Putting Patients at the Center of the Organization
I have previously quoted Porter and Lee, who argue the successful healthcare organization of the future will put patient care as their focus, but I have suggested some reasons most will find this difficult to do. So how can the increasingly large, bureaucratic, business-centric healthcare organizations make sure their focus is really on patients? One approach, which I think needs wider implementation, is the notion of the clinical microsystem.
I did not encounter the term until a couple of years ago, but the notion has been promoted by Dartmouth Institute for Health Policy and Clinical Practice for many years. The notion of the clinical microsystem as a means for quality improvement has also been supported by the Joint Commission on Accreditation of Healthcare Organizations and the Institute for Quality Improvement. The clinical microsystem, as conceived by the Institute, “is a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. A clinical microsystem is a complex adaptive system, and as such it must do the primary work associated with core aims, meet the needs of its members, and maintain itself over time.”
This is a more formal statement of the notion that medical care is delivered by teams of people, and as they work together, they develop both explicit and tacit knowledge about how to achieve good outcomes. This has always seemed intuitive to me, and it was a surprise to discover the barriers to implementation, some of which I have outlined in discussions of human capital and staff turnover.
Formal presentations of this idea often show a “bulls-eye” diagram with patients in the center, surrounded by a ring representing clinical microsystems as the first layer, followed by “meso-systems” as the second outer ring, and “macro-systems” as the third and final outer ring. Visually this creates the notion that the patient is the target, which makes sense to me as a clinician. But I find that our medical organizations are increasingly organized around the “business school” model. At the risk of over-simplifying, this conceives of organizational structures are vertical pyramids with the CEO at the top, and the front-line workers at the base (along with the patients, if they show up at all.)
Lest this appear too simple, consider the public discussion around the news reports that Volkswagen installed software in their diesel-powered cars to defeat emissions testing by the EPA. The CEO said he was not aware of the cheating. While this may be true, he was forced to resign and is being investigated for criminal misconduct by the German authorities. On the other hand, it is clear that his strategic goal for the company was to become the world’s largest auto manufacturer, and to do so, the company had to increase its market share in the United States, where buyers have traditionally shunned diesel engines. In this case, the culture of growth clearly caused some in the organization to take shortcuts, which may yet prove ruinous to the enterprise. For our purposes, though, the question is: Can this happen in healthcare organizations? I think the answer is almost certainly it can.
Given the popularity of the “business” model in healthcare, and the deliberate attempts to eliminate the “craftsman” model of healthcare most physicians carry around in their heads, can we escape pyramidal models? I suspect not, so I have a modest suggestion. Why not visualize the organization as an inverted pyramid?
At its most basic, all health care involves the interaction of two human beings, one providing the care and one receiving the care. This dyad is the inescapable minimum, the atom if you will, of the complex molecule that represents a healthcare organization. In this organic model, the clinical microsystem represents a collection of numerous dyads organized around a ward, clinic, or other small unit. What if the “meso-structures” such as clinical departments, and the “macro-structures” such as hospitals and clinics, were all thought of as infrastructure to promote optimal function of the dyads? In this model, the CEO is at the point of the pyramid. His/her function is to balance all of the forces so as to maintain organization equipoise and so create the conditions for optimal functioning of the dependent microsystems.
Could such a system work? I am sure it could, but there are obvious barriers. The first is that the CEO and her Board of Directors would have to agree the primary objective of the job was to support the clinical enterprise. Most large organizations, though, have other roles. The organization, for instance, is probably a major employer and driver of the local economy. There is a large constituency supporting the importance, even primacy, of that role. Second, in an era of increased competition, at least in some markets, the work of supporting microsystems is largely invisible to the general public. Problems averted and complications prevented are difficult to measure and don’t lend themselves to banner headlines in the local media. A new building, on the other hand, is a visible sign of power, although usually advertised as “progress.” There are others, but I think the point is clear—there are competing priorities.
If we are going to make patients the center of the enterprise, everyone, from the Board of Trustees to the kitchen help have to buy into the notion. This is a huge cultural challenge and will certainly cost money, both directly and indirectly, over the near term with payoffs delayed into the future which may be difficult to measure. Can the organization afford it? I suggest the question is: can the organization afford not to?
29 September 2015
 Porter ME, Lee TH. Why Strategy Matters Now. N Engl J Med 2015;372(18):1681-84.
 https://clinicalmicrosystem.org/ Accessed 29 September 2015.
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