FDA approval of paroxetine for menopausal hot flushes.

solutions than smaller sums on maintaining protected time for their staff to drive change. And yet clinicians know more than outsiders about health care’s customers and context; they have street credibility and established trust relationships in an environment where those characteristics count; they can often reuse experiences in multiple projects; and they’re usually mission-driven to improve outcomes. They also don’t then resell the lessons learned; they give them away, in presentations and papers. These insiders, however, often face three barriers to innovation. First, principles of rapid-cycle innovation are part of neither medical training nor clinicians’ experience. Even in academic medical centers emphasizing research, clinicians who conduct controlled experiments in the laboratory often don’t consider deploying them when seeking to improve care delivery. But just as operatingroom “timeouts” introduced new discipline in clinical settings, we’ve seen care teams embrace rapid validation methods, testing and evaluating new ideas quickly. Second, insiders’ experience can become constraining. Henry Ford is often credited with saying that had he asked his customers what they wanted, they would have said “faster horses.” Though he apparently never said that, the story highlights the trap of envisioning incremental gain along established dimensions and the difficulty of envisioning the kind of change that replaces horses with cars. It’s important to enforce divergent thinking, in part by using analogies when breakthroughs from outside health care can expand our vision. Third, clinicians are busy. Health care organizations, operating on thin margins, rarely allow for slack in staff work. Many organizations say they simply cannot introduce time for stepping back and reimagining that work: it’s too costly to take the workers who add the most value off the front lines. But it can be done with selected individuals and at strategic times. Companies that have begun insourcing innovation couldn’t imagine doing so before they’d designed new time-allocation practices. Time for engagement is even more critical in health care: new ideas create no value until they’re implemented, and effective implementation in health care requires clinician acceptance. Forward-thinking health systems understand the obligation to improve value. Health care can benefit from outside perspectives in this endeavor, but clinicians have the requisite drive, experience, and context to be productive innovators. If we adapt and internalize proven innovation principles from other fields, much effective innovation can come from within.