Leading Large Health Systems to Peak Performance Using Microsystem Thinking

I prefer self-executing or self-implementing systems.

Robert Galvin, former ceo of Motorola, personal communication to Paul Batalden, 1997.

In this section we provide our own leadership framework for leaders of macrosystems and mesosystems. This framework is based on our reflections on the general leadership frameworks and on our own experiences in working with hundreds of health care leaders who wish to have all parts of their systems provide care that is excellent in quality, safety, reliability, and cost. We first touch on the leadership process and then turn our attention to two specific facets of leadership—learning and doing.

Health care systems at all levels benefit from leadership because the work of health care at every system level is often ambiguous and uncertain (McCaskey, 1982; Weick & Sutcliffe, 2001). Steadfast aims and values that promote better quality, value, and flexibility to meet a particular patient's special needs, and also promote work settings in which professionals can experience growth and a sense of accomplishment, are necessary but not sufficient to achieve those outcomes. A leader is confronted with more invitations to act, more frustrations to address, more questions to answer, more information and measurement to interpret, and more problems to solve than he or she has time available to address. To simplify the challenge of leadership, recall that leading involves three fundamental processes: (1) building knowledge, or learning; (2) taking action, or doing; and (3) reviewing and reflecting (Batalden et al., 2003).

Learning: Understanding Microsystems by Using Multiple Frames

In performing these three fundamental processes leaders use frames: that is, a set of assumptions or mental models, that help them understand the work of the microsystem—the place where patients and careteams come together. All leaders know that they need to learn, to gain a deep understanding of that which they wish to change. Leaders can gain a deeper understanding of microsystems by using the eight frames discussed in the rest of this section.

The literature describes the many ways in which assumptions and paradigms shape what all of us think we know and what we do (Argyris & Schön, 1996; Bolman & Deal, 2003; Kahneman & Tversky, 1982; Kuhn, 1970; Lakoff, 2004; Lakoff & Johnson, 1999). Leaders with multiple ways of framing what they are trying to understand or improve have the benefit of increased versatility and have been empirically shown to be more effective in their work (Bensimon, 1989, 1990; Birnbaum, 1992; Bolman & Deal, 1991, 1992a, 1992b; Heimovics, Herman, & Jurkiewicz Coughlin, 1993, 1995; Wimpelberg, 1987). A leader might use the eight frames discussed here in exploring the work of a clinical microsystem, to inquire into what is happening, to construct options for action, and ultimately to make thoughtful, effective, and sustainable changes within an organization (Figure 4.6).





Mechanical / Physical



Mechanical / Physical








Biological systemframe. This frame enables the leader to "see" evidence of vitality (Zimmerman, Lindberg, & Plsek, 1999). With this frame the clinical microsystem can be seen as a living, adaptive entity with the properties that complex adaptive systems have. It engages in generative work. It has emergent properties. It has structures, processes, and patterns, as do all other living systems.

Sociological system frame. Using this frame the leader might examine the relationships, the conversations, the interdependencies, the coupling, and the efforts to make sense and take meaning from the work of the clinical microsystem (Bolman & Deal, 2003; Scott, 1987; Weick, 1995).

Mechanical, or physical, system frame. With this frame the leader might look for the flow of the work, the temporal sequencing of the work, the spatial relationships involved among the people and equipment, and the integration of operations and logistics (Damelio, 1996; Hunt, 1996; Langley, Nolan, Norman, Provost, & Nolan, 1996; Oshry, 1996; Scholtes, 1988, 1998).

Psychological systemframe. Adopting this frame the leader sees the clinical microsystem as a setting for behaviors, the interplay of the forces operating in a specific context the motivations behind the behaviors, and the personal and professional development of individuals (Barker & Schoggen, 1973; Batalden & Leach, 2005; Lewin, 1951; Lewin & Lewin, 1948).

Information system frame. Using this frame the leader can inquire into the flow of information and the obstructions to that flow, the cycle times of information and measurement, the ways measures reflect the work, the ways in which information is stored, the ways in which data are handled, and the ways in which information is displayed, analyzed, and used to inform the daily work (Centers for Medicare & Medicaid Services, 2006; Greif, 1991; Nelson, Splaine, Batalden, & Plume, 1998).

Anthropological system frame. This frame facilitates leaders' efforts to explore a microsystem's cultural milieu, the values, the symbols and artifacts, the rituals and ceremonies, the celebrations, and the way learning occurs (Bolman & Deal, 1984, 2003; Schein, 1999, 2003; Senge, Scharmer,Jaworski, & Flowers, 2004).

Political system frame. The leader can use this frame to inquire into the citizenship and equity, the coalitions, the power dynamics, the conflict and negotiating, the governance, and the way control operates in the daily work of the clinical microsystem (Bolman & Deal, 2003; Fisher, Kopelman, & Schneider, 1994).

