The leaders of the Keystone ICU project emphasized the importance of informal clinical leadership for success as well as paying attention to both the technical and the adaptive work involved in making successful change. Richard Bohmer of Harvard Business School has taken this one step further, describing “clinical microsystems” as the key to improvement.
Clinical microsystems are composed of and controlled by front-line clinicians whose primary work is patient care. Although many have little interest in leading, the success of health care reform depends on them.
He goes on to define four key tasks for the clinicians leading microsystems. First, and most importantly, they have to establish the group’s purpose and emphasize that the goal is both shared and requires collective action. Having done this, it becomes necessary to ensure the clinical team can actually execute its plans.
Local care systems must address two perceived tensions—one between evidence-based medicine and patient centered care, which requires the flexibility to deliver standard care where the evidence is strong, and customized care where it isn’t, or when standard care conflicts with the patient’s preferences; and one between medical and human needs, by ensuring caring and compassion as well as clinical precision.
These requirements may suggest that creating an effective microsystem is a technical design challenge requiring recruiting, staffing, task allocation, information technology selection, and process design. But since a microsystem’s performance is as influenced by its culture as by its processes, the challenge is one of leadership. The team’s culture guides decision making where protocols fail to provide appropriate variation and encourages compassion in technical settings. And the way local clinical leaders speak and act to model the balance between standard and custom, technical and human, helps define local team culture.
The third task is monitoring system performance, although he points out that for many clinicians, “control at a distance” is challenging. The final task in improving performance.
Clinical leaders must model the combination of humility, self-doubt, restless curiosity, and courage to explored beyond accepted boundaries that drives organizations to relentless improvement despite colleagues’ preferences for stability and familiarity…Without formal authority, the only tool that clinical leaders have is their behavior; what they say, how they say it, and how they model good practice.
I have been involved in leading dialysis units for more than 30 years in several settings. Dialysis units constitute a clinical microsystem, and it is instructive to consider the factors that seem to be associated with success or failure.
As medical director for outpatient dialysis units, I have a role defined in statute and incorporated into a contract that I have with Dialysis Clinic, Inc, (DCI), the owner of the units. Originally, those terms covered all clinical aspects of patient care; more recently the requirements have become increasingly specific and “rules” are being constantly refined and imposed through the survey process. When I took on the position, the unit had been in operation for 13 years, six under another local medical director, whose approach to clinical care was not congruent with mine. I was fully aware that my first task was to define my expectations as clearly and as consistently as possible.
Since my office and primary hospital are not co-located with any of the dialysis units, I knew I was going to be dependent upon the skills of my nursing staff to be my “eyes and ears” at the chair side. The better they could describe what was happening to the patient, the better decisions I could make. I also realized it would take time for those skills to develop and mature, so I needed to make the position attractive to nurses who were willing to make long-term commitments to the job. I knew from previous experience that the high death rates and high turnover of patients was a major cause of compassion fatigue, which led to turnover. The solution, it seemed to me, was to develop indicators of nursing “craftsmanship.” These intermediate goals might help the nursing staff place the mortality rates in perspective and give them something they could be proud of. This was the impetus behind our first CQI project.
I was successful and I now have a cadre of nursing leaders who have been with me for many years. My “rookie” nurse manager is a five year veteran, and I have two with more than 25 years’ experience. This contrasts with the reported median experience of 18 months. As a result, we have been able to attain and maintain clinical performance that meets or exceeds norms, to have hospitalization rates consistently below the norm, and to operate in a financially successful way despite constrained reimbursement.
There were organizational supports for this effort. First, DCI’s human resources policy included a generous benefits package and rewarded longevity. Second, the company had the notion that medical directors were in the best place to know the local demands, and largely left me to my own devices as to how I went about my tasks. As regulatory requirements became increasingly specific, the central office and the local units worked together to make sure required items were accomplished. Units that found better ways to do things were encouraged to share best practices. Third, the company operated the business primarily through its local administrators.
