Creating the Conditions for Breakthrough Clinical Performanc

T oday’s healthcare industry is no longerwell defined, and traditional strategies and tools do little to adequately respond to the rapidly

changing environment. Globalization, technological

innovation, regulatory restructuring, demographic

shifts, and environmental pressures have all conspired

to continually redraw the competitive landscape.1

Rather than create specific strategies for success, we

propose that healthcare leaders focus on creating the

conditions that will engage and allow the organiza-

tional participants to successfully adapt and respond

to the ever-changing landscape.

Kathy Scott, PhD, RN, FACHE, and Jennifer S. Mensik, PhD, RN, NEA-BC, FACHE

The underlying premise of this article is that sustainablequality outcomes depend on a clinical-delivery frame- work that focuses on the experience of its customers as well as the expertise and capacity of its members. Although there is basic agreement concerning the desired outcomes of clini- cal delivery, there has been no clear delineation of the antecedents for a clinical delivery structure to create these outcomes. We propose six antecedents that, when valued and nurtured, create the conditions for effective and reliable clini- cal delivery in today’s healthcare systems.

THE HEDGEHOG: CLINICAL DELIVERY Jim Collins, in Good to Great and the Social Sectors,2 describes an organization’s hedgehog as “an operating model that reflects understanding of three intersecting circles: what you can be the best in the world at, what you are deeply passion- ate about, and what best drives your resource engine.” His research demonstrates that a relentless focus on the hedgehog is critical for organizations in both the business and social sectors to move from average to great performance. The hedgehog of healthcare organizations is clinical delivery.

We define great performance as clinical delivery that consis- tently fulfills the Institute of Medicine’s (IOM) six aims for healthcare systems of the 21st century—healthcare that is safe, effective, efficient, equitable, timely, and patient focused.3

When these six aims are combined with high reliability, or a system that yields the same results on repeated trials4 regard- less of the day, time, person, or team, care is transformed and organizational performance reaches a new level.

There are four different levels in which care is delivered. Donald Berwick5 cites the experience of patients and com- munities as Level A; the functioning of small units of care delivery, or microsystems, as Level B; the functioning of the organizations that house or otherwise support microsystems as Level C; and the environment of policy, payment, regula- tion, accreditation, and other such factors as Level D (Figure 1), saying, “The model is hierarchical because it asserts that the quality of actions at Levels B, C, and D ought to be defined as the effects of those actions at Level A, and in no other way.”5

Because the core product is delivered within a specific context, the work of clinical planning, design, implementa- tion, monitoring and ongoing improvement cannot be done in isolation from the context. “The microsystem is where the work happens; it is where the quality experienced by the patient is made or lost.”5 Therefore, the voice of the partici- pants at the microsystem level is critical at each stage of the process—and it is through their acceptance of the product and process that change becomes successful over time.

THE SIX ANTECEDENTS There are six proposed antecedents needed to transform clinical delivery for breakthrough performance (Box 1). These six antecedents affect each of the four levels of clinical deliv- ery and together inform and enhance the redesign of care at the microsystem level. These antecedents are based on the key principles for redesign identified by Berwick5—they are

knowledge based, patient centered, and systems minded. The antecedents are: • A unifying vision and framework that connects clinical

delivery with the heads and hearts of the people • An infrastructure that supports knowledge management

and distributed decision making • Movement to an effective patient-centric interprofessional

team model • Innovation support and management • Ongoing assessment and management of organizational

bandwidth • Nursing and medical leadership in partnership at every

level of the organization representing clinical delivery and their respective professions These antecedents create the conditions to redesign and

deliver clinical care as well as optimize patient and organiza- tional outcomes in today’s healthcare systems.



The organization’s vision articulates the logic by which it adds and captures value. In order to be effective, the vision must be shared and adopted by the members. When this logic provides meaningful connections to the daily activities and contributions of the members, it not only instills a sense of pride and meaning, but also provides a sense of direction.

A critical leadership skill at every level of the organization is that of connecting the organizational and/or leader’s vision to each participant’s own aspirations. The very best leaders understand that their key task is inspiring a shared vision, not selling their own idiosyncratic view of the world.6 People care about making a difference in the world. Leaders help others connect the dots that provide individuals and teams with direction, meaning, and a sense of ownership.

Framework A unifying framework helps to orient people quickly to the important work they do within the context of the whole. A framework should be evidence based and focus on the Nurse Leader 49

Figure 1. Levels of Care Delivery and the Patient Experience

hedgehog. The IOM’s six aims for healthcare improvement3 is an excellent example of an evidence-based framework that could readily be adopted to provide healthcare organizations with clear direction for clinical delivery. When the framework informs the planning, operations, and design of the organiza- tion, it supports the hedgehog and leaves no doubt in peo- ple’s minds of the organization’s priorities.

