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Fireflies

The Tier Framework: how to break silos, create teamwork, and adapt quickly in a healthcare environment

One of the greatest obstacles for healthcare executives is navigating complexity. Lewis Lipsitz, MD, describes healthcare’s complexity as both in lay terms by its complicated design and in scientific terms by its nonlinear, dynamic, and unpredictable nature[1]. But this should not be a deterrent. Dr. Lipsitz believes that several of its intrinsic properties can be exploited to influence its dynamic behavior and guide it in a more favorable direction. According to him, the ways to do so include 1) nonlinear interactions of component parts, 2) emergent, self-organized behavior, and 3) the dependence on simple rules.

Nonlinear interactions of component parts

In simple language, nonlinear interactions of component parts translate into coordinating patient care amongst different employees as a patient transitions from one process inpatient care to another. A simple example of this is when a patient transitions from the Emergency Department (ED) to an inpatient medical unit. As simple as this transition may seem to an outsider, the reality is that it is fraught with opportunities for improvement. For example, it is common for the unit physician and ED physician to disagree on whether the patient should be admitted in the first place. Meanwhile, as they argue, the patient is left to wait in limbo.

Emergent, self-organized behavior

The second opportunity translates into healthcare teams being able to make decisions on their own without permission from leadership.  Due to the nonlinear, dynamic, and unpredictable nature of healthcare, permission can have fatal consequences. As such, those closest to the frontlines where patient care is delivered must be empowered to adapt quickly. Dr. Lipsitz points out that in nature there are models for this behavior such as the flocking of birds, schooling of fishes, and synchronized lighting of fireflies. These natural systems are lacking in healthcare and, thus, must be designed.

Dependence on simple rules

The nonlinear, dynamic, and unpredictable nature of healthcare also means that whatever systems are put in place need to be simple and easy to follow. Healthcare policies in thick binders will not be read by the frontline staff and, as a result, are highly ineffective.

The Tier Framework

Designing a system to break silos, create teamwork, and allow frontline workers to adapt quickly begins with a simple, yet powerful framework we have branded the “Tier Framework,” as seen below.  

Image 1 – The Tier Framework

In this framework, we identify the different tiers, i.e. parts, within the larger healthcare system, i.e. the whole.

Enterprise Tier

We begin at the base with the Enterprise. This is where the executives reside and where strategic decisions are made regarding the direction the healthcare system is going in. We choose to put them at the base because, in true servant leadership, their primary objective should be to support all the other tiers so that the best patient care can be delivered. Most healthcare systems do not have a problem identifying this tier or its’ players. However, that is not the case with the next tier up.

Service Line Tier

Within the Enterprise, there are many Service Lines. A Service Line is a specific grouping or population of “like” patients and is based on patient encounter attributes such as inpatient versus outpatient, Major Disease Categories (MDCs), Diagnosis Related Groups (DRGs), ICD procedure codes, or Healthcare Common Procedure Coding System (HCPCS) codes. A Service Line is also a reorientation of strategy, resource planning and allocation on the horizontal continuum across provider entities, versus a vertically oriented approach segregating provider types into independent operating units, or silos. The concept is borrowed from a Lean Manufacturing concept know as a Value Stream.

By identifying this tier, a healthcare organization can exploit nonlinear interactions of component parts. Although there are healthcare organizations that have identified Service Lines, few have identified the end-to-end path that a patient experiences. Even fewer have identified what that path should look like, creating clear standards to guide the patient journey. Doing so creates guidelines to synchronize patient care. In our above example, a standard on when to admit and when not to admit a patient would have guided the interaction between the ER physician and the unit physician.

To reinforce the compliance to that standard, a Service Line Manager would be required with end-to-end ownership and authority. For many healthcare systems, a Service Line Manager may be in place, but rarely, owns or has authority to manage the Service Line from an end-to-end perspective. Executives at the Enterprise level must ensure this ownership and authority are granted.

Image 2 – A Service Line takes the perspective of the patient journey

Unit Tier

The next tier up is the Unit. Within a Service Line, there are many Units. Like the Service Line tier, it is critical to identify someone to take ownership and accountability of ensuring the Unit follows the Service Line standards, creating nonlinear interactions of component parts across units, and creates internal Unit standards as well, creating nonlinear interactions of component parts within the Unit. This individual is typically called a Unit Manager. It is worth noting there are typically several shifts within a day. A Charge Nurse can be utilized to have ownership and take accountability of each shift, whereas a Unit Manager can have ownership and take accountability of the overall Unit.

