“Covid-19 is a symptom of an interconnected and interdependent world, with the health care system and associated supply chains bearing acute pain from its indiscriminate spread. Our current healthcare systems are not well-structured to address these problems. Transforming them will require a combination of short- and long-term solutions built on system-level resilience and leader effectiveness…Legacy models from the 19th and 20th century, characterized by firmly structured hierarchies and siloes of information, have proven too rigid in the face of 21st century change and demands, especially around technology innovation. Covid-19 has laid bare these tensions between past and present. Leaders are being asked to make faster decisions, with more information, and less clarity.”
Lobdell and associates have laid out the challenge to healthcare organizations as they see it, exacerbated, though not caused by, the coronavirus pandemic. Three of the authors are associated with the McChrystal Group, which advocates tearing down silos and re-imagining hierarchies based on Gen. McChrystal’s experiences in Iraq and Afghanistan, so it is not surprising they look to that experience as a path forward. The authors recommend turning to “fusion cells,” which might elsewhere be called cross-functional teams, or what I have termed “clinical microsystems.” They recommend five steps to establish an effective fusion cell.
1. Identify a software platform that will allow everyone in your hospital system to conveniently, and with minimal technical barriers, entry.
2. Designate a regular meeting schedule and ensure it is given priority.
3. Invite an array of internal and external partners and open the meeting to anyone who wants to attend.
4. Establish a tight agenda to address the major areas that need decision, rapid evolution, and innovation.
5. Empower those closest to the front lines to share insights to keep learning fresh and relevant.
They see the goal of this approach as enhancing and supporting the critical element of any healthcare institution—its people. But, they note, changes are needed at three levels: the individual, the team and the institution. At the individual level, they recommend efforts to improve individual resilience and cite some of the issues I have addressed in these pages. At the team level, they note the deeply ingrained individualism of physicians must be transcended by focusing on the team and a common purpose is necessary, which, I would add, is a major challenge. At the institutional level they point to the need for leadership development.
“To push decision making deeper into the organization and closer to the front lines of care delivery, systematic changes must be made. Leadership must take steps to promote sustainable individual and team-level leadership skills…There aren’t prescriptive ways for this to take place, but a combination of formal and informal actions…offer a higher chance of lasting success.”
I agree with this assessment, of course, since their assumptions and mine are congruent and underlie many of the arguments I have been making about physicians, physician leadership, medical organizations, and the challenge of improving the quality and safety of care. But it is fair to point out obstacles also.
Perhaps one of the biggest is determining what the primary mission of the organization actually is and measuring progress. I have seen many statements about a goal of “improving health,” but what does that really mean, particularly when doctors, hospitals, and support staff, are dedicated to “treating disease?” How is health to be measured, and what, if anything, can an organization do to “improve” health? Mission creep, as it is termed in the military, is a real problem. I suggest the immediate challenge is to improve how we treat disease as measured by both quality metrics and dollars, with recognition that a bureaucratic focus on eliminating variation is not the answer. We want to eliminate unnecessary variation, which is more difficult to determine, so I suggest starting by eliminating harmful variation, which is easier to capture, (“never events.”)
The second major challenge is to define the organizational goal in a way that creates “buy in” for the people who have to make it happen. Many talk about saving money, which is fine as far as it goes, but I rarely see missionary zeal develop on that basis. On the other hand, I do think we can create the necessary enthusiasm for “doing a better job of taking care of our patients.” It might seem a chicken and the egg problem, but I believe we need to re-establish the original notion behind quality measurement—doing the right thing for the patient will result in “improved” numbers, not the reverse. Too often, if we aren’t vigilant, checking the boxes will obliterate any sense of mission, which, in turn, makes any system of organization, including fusion teams, doomed to fail.
Perhaps the coronavirus pandemic is the crisis that will spur those in health care to try drastic remedies to address long-standing issues. But it will take leadership, vision and courage. But what if most healthcare organizations have opted for “good hands” leaders, or what the authors of this paper term “legacy leaders?” One response to the stress is to seek even safer hands, but what we need are “learning leaders,” who are “constantly seeking to expand, learn and grow from failures, and look anywhere and everywhere for good ideas.” Long term, this clearly requires drastic changes in training, experience, and expectations. Short-term we don’t have enough people ready to go, so avoiding catastrophe probably means current leaders must be able to prove that old dogs can learn new tricks.
11 October 2020
 Lobdell KW, Hariharan S., Smith W, Rose GA, Ferguson B, Fussell C. Improving Health Care Leadership in the Covid-19 Era. 4 June 2020. Accessed 10 June 2020 at https://catalyst.nejm.org.doi/full/10.1056/cat20.0225.
 https://www.mcchrystalgroup.com/. Accessed 11 October 2020. The other authors are associated with Atrium Health in Charlotte, NC.
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