The perspective taken here is that such a focus, while urgent, often misses two important issues that, if not addressed, could negate or neutralize the benefits of reform and have broader long-term consequences. First, much of the focus of healthcare reform and affordable care has been on “accountable care organizations” (ACOs) (Meyer, 2011; Devers and Berenson, 2009). ACOs are the instrument through which Medicare reimbursement will occur and how providers are being encouraged to collaborate to achieve lower costs and higher quality. The focus has NOT been on how such organizations are to be designed and there is a dearth of research, case studies, and other efforts to describe the organization designs that will be necessary – even essential – to meeting the objectives of healthcare reform. Second, with the focus on the financial side of reform, environmental and social responsibility issues are receiving less attention. The healthcare industry, in the largest sense of the term, is responsible for an enormous amount of social and ecological consequences, both good and ill. An effective healthcare industry promises important improvements in the quality of life; but an ineffective industry destroys lives, families, and communities and dumps or leaves excessive amounts of toxins in the environment. By not attending to the design of the organizations that will deliver care and their ability to support or generate positive social and ecological consequences, we will have missed an important opportunity to affect change. The purpose of this chapter is to describe how the design concepts of agility, adaptability, and sustainability can be used as appropriate “design criteria” (Mohrman and Cummings, 1989) for healthcare systems. Although designing for agility and sustainability are addressed within a U.S. hospital system, the importance of the issues extends well beyond those borders. Sustaining economic, clinical, social, and ecological outcomes requires the ability to adapt no matter what the regional, regulatory, or cultural context. Healthcare systems everywhere can benefit from the
initiatives that came out of these conversations – quality and technology – would become important pillars of Alegent’s sustainable design. While both quality and the electronic enablement of care had been on-going programs within Alegent, the DAs helped re-focus and their purposes and implementations. On the quality side, at about the same time as the initial DAs were being implemented, Alegent’s board was asking the CEO, “How are we holding Alegent accountable for the quality of care we provide?” (Maas, 2008). The question generated important discussions at the board level, initiated a strategic planning effort, and resulted in “The Quality Revolution” strategy. As part of the plan, the board renamed the Professional Affairs Committee – which had been responsible for quality but spent most of its time on credentialing – to the Patient Safety and Quality Committee. Internally, and partly as a result of his experiences in the original DAs, the chief medical officer kicked off a revitalized quality effort with a 2½-day quality DA. Aligned with the clinical service line visions, it developed a list of the market and other environmental trends in quality to create an internal quality strategy. Then, the DA helped to support physicians in building a process and framework they could own to drive evidence-based care across the hospital system. The CMO took the DA results and realigned the medical staffs at the hospitals. At the time, there was no organized way to bring the different medical staffs together. Utilizing a “mirror organization” concept, each hospital medical staff used the same structure – a quality council composed of the chief medical director, vice chief medical director, and other physicians. The leaders of the hospital quality councils sat on a governance body – the Physicians Leadership Council (PLC) which reported directly to the board as part of the Quality Revolution strategy. Part of that governance process was a routine for developing “evidence-based” care
Galbraith, J. R. (1994). Designing organizations: An executive briefing on strategy, structure and process. San Francisco: Jossey-Bass. Galbraith, J. R. (2005). Designing the customer-centric organization. San Francisco: Gillies, R., Shortell, S., Anderson, D. Mitchell, J., & Morgan, K. (1993). Conceptualizing and measuring integration: Finding from the Health Systems Integration Study. Hospital and Health Services Administration, 38(4), 467-489. Goldman, S., & Graham, C. (Eds.). (1999). Agility in health care: Strategies for mastering turbulent markets. San Francisco: Jossey-Bass. Haeckel, S. (1999). Adaptive enterprise: Creating and leading sense-and-respond organizations. Boston: Harvard Business School Press. Hanna, D. (1988). Designing organizations for high performance. Reading, MA: Hoffman, A. J. (2010). Climate change as a cultural and behavioral issue: Addressing barriers and implementing solutions. Organizational Dynamics, 39(4), 295-305. Howell, W. (2011). Business intelligence: Key to hospital’s sustained success. Retrieved January 24, 2012 from Lawler, E.E. (1986). High-involvement management. San Francisco: Jossey-Bass. Lawler, E.E., & Worley, C. (2006). Built to change. San Francisco: Jossey-Bass. Lawler, E.E., & Worley, C. (2011). Management reset: Organizing for sustainable effectiveness. San Francisco: Jossey-Bass.
Table 1 Design Features of an Agile, Sustainable Organization Design Feature Description Supporting Sustainability Board Composition and Purpose Board members that represent an organization’s multiple stakeholders and the information required to balance outcomes across those stakeholder demands Clear Long-term and Short-term Strategies A sustainability-oriented and change-friendly identity consisting of internal values and an external brand/image/reputation that explains long term success and a triple bottom line objective Short-term strategic intents that describe how the organization will win – across financial, social, and environmental outcomes - in the current environment Flexible Structure, Lateral Coordination, and Ambidextrous Work System A structural form that places organization members in contact with the environment and results in a strong external focus A flexible, lateral decision making, operating, and resource allocation process The ability to support both traditional and innovative work designs Talent and Performance Management A philosophy and practice of shared leadership reinforced by performance management systems that measure and reward sustainable activities Change and Learning Capabilities The ability to implement organization change, especially the transition from one strategic intent to another, and the ability to apply past learnings to current operations. Table 2 Alegent Health and Sustainable, Accountable Design Criteria