Think and Act Differently

be different change fix this next for healthcare providers ftn for healthcare providers healthcare hierarchy of needs hhn lifestyle congruence systemize systems tara vossenkemper Jun 10, 2021
Use second-order change to create lasting upgrades in your business or your practice.

|By Tara Vossenkemper, Ph.D., LPC

During my doctoral program, I had to take a systems class. Rocco was the instructor. Rocco was old school - he liked original systems thinkers, and he spent a lot of time talking about Bateson, Minuchin, and Haley like they were his besties.

One of the required readings in that class was a book called Change. One very basic premise of this book is that there are two types of change: first-order change and second-order change. 

First-order change is superficial. It’s change within the confines of the current system and, honestly, it’s change that serves as a band-aid. Think of this as noticing a leak in a boat and starting to scoop the water out. Scooping the water out is helpful, but it’s not enough to stop the water from coming into the boat through an unknown leak. First-order change isn’t bad or wrong, but it’s usually not enough to fix a problem in a sustainable way. 

For healthcare providers, first-order change is learning more techniques for your “toolbox” with the intention of becoming a better provider. People think, “I just need more strategies” or, “I just need to know this specific technique.” The problem is likely not about the number of techniques we know. Just because you have a hammer doesn’t mean you can build a barn. It’s the same thing with healthcare. Tools are great, but they’re not the be-all-end-all. 

Now, second-order change. Second-order change is changing the rules of the game. It’s a complete paradigm shift when looking at a problem. It’s changing the foundational structure or understanding of what the problem is, and as a byproduct, introducing new and sustainable ways of solving it. The kicker, though, is that it’s harder. When it comes to second-order change, what we’re in essence asking you to do is to keep a cool head when you’re under pressure and not rely on your first reaction to be your only reaction. 

Let’s take a quick moment to unpack a little further. 

Change and the Healthcare Hierarchy of Needs

First and foremost, I’m not writing about this just because I love it (although I do - #SystemsAllDay). I’m writing about this because second-order change needs to be a functional part of your process. It needs to be embedded in your psyche. When it comes to assessing your business with the Healthcare Hierarchy of Needs (HHN) and coming up with solutions to your vital need, second-order change needs a place at the head of the table. And this needs to happen each and every time

Here’s an example of what I mean. Let’s take the very first question for the entire HHN, which falls within the sales level. The question is about lifestyle congruence and is “Do you know what your practice’s sales (billable sessions) must be in order to support your personal comfort level?” 

Now, let’s suppose that you say “no” to this question. First, this is now our vital need because it’s the lowest possible question on the HHN. Second, this also means that we have a little bit of digging to do. Let’s further assume that opt to take a closer look and you realize that you’re about 10 billable sessions per week shy of your lifestyle congruence goal. Now, here’s where first and second-order change can come into play.

First-order change response: See more clients. You’ve cut back your billable hours to make room for business needs, but if it’s only 10 more client hours per week, then it looks like you’re going to have to increase those hours to make it happen. That’s what lifestyle congruence is all about, right?

WRONG. Wrong, wrong, wrong. Dear lord, please don’t increase your own billable sessions per week in order to make lifestyle congruence happen! Yes, I understand this is a viable option, but it’s not a second-order change option. It’s just the band-aid (or water bucket). Not sustainable and not helpful big-picture.

Second-order change response(s): Hire another clinician. Increase self-pay rates. See if any current employees want to increase their hours. Contact your insurance companies for higher reimbursement.

Note that none of the second-order change responses entails you seeing more patients. And while we’ve all probably been guilty of thinking, “I’ll just see more clients,” what we’re doing is setting ourselves up to fail. When we, as the practice-owner, see more clients without restructuring the system, then we’re just waiting for the bottom to fall out again, which will put us back in the same position again. That’s exhausting, I want no part in it, and I want you to have no part in it, either. 

One reality is that we have to have a sense of what second-order change is at the same time that we’re engaging in HHN assessments and treatment interventions. If the HHN is both a diagnostic tool and a way to focus our interventions, then we need to guarantee that our interventions aren’t going to keep us stuck in a holding pattern. We need second-order change interventions. 

Doing more work in our business often leaves us trapped.

One last component to all of this is that the mindset shift is hard. It’s easy to think, “I’ll fix it, I can do it, I’ll do it myself, I got this, it’s all on me, blahblahblah martyr martyr.” WRONG. We are wrong when we stay there. I feel compelled to say this for you (and for me - I’m in this, also). It is not serving anybody when we stay stuck as the sole provider/doing/responsible one in our business. It is not helpful. It only gets in our way. 

When we can have an accurate assessment of our business (#HHN), come up with second-order change interventions, and enact them in such a way that we’re not going to have the exact same problem in a month or two, then we are setting ourselves up to benefit and be benefitted by the business we so love and cherish. And the sooner you can incorporate that line of thought, the better.

Tara Vossenkemper, PhD, is the founder and owner of The Counseling Hub, an accidental group counseling practice in Columbia, Mo. Tara has since stepped into consulting in a more serious capacity, setting out to ensure that practice owners know both what they need to do and how to do it. Tara's favorite consulting-related topics center around tracking, culture, structure, and diagnosing core issues.

Tara is known for her colorful language (#PuttingItNicely), love of The Office (#USVersion), neuroticism around dashboards (#FormulasAreLife), and hashtags (#AllDay). When she's not in the office, Tara can be found hanging out with her husband and two young sons, probably drinking a glass of red and wishing it was quiet enough to read.

Check out Tara’s professional bio and her practice, The Counseling Hub

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