Wang, Hyun, Harrison, Shortell, and Fraser (2006) found the following factors to be criti- cal to successful care design in a context of system change: (1) directly involve all leaders at all levels; (2) strategically align and integrate improvement efforts with organizational mission and priorities; (3) systematically establish infrastructure, processes, and perfor- mance appraisal systems for continuous improvement, and (4) actively develop champi- ons, teams, and staff.
Various professional healthcare organizations have also proposed models. For exam- ple, the American Association of Critical Care Nurses and the American College of Chest Physicians developed two complementary initiatives, the Standards for Establishing and Sustaining Health Work Environments and the Patient-Focused Care Project. Both projects propose processes to create new interdisciplinary practice environments. They call for new practice and education structures to integrate selected aspects of medical and nursing education in order to promote respect and knowledge about each other’s discipline, new ethics committees, and creating structures to position medical directors and nurse managers as peers with equal accountability for clinical outcomes and team performance (McCauley & Irwin, 2006; Reineck, 2007). Implementation would include interdisciplinary patient rounds, mechanisms for respectful interdisciplinary approaches to competence issues, and team building. Parsons (2004; Reineck, 2007) also proposed a Health Promoting Organizations Model for systems change that includes unit-shared leadership, participatory management, and empowerment of staff nurses.
The care designs of the next generation will likely continue to recognize structures, processes, and outcomes of provider interactions with each other and with patients, but they must genuinely reflect care across disciplines and settings. Silos of medicine, nurs- ing, and other healthcare disciplines simply will not work anymore. As systems become more integrated, “The old compartmentalized and segmented system of the 20th cen- tury is no longer viable to the content and mechanics of a complex and technologically driven healthcare infrastructure. The emerging realities of a 21st century model of health care are changing all the rules for service delivery and clinical relationships” (Porter- O’Grady, 2001, p. 64; Porter-O’Grady & Wilson, 1999). Interprofessional collaborative practice promotes team identity, conserves energy by a unity in direction, and invites harmony of efforts. Respect and peer collaboration promote a complementary matrix of authority and shared purpose (Ives Erickson & Ditomassi, 2008; Senge, 1995).
Essential elements to successful implementation of innovative care models also include continued intentional communication and a sensible business plan. Poor or inadequate communication within the organization and among outside constituents can quickly kill any new idea. Furthermore, any new model must also exhibit a healthy respect for business. It must be strong, formal, and rigorous. The plan should include analysis of assumptions, strategy, operations, resources and management, evaluation, and even a
contingency plan (Morjikian, Kimball, & Joynt, 2007). The business plan must show a mechanism for projecting and evaluating cost savings and organizational mission sup- port. Some examples of such models of care include the Primary Care Team in Austin, TX, that showed a reduction in staff turnover by 64% (Batcheller, Burkman, Armstrong, Chappell, & Carelock, 2004; Morjikian et al., 2007) and the Transitional Care Model in Pennsylvania that reduced readmission rates, inpatient costs, medical complications, and mortality while improving patient and physician satisfaction (Morjikian et al., 2007;
Naylor, et al., 1999, 2004).
When creating a team to implement change, it is especially important to include as many views and as many representatives as possible. Any group or faction that is not included will surely emerge at some point to resist or sabotage. Wheatley (2001a) further admited, “I haven’t become insistent on broad-based participation just to avoid resis- tance. . . . I’ve learned that I’m not smart enough to design anything for the whole sys- tem. None of us these days can know what will work inside the dense networks we call organizations. We can’t see what’s meaningful to people, or even understand how they get their work done. We have no option but to ask them into the design process.”
Practice redesign that really works can happen only when it is done by a community.
A group of people with shared interests and a desire to solve a problem can do anything.
I am still looking for us to find the courage and creativity to include actual patients in the design of our care and practice models. Kerfoot (1998) quoted Kao (1996, p. 194),
“Change is the sum of a thousand acts of re-perception and behavior change at every level of the organization.” Wheatley (2001a) further observed:
Every change, every burst of creativity, begins with the identification of a problem or op- portunity that somebody finds meaningful. As soon as people become interested in an issue, their creativity is instantly engaged. If we want people to be innovative, we must discover what is important to them, and we must engage them in meaningful issues. The simplest way to discover what’s meaningful is to notice what people talk about and where they spend their energy.
To engage a community in the creative design of care systems, it is most helpful for the leader to work beside, rather than above, those most involved. Wheatley (2001a) confirmed, “I need to be working alongside a group of individuals to learn who they are and what attracts their attention. As we work together and deepen our relationship, I can then discern what issues and behaviors make them sit up and take notice. As we work together, doing real work, meaning always becomes visible.”
