage Points

How do you identify leverage points?  You have to look for root causes.  If physicians were not educated about integrative healthcare, how could they practice it?  Medical schools were the place to start.

The Leadership Program in Integrative Healthcare is another example of using a leverage point to change the system.  In 2015, the lack of trained executives who could create, operationalize, run, and sustain an integrative program was becoming a real problem. The field was growing rapidly and while there were plenty of places to learn the clinical side of integrative healthcare, with the exception of a few conference workshops, no programs existed that taught the skills a leader would need to start or expand a program. Knowing how to place acupuncture needles and knowing how to approach the C suite to get acupuncture accepted are two different things.

Because integrative clinics and centers were having a hard time filling leadership positions — in some cases, it was taking more than a year to find a qualified applicant — Bravewell decided to tackle the problem.

The philanthropists asked me to analyze the situation and make a recommendation.  We held several think tanks with current integrative leaders and engaged in a host of one-on-one conversations with industry leaders.  The first question was:  Did we need our own program or would sending people to the existing conventional leadership programs suffice?

To answer that question, we compared traditional leadership philosophy and integrative philosophy.  We also compared challenges that leaders faced in trying to establish integrative medicine as a norm with challenges other healthcare leaders typically faced.  Our conclusion was that a leadership program focused on integrative medicine was, in fact, needed to help the field to grow and stabilize.

At the end of the RFP process, Bravewell chose to build the program at Duke University.  But our work wasn’t done.  We needed to articulate what integrative leadership actually was and on what philosophical foundations it rested.  We needed to come up with learning strategies that would work.  To accomplish this, a group of us brainstormed the questions, identifying mindfulness and self-awareness and self-regulation as key.  Integrative leadership clearly started from within each leader.  We then wrote the program’s first white paper — The Pebble in the Pond: How Integrative Leadership Can Bring About Transformation.  Two years later we expanded on the idea and wrote the second white paper — Informed Mindfulness: The Power of Awareness and Choice in Effective Leadership

The program is now in its fourth year.  By February 2019, we will have graduated over 100 integrative leaders.  Graduates work in a variety of settings, including Hackensack Meridian Health, the University of California, Berkshire Health Systems, Duke Integrative Medicine, Bronx Lebanon Hospital Center, Carolinas Rehab Center, Boston University, University of Florida Integrative Medicine, the VHA, Penny George Institute for Health and Healing, the NIH Clinical Center, RISE Vermont, NY Presbyterian Hospital, the College of Nursing and Health Sciences at the University of Vermont, Banner MD Anderson Cancer Center, Delta Airlines, Jenny Craig and many more.  International students from Mexico, Spain and France have also graduated.

The formula: Identify the situation and need, assess the missing element (the leverage point) that would remedy the situation, create and then verify a plan that would provide the missing element and that could be accomplished, and then implement the plan.

Then, if you have done your work correctly, you can stand back and watch change begin to happen.



Bonnie J Horrigan is the Executive Director of The Heathy US Collaborative, a 501©3 dedicated to improving the health of the American people.  She also serves as Core Faculty for the Leadership Program in Integrative Healthcare at Duke University.


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