Economic system frame. With this frame the leader assumes that what is real in the clinical microsystem is to be found in understanding the customers and suppliers, the inputs and outputs, and the costs, waste, and benefits of the work (James, 1993; James & Savitz, 2005; Liker, 2004; Monden, 1998; Ohno, 1988; Toyoda, 1987;Womack & Jones, 1996).

Examining a clinical microsystem with the aid of multiple frames allows the leader to understand it more deeply and to formulate more effective action strategies. Further, by making the assumptions and frames explicit the leader can invite others to a shared sense of the work and change. We are reminded of the truths in these observations made by Kofman and Senge (1993):

• Life (in this case, the clinical microsystem) cannot be condensed.

• We make models (that is, our understandings of the microsystem) of what is not condensable for our convenience and understanding.

• We attach measures to our models to assist us in conducting tests of change for improvement.

• In doing so we must avoid confusing our measures and models for the thing (the clinical microsystem) itself; to do that would be to confuse the map for the territory.

Doing: Leading Macrosystems by Deploying and Executing the Plan

So what might senior leaders do to lead macrosystems for microsystem peak performance? Leaders can use many useful frameworks, such as those listed earlier, to guide their mission critical work, that is, to take their system someplace else, to raise it to the next level of performance. The goal is to make lasting changes in the capability of the health care systems that they lead—to improve health outcomes by fostering safe, reliable, efficient, and flexible systems of care. Leaders could start in many ways, using a plethora of approaches, but we believe that it is wise to begin with the six action steps outlined in the rest of this section.

It would be smart and effective for Jack Candoo and his senior leadership team, described in the case study at the beginning of this chapter, to reflect on each of these six actions and to act on them in a way that fits the local culture. This would give them a sound path forward toward making the deep and lasting systemic changes that would profoundly improve the quality, reliability, and efficiency of their health system. Of course in making these changes they must also link the front office with the front line by working through the mesosystem, as discussed later, in the section titled "Connecting."

Action Step 1: Bring Meaning to the Work. Show frontline, midlevel, and senior leaders why the work they do makes a difference. Provide a worthy patient-centered aim that provides genuine meaning. Promote the worthy aim to animate and energize all the organization's staff to wish to excel because, in the end, their excellence benefits the people, the patients and families, that the organization exists to serve. Recognize that staff allegiance will naturally and more powerfully gravitate toward achieving a worthy patient-centered aim than toward fulfilling an organization's request for loyalty. Connect the organization's work to the aim by focusing on meeting the health needs of individual patients and families and the needs of communities. Create a simple, compelling story of a memorable (fictional) patient to describe what ideal patient-centered care looks like in a thoughtful, compassionate, and reliable environment. Tell this story at all levels of the organization to develop exemplary care, processes, and systems.

Connect the organization's work to core staff values, professional development, and the formation and personal growth of all staff. Challenge everyone to become personally engaged in safeguarding care and in improving care. Good people respond positively to worthwhile challenges. Recognize that challenges arising from the external environment (for example, public reporting of quality metrics, shifting to pay for performance, meeting new regulatory requirements) act as secondary motivators for most staff.

Action Step 2: Create the Context of the Whole. Establish a simple vision and strategy for the whole system, one that can be understood by all stakeholders and can be carried into every organizational unit. Consider using the image of the inverted pyramid (Figure 4.2), which puts the patients and those caring for patients at the top, highlights the handoffs between units and small systems, and recognizes the critical supporting roles played by the midlevel departments. Foster inquiry, learning, and change within, between, and across microsystems and mesosystems to achieve the worthy aims of the whole organization. Seek to engage every person—at the level and place of his or her own work—in the two fundamental tasks of (1) doing his or her work and (2) improving patient outcomes.

Action Step 3: Define Possibilities and Limitations. Share your views on the realities that the organization currently faces, and make the connection between those realities and the daily work of frontline microsystems. Make a distinction between what the system will do and what it will not do. Be clear about the contributions that the clinical microsystem can make to both advancing the worthy aim and enhancing the whole organization's well-being. Create an appreciation of the health care regulatory environment and the reimbursement mechanisms and the ways these external forces influence all levels of the health care system—micro, meso, and macro.

Action Step 4: Create Supportive Infrastructures for Health Information and Human Resources. Recognize that even though decisions about information technology and human resource policy are often made at the macrosystem level, they are acutely felt and have profound effects at the microsystem level. Take action to optimize the ability of these decisions to support frontline work.

Excellent health care requires excellent information. Information is at the heart of health care work. Making information readily accessible and ensuring that it contributes to the flow of good work in the clinical microsystem involves knowing the following:

• What the microsystem is trying to do

• How information helps and how it hinders doing what is needed at the point of care

• How information supports and how it limits efforts to improve care

• How information technology can reduce the workload in the clinical microsystem's daily functioning

Support doing the right thing at the right time by creating real-time, feed forward data flows—a method of collecting and using information as soon as it is needed and reusing it later in the process as needed. Create informative feedback data displays by developing a method of analyzing and displaying data to provide insights on past performance and on the relationship between processes and outcomes. Give people insight on performance and data they can use for maintaining quality or improving it through feedback that uses balanced metrics—a well-rounded set of measures that reflect important dimensions of quality and performance.

