Patients, populations, and caregivers: opportunities and challenges at the intersection.

Indeed our world is changing, and Dr. Eugene Nelson and his colleagues present a marvelous glimpse of the future, the trends likely to have an impact on healthcare, and a model for managing care for individual patients and small populations by focusing on the front lines of patient care. As they describe it, ". . . where patients, populations, and caregivers meet." The approach builds on the essential quality characteristics of price, choice, service, and outcomes quality, and shifts our focus from the configuration of larger delivery systems to the operational units within the system responsible for the actual provision of services. These are the units that make a difference in the cost and quality of care provided. My commentary will focus on some of the managerial and research opportunities for understanding, learning, and improving that occurs when we focus on a more "microunit" within the larger delivery system, and some of the challenges that remain as we begin "move[ing] care management to frontline microunits .... " While a good share of the healthcare world is focused on vertical integration, aligning physicians, developing community partnerships, and other macrolevel activities, the microunit approach presented here and by others (Christianson, Taylor, and Knutson, 1998) moves us to the "molecular level" of organizations and defines the provision of services in more operational terms. It provides an opportunity for managers to think in terms of units that can, in fact, be managed and continually improved over time. Managerial Opportunities The focus on microunits permits the application of knowledge about groups and their coordination in very operational terms such as diagnosing their stage of development, assessing the prevailing climate and culture, and understanding the process characteristics such as conflict and leadership that affect their performance. For example, considering just the idea of stages of group or unit development le.g., forming, storming, norming, performing, etc.) permits managers involved with a microunit approach to stage the unit as part of a life cycle process and thus anticipate possible problems normally associated with that stage of development; and, depending on the stage, have realistic expectations of what should be happening within the unit. Given this diagnosis-and it is recognized that it is not possible to predict with certainty that all units will proceed through the various stages-the staging provides a guideline to help develop appropriate intervention strategies to improve unit performance Fried and Rundall 1994). By focusing on microunits within healthcare organizations, managers also have the opportunity to become much more dynamic and strategic in their decision making. Such small, relatively homogeneous units can be adapted rapidly to shifts in consumer and purchaser demand, clinical innovation, and market competition. Through the active management of microunits, managers can enhance their organizations' responsiveness to new and evolving information about patients, populations, competitors, and best practices in healthcare. Microunits also offer expanded opportunities for customizing organizational practices to the needs of smaller, more homogeneous groups of consumers (McLaughlin and Kaluzny 1997). Such strategies may allow organizations to ensure higher overall levels of consumer satisfaction and loyalty. Research Opportunities The microunit approach also makes an equally important contribution to the health services research community. By focusing on a smaller unit of analysis, it permits the analysis of fundamental processes both within and between units that would not be possible when the larger organization is defined as the unit of analysis. Using microunits as analytical constructs, researchers can look inside the black box of organizational performance and identify key clinical and administrative leverage points. …