KNOWLEDGE MANAGEMENT AND DISTRIBUTED DECISION MAKING There are two sides to the knowledge management coin—one side focuses on knowledge sharing, and the other on knowl- edge making or learning. Both are critical to everyday prob- lem solving, ongoing improvement, and innovation.7 In complex healthcare systems, there is a great dependence on people throughout the organization to create and share their knowledge to enhance and assure that the core work of clini- cal delivery is safe and effective. Therefore, there is an increas- ing emphasis on individual worker competency and freedom in terms of learning, decision making, and taking actions.

Technology can be a very useful tool for knowledge workers, but technology is not enough. Through the use of electronic devices, medical records, and searchable databases, information can be accessed more readily. Evidence-based decision supports can be designed and integrated into the workflow process. Technology, however, does not replace the need for workers to customize the information and services to meet the needs of a specific patient or situation in a particular context.

Creating a culture and infrastructure that encourages and connects the “coming together” of key stakeholders formally, informally and spontaneously, is critical. Through the devel- opment and communication of a few simple rules and/or principles, guardrails are established to keep the actions mov- ing toward the unifying vision. The leaders’ focus changes significantly in this model from problem solving for others, to

generating a clear and adequate understanding of the prob- lems or opportunities and framing them in ways that enhance the ability of others to respond to the problem or situation.

MOVEMENT TOWARD AN EFFECTIVE INTERPROFESSIONAL TEAM PHILOSOPHY AND MODEL Healthcare organizations are composed of many different pro- fessions that are central to the organization’s success. Historically, physician roles and the medical model of health- care have dominated. As we understand more about the com- plexity of systems (society, organizations, and the human body), the need to coordinate and embrace the expertise and values of multiple professional groups becomes more apparent.8

A true interprofessional model values the contributions of each member of the team, working through the tensions in the interest of the patient. When diverse members of a team come together, especially in stressful environments; significant conflict and communication failures can result. In a hierarchi- cal system, such as healthcare, the highest person on the totem pole usually “wins” the debate. Often times these debates do not include the patient nor do the resulting actions serve their best interests. Different professional views are important, however in defining the patient’s needs, pre- senting courses of action and bringing different expertise and values to bear on resolving problems and making key deci- sions.8 The skills of communication, collaboration, negotia- tion, and conflict management are critical, therefore, to work through the professional tension and benefit from the contri- butions of the team members.

The challenge for leaders and members of interprofession- al teams is in managing the team processes that occur in all teamwork while simultaneously managing their individual professional identities9 for the patient’s benefit.

When leaders effectively identify the underlying values that support and detract from interprofessional teamwork, they are able to more effectively redesign the infrastructure to promote and support team values and success. This work begins with the identification of key principles to guide the work and behaviors of the organization, as well as with an honest assessment of the current practices and behaviors that promote the status quo and detract from interprofessional team work.

INNOVATION SUPPORT AND MANAGEMENT Healthcare cannot sustain itself through cost reduction and reengineering alone; and the conventional delivery of healthcare services is not able to stand up to the combined forces of market fluctuations, healthcare financing, new technologies, and the aging population. History shows, in fact, that “the companies that invest in their innovative capabilities during tough economic times are those that fare best when growth returns.”10

Innovation is often thought of as a radical or brand new idea or concept. It can also be a recombining of current and disparate ideas that result in something new. Innovation can be anywhere on the continuum of incremental to radical. It

August 201050 Nurse Leader

Box 1. Antecedents to Transformation of Clinical Delivery for Breakthrough Performance

1. A unifying vision and framework that connects clinical delivery with the heads and hearts of the people

2. An infrastructure that supports knowledge management and distributed decision making

3. Movement to an effective patient-centric interprofessional team model

4. Innovation support and management

5. Ongoing assessment and management of organizational bandwidth

6. Nursing and medical leadership in partnership at every level of the organization representing clinical delivery and their respective professions Nurse Leader 51

may involve small to major changes through the introduction of technology and/or through fundamental change to the business/clinical models themselves. Innovation is more than the concept itself, however. It is the implementation of that idea into the environment.11

Innovation is a necessary ingredient for sustained success, and it has to be managed, requiring a well-defined process and orga- nizational time, energy, tools, rules, and discipline.12 The process begins with senior organizational leaders articulating the degree of innovation and risk they are willing to support and then, through the creation of a formalized structure and culture, to support the resource-intense process and risk. Sufficient project and data management support are needed, as well as a robust change-management model. The budgeting process for innova- tion work cannot compete head-on with the short-term needs of a department or organization. A separate and defined budget- ing track for innovation is needed that includes financial rigor and planning, as well as selection criteria that consider the potential return on investment, potential loss, the degree to which the innovation will directly impact clinical delivery, and the degree to which the innovation could differentiate the organization in the marketplace.