Excellent health care requires not only excellent information but also excellent staff. Creating a human resource value chain that will attract, select, orient, develop, and retain staff is essential to high performance. Align recognition, incentives, and rewards for individuals and groups to foster accountability for improving and maintaining quality, efficiency, and flexibility. Attaining the requisite alignment of incentives is complex and fraught with difficulties; therefore senior leaders will need to take the time to examine and understand how current incentives influence attitudes and behaviors and how revised incentives could be working, and then make adjustments appropriate for the culture of the organization.

Again, human resource policies set at the level of the macrosystem have great impact at the microsystem level. These policies may either contribute to or conflict with the creation of a work environment where every staff member can say he or she agrees with each of these challenges offered by Paul O'Neill (personal communication to M. Godfrey, 2003), past CEO of Alcoa:

• I'm treated with dignity and respect everyday by everyone I encounter . . . and it doesn't have anything to do with hierarchy.

• I'm given the opportunity and tools that I need to make a contribution and this gives meaning to my life.

• Someone noticed that I did it.

O'Neill also stated that a high level of worklife satisfaction is present when every employee can "strongly agree" with these three statements.

Action Step 5: Stay Connected. Stay connected to the clinical microsystem and create conditions to grow capability from the inside out. Show up at the site where the work is done and where learning and change must happen. Macrosystem leaders can offer their curiosity and their questions, encourage and develop staff, and recognize and celebrate gains. Foster and ensure good leadership in each and every microsystem. Create the conditions that bring action learning and reflection into the daily work environments of all staff. Promote the growth of the microsystems and the people who staff those systems.

Action Step 6: Drive Out the Fear of Change. Encourage staff to improve and innovate constantly. Challenge microsystem leaders and staff both to learn how to change and to actually make lasting change that optimizes performance. Promote frequent and rapid tests of change at all levels of the organization. Celebrate successful changes and also learning/mm failures, the unsuccessful changes that nevertheless provide valuable learning. Encourage inquiry and learning for improvement while diminishing the justifying and rationalizing behaviors that commonly limit learning and often lead to trapped thinking (Weick & Sutcliffe, 2003). Remind all staff at all levels that they have two jobs—to do their work and to improve the way they do their work—with a constant focus on best patient outcomes and greatest real value.

Connecting: Leading Mesosystems by Connecting the Front Office with the Front Line

In the image of the inverted pyramid, a large space separates senior leaders from the front line. This midlevel space is occupied by the intermediate levels of the organization, or the mesosystem. Health care macrosystems have many midlevel structures and leaders. As previously noted, examples include supporting functions (for example, human resources, information systems, medical records), clinical departments (for example, nursing, medicine, surgery, pharmacy, care management), and service line programs and centers (for example, oncology, women's health, primary care). Macrosystem leaders know that this level of their organization is critical for moving the organization's message between top and bottom and the mesosystem must be taken fully into account to create the conditions needed to generate high performance at the front line. The leaders of these vital midlevel systems face a wide variety of challenges and opportunities to improve the quality and value of patient care.

When a health care system seeks to execute its quality improvement strategy, it has to work through the midlevel systems to have the desired effect on the frontline microsystems. Although direct communication between the front office and the front line is desirable and often occurs, the mesosystem leaders need to buy into the strategic plan and carry the strategic message to the frontline leaders, as well as carry responses and concerns from frontline leaders back to senior leaders. To perform this important linking function well, mesosystem leaders need to attend to the fidelity of the message while also adapting the message to the recipients. Midlevel leaders require an understanding of and firm commitment to the strategic plan. They must also understand and support the microsystems to achieve success in the short run and sustain it in the long run.

The mesosystem leaders play a vital role in making the connection described by Bossidy and Charan (that is, the link between strategy, operations, and people) that is needed for successful execution. Midlevel leaders, in essence, mediate the cultural supports and the cultural changes a health care system requires if it is to move from providing care of erratic quality at the front lines to measurably improving the quality and value of that care. Midlevel leaders usually select the microsystem leaders, orient them, set their expectations, review their performance, and demand (or avoid) accountability for microsystem performance. The midlevel leader's personal style of work often speaks more convincingly about the desired way of work than any amount of words could.

All work in mesosystems must be undertaken with the clear understanding that the general aim is to improve patient care outcomes with more reliable and more efficient systems that are regularly reflected on and redesigned. Absent such a focus, understandings about work easily degrade into conversations about workload equity and problems of the past. Exhibit 4.3 displays commonly occurring needs, related skills, and helpful tips for mesosystem leaders.

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