Defining the whole: Integration theory relevance in healthcare management

In mathematics, integration is a method of summing up the parts to find the whole. Each integral, derivative and function has intrinsic importance and meaning; however, one must look further to understand how an area is wholly defined. Likewise, in operational integration, we strive for seamless alignment, whether that’s looking at the interconnectedness between people and their duties or across the entire workplace system. Defining both the pieces and the whole of workplace integration is a pathway to reimagining how we can create value in a purposeful, deliberate and disciplined way. When we identify the derivatives of people and context, we are in a position of insight that can be leveraged to make changes in how work models are redesigned. The redesign is not simply about who performs the work, but how the work gets done along degrees of intention and purpose.

The following tactical steps will give you the closest approximation to short-term prediction of success through best practice:

• Ask each member of a group how they feel about the work they produce; this helps to expose areas of truth which are vital to decision-making on redesign and a major qualifier to weigh in determining team or group essence.
• Identify your team leader, the information seeker, the energizer, the harmonizer, and the blocker with three broad categories of small group roles defined as:
  1. Task roles
  2. Building and maintenance roles
  3. Self-centered roles
• Meet with this identified group and ask the same question to unravel important in-group dynamics to moderate.
• Analyze whether each person to role is a good fit and if there is an opportunity to better match strengths through interest to relevant tasks and relative responsibilities.
• Boost the attractiveness of a redesign and emphasize how it will be beneficial.
• Synthesize it all iteratively and produce a modified or wholly new model for longitudinal commitment.

We translated these tactical moves across our contact center staff, a centralized hub for all appointment scheduling activities and all germane administrative support post encounter. Our contact center manager compiled her monthly audits, personal coaching notes and annual performance goals for each staff member’s one-on-one informal meeting. Together, they identified strengths and talked through the linkage of those strengths to interest(s). They walked through the most significant assigned responsibilities and identified areas where retooling a singular approach could derive greater satisfaction.

For example, we discovered our lead customer service representative who handles all medical records requests and disclosures was using a manual process to log every transaction on a spreadsheet rather than accessing the storage vendor’s dashboard. Although she was intrinsically hesitant to transition from her comfortable, rote process, she ultimately found great satisfaction by receiving manager-level user privileges and new settings/preferences, a new intuitive interface and a cognitive connection to Lean work by eliminating the cost of not doing something more valuable. Applying Kurt Lewin’s change process, we encouraged her to develop a timeline for unfreezing and refreezing over the course of three weeks, which tempered the anxiety spawned by the change and gave her the breadth to control and take ownership, making this redesign in her approach a huge hit.

This same employee types with incredible error-free speed; though she thinks nothing of it, we leaned on this natural talent to improve response rates to incoming calls by designating her to manage a scheduling bot which would ultimately be less stressful and concomitantly improve access. Tacitly assigning her these assets dramatically enhanced the patient experience. As an individual who covets work that doesn’t require face-to-face interactions, the idea of not needing to interface verbally and still perform at a higher level was wholly appealing and beautifully aligned with her needs.

While this employee was rather shy, we discovered her desire to be recognized outside of the contact center microcosm. By assigning her as the VIP liaison, we grew her engagement across the department, which helped her earn a reputation as the department’s “go-to” person among physician leadership and faculty. Similar targeted efforts were made with five other contact center members, which helped them earn accolades across the Clinical Practice Management Plan and external consulting groups.

As the healthcare industry’s trajectory evolves from volume to value, incentives and disincentives are helping to drive changes in behavior, delivery systems and the degree of interconnectedness of systems and organizations. System and organizational design groups are forced to evaluate value creation as a function of how well processes interlock and how well people coexist to maximize utility — of creating reinforcing measures of satisfaction through the patient’s journey —and doing so in a way that will positively treble through the system in a synchronized, reliable and reasonable fashion.