The way the administrator did her job mattered to the operational and clinical success, though. To build a long-service professional workforce, I built a clinical system that stressed mutual respect, trust, and accountability, and actively worked to drive blame out of the picture. My first administrator, though, was temperamentally incapable of being positive. For instance, I instituted a new clinical protocol that required nurses to make an assessment and make a choice from a menu of actions. This required me to trust the nurse would make good decisions.
The very same week she sent out a memo threatening termination for any nurse manager who let her staff work overtime. Even when I talked to her about the discordance, she was unable to see how the two were related. My second administrator was attuned to clinical goals and was able to get her job done in ways that facilitated attaining them. When she needed to curb overtime, she would talk to the nurse manager and find out what was going on with the patients first, before deciding if an administrative intervention was needed. In other words, she trusted the nurse to tell her the truth, too.
The contrast with the hospital’s dialysis unit is instructive. When I first came to town, the unit consisted of two nurses, two dialysis machines, and one room. There were two nephrologists and we both interacted with the nurses as physicians rather than as medical directors, but since both of us were experienced outpatient medical directors, we were able to provide the necessary guidance. After a couple of years, I was asked to help design a new unit, where we expanded to six beds and an appropriate number of nurses. However, this advice was informal (and uncompensated.) With the growth in numbers of patients and procedures, the cost began to mount, and so the hospital and dialysis company reached an agreement to contract out dialysis services. I began the formal medical director as a result of that contract. Although I was paid by the dialysis provider, my role in terms of the medical staff was still defined by hospital Medical Staff rules.
When the growth in procedures continued unabated, the hospital became convinced it could provide the services cheaper than the contract price. This opinion arose mostly because of the difference between the acquisition costs of the supplies and the contract price. Following termination of the contract, the hospital attempted to run the unit without a formal medical director, but the increased burden of regulations made that impractical, so they contracted with me to provide advice to them. The contract specifically excluded any operational control of the unit.
The unit was led by a dialysis nurse, but most management functions were provided by nursing directors with various levels of interest and understanding of the needs of a specialized unit. As a result turnover became a problem. Experience and skill levels has continued to fluctuate as nurses serve out their bonus time and move on.
Bohmer addressed this issue in his paper as well.
Institutional leaders can encourage and support unit-level and front-line clinical leadership by framing the organizational purpose as value creation, giving local leaders the authority to make microsystem changes, tolerating the failure of some new delivery ideas, and creating professional pathways for clinicians who want to make leadership a career option…CEOs may resist investing in developing clinical leadership and decentralizing control or may believe the process is too slow to address current pressures. But the need is evident, the tasks are clear, and the skills are at hand—data orientation, the relentless pursuit of excellence, and a habit of inquiry are all second nature to clinicians. Ultimately, investment in such leaders will be essential to achieving the goals of health care reform.
While the financial pressures on providers are obvious, the benefit of the change, either in clinical or financial terms is less obvious. We had a recent discussion with our CFO about calculating savings from clinical initiatives, and he admitted it was difficult, and required a lot of educated guesses. In the end he wasn’t sure that most initiatives actually saved any money. If administrators and clinicians don’t operate from a basis of mutual trust and respect, and a shared understanding of the other’s reality, then paralysis is the likely result.
Some years ago I heard a speaker, whose name I have forgotten, talk about institutional change. He told the story of watching a TV news report where an man who survived a fire on an oil platform in the North Sea was being interviewed. The interviewer pointed out that the platform was more than 100 feet above the surface of the water, it was winter time, the water was cold, and staff had been trained to never jump into the water as survival time before fatal hypothermia was about four minutes. Given all this, the interviewer asked the man why he jumped. He replied that he chose the probability of death over the certainty of death. The speaker stated most people made change only when their platform was on fire.
Many of our medical organizations are on fire, but not everyone admits it and there is real tension between those who want to jump and those who want to stay despite the certainty of death. Where are you? Are you willing to lead the microsystems of importance to you and your patients? Are you willing to work with your nurses and administrative staff to develop effective teams along the lines outlined here?
 Bohmer, Richard M. J. Leading Clinicians and Clinicians Leading. N Engl J Med 2013;386:1468-70.
 At my request, the position was turned over to one of my associates when I entered into the medical staff leadership.
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