To survive as the creative leader who designs new care systems from an entrepre- neurial perspective, you must choose a work environment that will support and encour- age your efforts, and you must know your organization. Kerfoot (1998, p. 181) warned,
“Creativity does not exist in hostile environments where all of one’s time is spent think- ing about survival.” Part of your job as leader is to develop a culture and context that fosters creativity. Kerfoot (p. 181) outlined some basic functions of the leader to promote a fertile environment for creative thinking and invention: “promoting conversations and dialogue; providing access to information; building relationships across disciplines;
teaching, re-perceiving, rethinking, questioning, innovating; creating a culture of inno- vation; orchestrating and executing.” Beyond such characteristics, some “organizational agility” is helpful to understand the culture and strategize what will actually work in the specific organization (Morjikian et al., 2007).
Care redesign requires an attitude of entrepreneurial innovation. Some think that this is simply a personality style among creative thinkers. But innovation actually happens much more systematically from the recognition of a problem crying for a solution or an opportunity for positive change.
Drucker (1998) outlined four areas of opportunity for innovation: unexpected occur- rences, incongruities, process needs, and industry and market changes. Others include demographic changes, changes in community perceptions, and new knowledge that changes circumstances. Unexpected occurrences include unexpected failures as well as successes. Drucker shared the example of the Ford Edsel, which is the most famous fail- ure of a carefully designed car in the modern automotive industry. Analyzing that fail- ure, the people at Ford realized that the American market had moved from the expected income-group basis to the unexpected lifestyle focus, so they recovered by developing the Mustang and thus resumed, at that time, their leadership in the industry. An example of the inability to recognize an unexpected opportunity for success is the German scien- tist Einhorn who, in about 1904, developed novocaine, the first nonaddictive narcotic. He intended its use in major surgical procedures such as amputation. Surgeons continued to prefer general anesthesia, but dentists quickly adopted the new novocaine. Nevertheless, Einhorn spent his life as a traveling preacher from dental school to dental school warning to stop “misusing his noble invention in applications for which he had not intended it”
(Drucker, 1998, p. 152).
Incongruities in practice also provide opportunities for invention. Drucker (1998) gave the example of the surgical procedures of removing cataracts. A major incongruity of the procedure was the step of cutting a ligament—so incongruous with the rest of the procedure that surgeons reportedly dreaded it. Although they knew of an enzyme that could dissolve the ligament, it was unusable. Alcon laboratories simply found a way to add a preservative to the enzyme to make it usable to the surgeon, immediately making the procedure more congruous with the processes of the operation, the operation became more common, and Alcon subsequently became the wealthy monopoly of the relatively simple drug (Drucker, 1998).
Other simple, but perplexing, realities of the work can promote invention. Process needs invite innovation, and healthcare leaders are experts at recognizing them. There are dozens of examples within your own healthcare setting. Do we work around them, or do we take them up as opportunities for innovative models? Industry and market changes continually provide opportunities for innovative approaches to healthcare delivery and leadership. A mere count of new and emerging healthcare provider settings in the last couple of decades provides a good example: indepen- dent centers for imaging, surgery, and instant care; health maintenance organiza- tions; and new models of free-standing psychiatric hospitals and clinics are some examples (Drucker, 1998), as well as nurse-managed clinics and community health centers.
Care models should endure beyond a time enough that they are not simply trendy re- sponses to current practices; they should fit within the mission and strategic plan of the organization and be based on evidence (Wolf & Greenhouse, 2007). One of the biggest challenges to design a new care model is the ongoing 7-day 24-hour consistent patient care that must be sustained through the midst of change. O’Reilly and Tushman (2004) suggested that an organization might separate exploratory innovation units from other existing traditional units to allow for different processes, structures, and cultures. Thus, it is possible to sustain one unit of service by gentle tweaking at the same time another
team is diving into full-speed change and redesign. The authors referred to such an orga- nization as “ambidextrous,” but warned that the units must be tightly integrated at the executive leadership level. In other words, we cannot be running two businesses at the same time, but we also do not have to do everything at once. We can recognize a variety of processes and cultures within the stewardship of our leadership.
Finally, leaders of new models of care must always pursue the perspective of the broader organizational culture, mission, and strategic planning; they will identify cham- pions for success of the plan and extend creative authority, will engage internal and external interdisciplinary team members and allies, and will identify opportunities for internal and external formal partnerships. They will take care to prepare contingency plans for resistance (Morjikian et al., 2007), and they will take the perspective of the en- tire organization and system.