One of our most effective initiatives is our “flash meeting,” designed to take place in a flash (15 to 20 minutes maximum). These meetings are focused on addressing high-frequency, low-severity occurrences on a monthly or as needed basis. We choose a different cohort every other meeting, always including team leads across each function (clinical, contact center, registration, administration) to generate two “pain point” bullet points for brainstorming. Our cohorts are typically one or two members representing clinical and non-clinical staff who are affected by some degree of separation during the patient encounter. The most productive meetings often confront the incoherence where staff handoffs or overlapping occurs. This can either be across non-like users or dissimilarly oriented staff hampered by some tangible or implicit vulnerability that causes frustration and unnecessary downtime. [For example: A flash meeting about delays in locating earbuds for wireless talkies for improved compliance or using patient “teach back sheets” to build continuity across all users.]

This cohort included the residency program coordinator, a longstanding medical assistant within the department; an LPN on the clinical care team of a high-profile, high-volume provider; and a registration employee with influential impact and spirited energy with a métier for absolute “clean” flow. From this meeting the idea was spawned to hang the earbuds — worn by front and back-office staff to communicate and inquire about delays — in the breakroom from a strip of tacky backed cork. Since all staff start in the breakroom to store their belongings in lockers and place their lunches in the fridge, the buds would be easier to find and help ensure all staff started their clinical sessions with their buds on. The cork strip was bejeweled with sparkly employee initials to add a flavor of fun and compliance was vastly improved.

The instruction sheets were created as a takeaway “teach back” for patients to lower call volume spurred by forgetfulness in the Q&A crosswalk during patient evaluations. These “white sheets” are also used to transport valuable information to checkout, including details for follow-up; if bloodwork is needed so we can ask in real time which lab will be used; whether an overbook is necessary, etc. We transpose these details into the appointment notes, the hub for all germane information to ensure fluid scheduling and fluid preparation for the return visit. Our registration employee came prepared with examples of “good,” “bad” and “excellent” throughput, which provided deeper understanding of why the tool itself was underutilized. We revealed myriad opportunities for improvement:

1. Several newer staff weren’t made aware of the “why” behind the tool and were haphazardly using them in a perfunctory manner, creating significant activity-based costs — the cost of wasted valuable time because staff continually needed to migrate to the back and away from the patient to obtain the details needed.
2. Many senior staff were missing details flagged on the sheet, likely a result of not taking the time to read the flags and map them spatially on the sheet for ease of use and adequate capture.
3. The remainder were not making the connection between the “how” of their workflow to the “who” and “what” on the receiving end as a function of their training and education not being tied to the rationale driving the objective.

From here we created a stream of concentric teach-back looping for all staff including residents to appreciate utility, to associate the importance of how adequate transportation of critical details is achieved efficiently, and to have awareness to readily identify the flags incorporated by weighted importance to consequence etc. Now that we had everyone’s attention, we used collective feedback to enhance the layout and ultimately memorialized the famous “white sheet” in laminate to post it front and center.

When processes and people are immiscible, it’s often the result of suboptimal training that lacks structured and methodical thought processing of how inputs drive outputs. In our own wheelhouses, we need to be conditioned to ongoing assessment of our processes, our people and the mission of the organization to create fitness. How fit we are operationally implies reinforcing repetitive activities that strengthen the reliability of how inputs drive outputs; a total quality mindset is invaluable. As leaders we are intuitively drawn to the implications and corollaries of gaps and the associative collapses in value due to vulnerabilities that go unchecked. We have the clarity to recognize them short of benchmarking, but are we always sentient without open reception of feedback loops and stakeholder wants and needs?

Leaders evolve their style as their teams mature — as reflected in Tuckman’s FSNP (Forming, Storming, Norming and Performing) model — so it is important to approach work with these five goals:

1. Build awareness of team role taxonomies.
2. Accurately assess the behavioral dimensions within groups (individual prominence, sociability, group goal facilitation/task orientation) to develop ownership and interest (they are not mutually exclusive).
3. Lean on those who have the greatest influence across prominence and sociability cohorts to stem continuous positive traction until soft transition is organically taking place unnoticeably; the “seeing is believing” phenomenon is an elixir for perpetuating small wins.
4. Inspire vulnerability as an asset that leads to more effective communication and esprit de corps through compassion; difficult dialogue is needed at times.
5. Accept the inherent crossroads of ongoing conditioning.