Zone Tier

The next tier is the Zone tier. The implementation of zones has several benefits. The first is a reduction in wasteful motion and transportation of frontline staff. Without zones, frontline assignments can be disbursed throughout a Unit, forcing staff to walk from one end of the Unit to the extreme opposite. This may seem counterintuitive, but, unfortunately, it happens more than it should. By concentrating frontline staff to zones, a practice known as geo-localizing, excess motion and transportation can be eliminated.

The second benefit is that zones create a team environment. A typical Zone has a tech, nurse, and physician that work together. This definition of a team is the first critical step in facilitating emergent, self-organized behavior. Without a defined team the act of self-organizing will not occur. By defining a team, ownership and accountability of a Zone is established. The team now has specific accountability over a set number of patients.

Image 3 – Sample layout with zones

Frontline Employee Tier

The last tier at the top is the most important because this is where patient care is delivered. As such, we must consider what a frontline employee needs in order to do so most effectively and efficiently. This typically comes down to three things: 1) proper staffing, 2) available and working equipment and supplies, and 3) proper training and development. In the Donabedian model created by Avedis Donabedian[2], these categories are known as structural and should be measured to indicate the quality of healthcare.

Image 4 – The three components of the Donabedian Model

Putting the Tier Framework into Use

Once you understand the Tier Framework, it is important to do a couple of things prior to using it. First, it is important to ensure your organization has each tier clearly defined. In my experience, the service line and zone tiers are often a focus. Second, once your tiers are clearly defined it is important to identify who owns and is accountable for each tier. With this completed, the framework can now be effectively used.

Catch-ball

The first reason to use the model is to establish alignment in the organization regarding the direction. In simple words, where are we going? The process to accomplish this is known as catch-ball and is depicted below.

Image 5 – Catch-ball

The Enterprise establishes key measures, typically known as Key Performance Indicators (KPIs), on how to measure organizational success and established targets for service lines to achieve. The service lines, in turn, develop a plan on how to achieve those targets. This is repeated throughout all the tiers until we reach the frontlines. Upon completion of this process, the owner of each tier should be able to clearly articulate what they are responsible for achieving both in plan and in measure.

Daily Management

Once everyone is aligned, frontline staff begin to deliver patient care per the plan developed. As we know, obstacles will get in the way. In order to have emergent, self-organizing behavior occur, we need simple rules in place.

For frontline staff, whenever a standard cannot be executed there should be a simple mechanism to alert the person who has ownership and is accountable for the shift, i.e. the Charge Nurse or Unit Manager. This mechanism should be at the point of use where patient care is delivered and should be as simple as pressing a button. The Charge Nurse or Unit Manager should help resolve the obstacle in real-time.

To accompany the button, the frontline staff should have a simple mechanism to capture what obstacle got in their way. I find that having predefined categories that align with the structure category in the Donabedian model of available and working equipment and supplies suffices. This Pareto analysis should be used to pinpoint reoccurring problems that leadership should work to address. If these problems cannot be resolved at the unit level, then they will be escalated to the next tier. This escalation will continue all the way to the Enterprise tier until the problem can be resolved. The goal here is to resolve most problems at the Zone level, i.e. emergent, self-organizing behavior. If new and better ways of working emerge at the Zone level, this should also be shared at the Unit, Service Line, and, potentially, Enterprise tiers, who would then own sharing those best practices with other units and service lines throughout the healthcare system.

Image 6 – Obstacle resolution and knowledge sharing

Summary

According to Jocko Willink, a former Navy Seal and best-selling author of Extreme Ownership: How U.S. Navy SEALs Lead and Win, teams must be broken down into small / manageable size and decentralize command. This allows everyone to have a clear understanding of what they own and are accountable for and to then own it. Healthcare systems need to follow the lead if they are to survive in the current landscape that is growing more and more competitive. For those who see the need, the challenge will quickly transition to designing systems that allow for 1) nonlinear interactions of component parts, 2) emergent, self-organized behavior, and 3) the dependence on simple rules. The Tier Framework is a great place to start.


[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511782/

[2] https://en.wikipedia.org/wiki/Avedis_Donabedian

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