Healthcare Organization Design: An Analysis
With regards to health and healthcare improvement, can the field of organisation design offer anything new?
Health is not just about healthcare. We know that individual and population health is created and destroyed by many complex and interacting variables, such as the environment we live in, poverty, access to education, access to healthy food, freedom from fear of crime and violence and much more. The positive and negative interaction of these variables ultimately creates the demand into our local, national and international healthcare systems. Whilst this is widely accepted, why does this understanding fail to be translated systematically and effectively into the organisation design of our healthcare systems? healthcare organization design
In addition, it is well-documented that only a small percentage of the population generates a disproportionately large amount of healthcare costs. Demand into these services continues to increase – no matter the advancements in care. So how do we act to change this? Health and ill health are at opposite ends of one continuum. Think of specific disease processes as value streams, and what we know can act to prevent them can also form part of those value streams.
As you would expect, this is extremely complicated to act upon, with a huge range of stakeholders owning different parts of the continuums – or value streams. The amount of fragmentation in any healthcare system is staggering. And this complication adds to the reasons why we haven’t seen a huge improvement in the circumstances outlined above. However, many methods have been experimented with over the last three decades, influenced by agencies such as the Institution for Healthcare Improvement (IHI) based in the USA; who also offer support to programmes elsewhere in the world. In the UK, the Health Foundation and in Scotland, Health Care Improvement. The UK-based organisations have been influenced by the work of the IHI and many have been trained in their programmes.
These ‘institutions’ have modern quality improvement thinking at their heart – influenced by the work of W. Edwards Deming (1900 – 1993). At OTM, collaborative approaches to organisation design are central to the methodology and core to its success. The IHI has and is promoting collaborative approaches to tackling and improving expensive disease processes and corresponding care provision through to trying to tackle the root causes of ill health – as outlined above. If we can prevent some people becoming ill in the first place, then this has to be the most ethical if not cost-effective approach we should invest in. But the challenge becomes: how do we continue to be able to afford the best healthcare whilst investing in preventing disease and thereby reducing demand over time?
These programmes have promoted the concept of ‘Collaboratives’ focused on identifying and implementing comprehensive care redesigns that serve the needs of the most complex, high-risk and costly patients.
Alongside this approach of trying to improve services and outcomes for patients, the IHI has recognised the need to tackle the prevention end of value streams and created population/regional-based programmes. They bring together the main stakeholders to work in collaboration and to experiment with evidenced-based and new ways of doing things to prevent ill health. They do this by applying quality improvement methods and tools.
So, is it working?
An evaluation of five of the Health Foundation in the UK’s improvement programmes highlight some interesting findings – issues that must be addressed for any successful healthcare organization design interventions.
The authors of the evaluation identified 10 key challenges to the success of improvement interventions in healthcare settings. These will resonate with anyone seasoned in the organisation design world, and these factors are central planks of any effective organisation design methodology – particularly here at OTM.
The 10 key challenges that the authors of the evaluation found include:
- Convincing people that there is a problem that is relevant to them;
- Convincing them that the solution chosen is the right one;
- Getting data collection and monitoring systems right;
- Excess ambitions and ‘projectness’;
- Organisational cultures, capacities and contexts;
- Tribalism and lack of staff engagement;
- Incentivising participation and ‘hard edges’;
- Securing sustainability;
- And risk of unintended consequences
The published literature on community-based coalition (collaborative) strategies offer only marginal evidence that collaborative approaches lead to health status/health system change. Surely this is counterintuitive?
The possible explanations cited are that the collaboratives have insufficient mechanisms for carrying out critical planning and implementation tasks; that the expectations of benefit and/or change outcomes are unrealistic; and that it is difficult to prove health improvement as a result of the collaborative – the challenges of measuring cause and effect.
There is no magic bullet in improving quality in healthcare (or in any other organisation). Or in tackling the issues of preventing demand into the healthcare system in the first place. Improvement requires multiple approaches, often apparently contradictory: strong leadership alongside a participatory and collaborative culture; direction and control and also flexibility in implementation according to local need and critical capacity — but at the same time, there is a need to avoid inducing a wearying loss of momentum. healthcare organization design
Improvement interventions are much more likely to succeed when they are developed with, rather than imposed on, healthcare professions and other partnering professionals. At the frontline, or at the level of the community, fostering a sense of ownership is crucial.
A structured, comprehensive and integrated methodological framework for change like we use at OTM is critical to success. The literature regarding effectiveness of the Collaboratives and quality improvement interventions highlights, in my view, the lack of structure and detail in supporting the leaders and change agents. A structured methodological framework can address the key challenges identified in the evaluation highlighted above. This, with the opportunity to learn from work being experimented with in the USA – the creation of an ‘adaptive ambidextrous organisation design’ in healthcare. This is where the key stakeholders created the new design (with all of the key elements of the health system) – to run parallel to the existing system. This tests the design whilst minimising the risk to ongoing care. It creates the space to innovate and learn and ultimately “draw” the existing system into the new.
Any such methodological framework requires the achievement of explicit assessment of total efforts required by different parties. They need to be undertaken at an early stage, coupled with the commitment to deliver on this effort. Senior and executive-level commitment for improvement work needs to be backed up by active support from start to finish, multi-way communication and strategic alignment — and appropriate resources for the task at hand. healthcare organization design
The Health System is highly complex however you cut it. As has already been covered, there is no magic bullet. However, at OTM, we do have our own collaborative whole systems methodology to organisation design that helps organisations understand the issues they face, either individually or as a collective and tackle them head-on with practical solutions that make a difference.
If you wish to learn more about healthcare organization design and our approach at ON THE MARK, contact us.
Wilma Paxton Doherty is a Consultant at ON THE MARK. OTM’s experience and passion for collaborative business transformation that’s supported by pragmatism, systems thinking, and a belief in people is unparalleled. OTM has been in business for 28 years and is a global leader in collaborative organization design consulting.
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