The universality of ingroup and subgroup coalitions is game for every manager, and I have referred to Sun Tzu’s The Art of War often to finesse breaking down barriers that impede great work, solid relationships and positive energy. Our satellite office suffered through months of high turnover, poor steering and empowering the wrong people (individuals too immature to use power to elevate rather than to divide), which required intervention. Initially faculty attempted to engage staff in an open forum, though this fell flat because physicians weren’t seen as leaders, only as physicians. It also failed because they hadn’t taken the time to manifest inclusivity of the front office staff, deepening the chasm of distrust and dissociation with what those physicians value. When I was asked my opinion about the “out of sight, out of mind” state of things, I was painfully candid: The “fake it until you make it” approach never works. So, we took action.

I involved our prominent staff in the recruitment process to select a new supervisor. I initially started a presence at our satellite once a week to create a sense of comfort and to draw staff in at their own pace and slowly passed the baton to one of my managers to safeguard against the ebb. We identified a fabulous candidate who sought teamwork and camaraderie. During her onboarding and many tete-a-tetes, we opted not to share any history to afford her the ability to repave the way afresh without an unwitting stigmatism of knowing too much. As she got her feet wet learning the ropes and slowly creating her space, I worked with our clinical nurse manager with whom tension had been festering as a byproduct of the factions formed across our clinical and administrative staff in our satellite location. I knew I had to look within, I had to allow myself to be vulnerable. I spoke to my nurse manager plainly and openly, asking her to join me in changing course and to travel together down a new road forged by respect, unity, compassion and leadership so we could “flow like water through rocks.” We planned an intervention and had a group lunch the following week: For the first time, this team watched us side by side speaking to the same message and demonstrating a well-balanced partnership, buttressed by a conjoint duty to citizenship, stewardship and alignment with purpose. Four weeks later, the shift in attitude and perspective was palpable, even though it remains a work in progress.  

Operations-minded people are very effective at managing scope though sometimes fall short miserably at connecting the dots. A requisite of adding value is not only working the periphery, but also having a vantage point from the weeds:

• Take the time to walk in others’ shoes and know the work, the flavorful nuances and the granularity of interdependence needed or topped out for your situation analysis.
• Create opportunities for counterparts who overlap at high touch points to fully understand the nexus where the handoff transacts; this mobilizes autonomy.
• Identify assumptions over throughput up to and trailing a nexus as a central point of immutable empowerment when each stakeholder can materialize more immediate gratification from clarity inherent in the how and why.
• Espouse, encourage and recognize ingenuity and innovation through role modeling and cascading small refinements born of user repetition and system “incoherence.”
• Foster idea creation and make those ideas actionable as fodder for continual adaptation of systemically smarter work despite apparent constraints or broad-based limitations e.g., an EHR that is too costly to change.
• Set the tone and the attitude to maximize “the small stuff” always overlooked as a function of curiosity abstinence. There is usually more than one untapped feature right in front of your nose.

We know context is everything. Our organizations are highly texturized by the interplay of every connection we continue to refine and develop as moving targets. These are the connections between people and work where our management and leadership efforts intertwine and create coalescence like water droplets on a slide. The more closely aligned all stakeholders are from their respective vantage points with the mission and goal of the organization, the greater the longevity of the interlocking framework to mitigate exposures and breakage.

That breakage is the proliferation of the derivatives inextricably tied either to systems or people and sometimes, a combination of both by varying degrees of separation and inflection points. The slow and progressive morphing through disparate interchange, collective mindset in concert, application of ideas through ownership and reward, pride in progress and ingenuity with recognition, and ultimately the satisfaction of “betterness” cumulatively create a reinforcing cycle of graceful movement. This carefully orchestrated effort breeds trust and drives closer proximity to desired outcomes as an organic conduit to transformative cultures. Moving the needle may require a compounding “two steps back and three steps forward” approach to generate small wins that continue to carry forward. My takeaway is always train to master, not to serve.