ORGANIZATIONAL BANDWIDTH ASSESSMENT AND MANAGEMENT It has been estimated that up to 70 percent of change initia- tives fail to meet their goals.13 In the face of healthcare reform at the national level and budget shortfalls at the state level, the next few years will require tremendous change for many organizations. Leaders and employees are overwhelmed with the number of change initiatives coming their way and are asking for guidance as to priorities and resource alloca- tion. Jim Collins states in Good to Great14 that the primary indicator of great companies is a focus on not only the strate- gic goals to be accomplished, but also on the avoidance or cessation of counterproductive activities. Current methods for prioritizing and rolling out change initiatives need to include an accounting of business goals and employee capacity,15,16

which includes cessation strategies. Organizational bandwidth, or capacity, has two components:

employee workload and organizational capacity. Employee workload consists of mental demand, physical demand, time pressure, effort required to reach desired performance, degree of frustration and support, and perceived performance. Organizational capacity consists of assimilation hours, necessary talent, financial resources consumed, and the expected return on investment.16 Organizations in the throes of change will benefit from regular and formalized attention to these two organiza- tional components and the gap between the intended and actual outcomes. Through the design of a regularly scheduled and structured pause at all levels of the organization, leaders can identify the expected changes that impacts their team, integrate or bundle multiple activities in meaningful ways for the end users, assess bandwidth (employee workload and organizational capacity), identify unnecessary work/activities and reassign resources as needed, and connect this work to the vision and the contributions of the people.

NURSING AND MEDICAL LEADERS AS PARTNERS AT EVERY LEVEL OF THE ORGANIZATION The US healthcare system spends more than double that of other industrialized nations and ranks comparatively low in indicators of care quality and population health.17

Inefficiencies and errors plague the system and all too often cause harm to patients.3 The two professions with the greatest potential to affect this performance are the medical and nurs- ing professions. Physicians control a large percentage of the healthcare expenditures by virtue of the orders that they write for tests and drugs, and the decisions they make related to diagnostics, procedures, and hospitalizations.18

Nurses are the largest of the healthcare professional groups and spend the most direct time with patients,19 attending to their physical, emotional, and spiritual needs. Nurses orchestrate the patient’s experience and keep them safe through ongoing surveillance—safe from infections, falls, skin breakdown, delays in treatment, and adverse events. They also attend to the needs of the families, implement medical and nursing orders, ensure that beds are staffed by the appropriate person with the appropriate skill set, and manage the majority of the complex clinical opera- tions in acute care organizations.

It is in the best interest of patients and organizations to strengthen and elevate both the leadership and profession of nursing alongside their physician colleagues at every level of the organization up to and including the governing board. When people belong to a profession, they can make sense of the nuances of specific situations, policies, strategies, struc- tures, and communications through their ability to recognize and interpret through the professionals’ values. When physi- cian and nurse leaders are equals at the table together, they are able to contribute to and influence decision making in ways that bring both the organization and the acceptance of the professional members forward. With the increasing emphasis on quality and clinical delivery effectiveness from the bedside to the boardroom, nurse and physician leaders with knowledge of the professions and the system are instru- mental in connecting the system to its purpose.

CONCLUSION We are entering new territory in healthcare and need the strength of every member of the team. With a focus on the six antecedents, organizational leaders and members will create the conditions that enable them to more successfully anticipate, adapt, and respond to the ever-changing landscape, maximizing and using expertise and capacity for breakthrough clinical performance. NL

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10. Chesbrough H, Garman A. How open innovation can help you cope in lean times. Harv Bus Rev. 2009; Dec:68-76.

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12. Davila T, Epstein M, Shelton R. Making Innovation Work: How to Manage It, Measure It, and Profit From It. Upper Saddle River, NJ: Wharton School; 2006.

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14. Collins J. Good to Great: Why Some Companies Make the Leap and Others Don’t. New York, NY: HarperCollins; 2001.

15. Voelpel S, Leibold M, Tekie E. The wheel of business model reinvention: how to reshape your business model to leapfrog competitors. J Change Manage. 2004;4(3):259-276.

16. Safar J, Defields C, Fulop A, Dowd M, Zavod M. Meeting business goals and managing office bandwidth: a predictive model for organizational change. J Change Manage. 2006;6(1):87-98.

17. The Commonwealth Fund Public Views on Shaping the Future of the U.S. Health System, New York, NY: The Commonwealth Fund; 2006.

18. Mayer J. The American health care system and the role of the medical profession in solving its problems. Ann Thorac Surg. 2007;84:1432-1434.

19. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey Bass; 2010.

Kathy Scott, PhD, RN, FACHE, is president & CEO of Kathy A Scott & Associates in Phoenix, Arizona. She can be reached at Jennifer S. Mensik, PhD, RN, NEA-BC, FACHE, is the director of clinical practice and research for Banner Health in Phoenix. She can be reached at

1541-4612/2010/ $ See front matter Copyright 2010 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl/2010.05.004

August 201052 Nurse

  • Creating the Conditions for Breakthrough Clinical Performance
      • Vision
      • Framework
    • References
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