Bringing Value:  Key Thinking to Help Get with the System

To be a more effective leader, take a harder look at “system thinking.” And start by gaining deeper insight into the vital elements of your organization.

Every organization has key work systems. Physician leaders need to know what they are, because they’re what enable their organizations to conduct business.

This understanding is so important that, in 1999, the Accreditation Council for Graduate Medical Education adopted six required core competencies for residency training programs — and one of them is the understanding of “systems-based practice,” which essentially encompasses the key work system concept.

EDITOR’S NOTE

This past August, we learned that Eugene Fibuch, lead author of the “Bringing Value” column since 2016, died after a long fight with cancer. An AAPL member since 1999, Fibuch submitted more than a year’s worth of columns in advance, and we will continue to publish the series under his byline for the foreseeable future. We send our condolences to his family, friends and colleagues.

A system can be defined as a collection of interdependent elements that interact for a common purpose.1 An important concept in that definition is “interdependence,” which suggests each component of a system can influence other components in either positive or negative ways. Additionally, it suggests that a functioning system is designed to achieve a common purpose — a product or service that meets customers’ needs.

Accordingly, physician leaders should take to heart two critical words found in the key work systems concept — “key” and “work.” The overall concept provides an important operational framework for leaders. The word “key” refers to a particular element within it so critical to the organization that, without it, the organization could not exist. The word “work” refers to how the organization’s service or product actually gets produced.

An excellent definition can be found in the Malcolm Baldrige National Quality Award criteria, which state:

Work systems involve your workforce, your key suppliers, your partners, your contractors, your collaborators, and other components of the supply chain needed to produce and deliver your products and services and your business and support processes. Work systems comprise the internal work processes and resources necessary for you to develop, produce and deliver your products and services to your customers and to succeed in your marketplace.2

Nine Categories

The Baldrige definition might seem too theoretical or academic, so an easier way to frame the idea is by categorizing all the work that needs to be done in the organization. There are at least nine general categories of work systems in all organizations that need to be aligned and functioning to achieve value for customers.3 They are:

• Staffing and maintaining your workforce.

• Training your workforce.

• Measuring the performance of work processes and outcomes.

• Rewarding staff members and promoting them appropriately.

• Reviewing and updating organizational design on an ongoing basis.

• Communicating to your key stakeholders.

• Developing and maintaining your information technology and knowledge management processes.

Two additional systems underpin the previous seven:

• Leadership.

• Strategic planning.

Physician leaders should understand that key work systems, as opposed to general work systems, are strategic in nature. Key work systems have multiple work processes that define an organization’s value-creation practices. This is important because these processes relate to maintaining overall productivity of an organization. Work processes can include product and service design, delivery of products and services, customer service, supply chain management and other business support processes.2

The concept of key work systems and their related processes is best illustrated by an example put forth by the Baldrige Performance Excellence Program:

“Consider a company that produces electronic widgets for the consumer marketplace. The decision on how to research, design, manufacture, distribute and service these widgets are key strategic decisions.

“Will you use contract research, or will you do research in-house for your next-generation product? Will you manufacture the widget yourself in your own facilities, or will you contract out the manufacturing? What subassemblies do you feel comfortable procuring through your supply chain, and what do you want to make in your facilities? Will you use your own sales force to reach the consumer marketplace, will you work through distributors who sell to retailers or directly to consumers, or will you use a combination of the distribution mechanisms?

“These decisions can have a major impact on how you protect intellectual property, how large your workforce will be, how many facilities you will own, your organizational design, and how your carbon footprint and you will meet your commitment to society.”2

Health care organizations, like most other organizations, typically have five to seven key work systems critical to their overall functioning.2 These might include:

• Leadership.

• Strategic planning.

• Customer relations.

• Knowledge management or IT.

• Process or operational management.

• Human resources.

• Measurement.

Each of these key work systems can be further divided into subsystems that vary by what the company does.

Built to Serve

Not all key work systems are equal in terms of their organizational impact. Within the Baldrige management model, the systems of leadership, strategic planning, customers and markets, human resources, information and knowledge management, and process/operational management are framed in such a way that leadership, strategic planning and knowledge management support the others.

A similar conceptual model views key work systems in such a way that the environment, the infrastructure and the strategies of the organization frame and support the other key work systems.3 Within this conceptual model, all key work systems should be aligned based on the strategic goals of the organization. It’s also important to remember that work systems have social and technical components; therefore, the functioning of individual work systems depends heavily on an organization’s tools, human capital and training to serve its customers.

Key work systems, by their fundamental nature, should dictate the development of the organization’s strategic plan. While working to help define that, physician leaders should keep in mind how their organization’s key work systems impact the organization’s overall strategy.

Work systems exist in a planned state based on how products or services are rendered to customers. However, they can adapt to changing or unplanned factors over time. This suggests that work systems are dynamic and able to change within a learning organization.

The Role of Physician Leaders

So how do physician leaders begin to understand and frame their organization’s key work systems? The process begins by understanding their organization’s mission statement4 — a formal summary of its aims and values — because the nature of an organization will drive the complexity of its work systems. (Compare, for example, a freestanding clinic to an academic medical center.)

Next, physician leaders should engage other leaders in a conversation about work systems so that everyone is on the same page regarding their understanding of how the organization is structured. A well-regarded way to bring senior leaders to a higher level of learning is to use a Six Sigma tool called kaizen. A Japanese word, it essentially means continuous improvement in all aspects of life. In business, it often is used during multiday, off-site workshops for senior leaders, known as a “kaizen blitz” and led by trained facilitators.5

Such an event helps senior leaders work together, define key work systems and align key work systems into a functioning whole. Accurately defining and aligning work systems allows for harmonious function of the organization. Once senior leaders understand how work is carried out in an organization, they can help link work systems to the mission of the organization and assure alignment within the strategic plan. Senior leaders should also always remember that they should never work in silos, as working together helps bring value to organizations.

Aligning on Alignment

All key work systems and their related subsystems should have similar work processes, measurement architecture, improvement methodology, etc., across the entire organization.4 That’s alignment, a key principle for any organization that seeks to bring value to its customers.

For systemic alignment, key work systems should comprise similar measurement styles, such as the same balanced scorecard or the same performance improvement methodologies throughout the entire organization.6

Fundamental to this idea is that well-functioning organizations have clear strategic objectives with defined action plans and accountabilities across all work systems. This framework reduces the development of silos within the organization. Outside of creating and sustaining a clear vision for the organization, creating alignment within the organization is a fundamental leadership task.6

Once you have defined your organization’s key work systems, then each work system needs to be dissected into its component subsystems and subsubsystems. Depending on the complexity of your organization, you might need to dig deep to understand how work really is accomplished.

This exercise is tiring and time-consuming, but it’s worth the effort. It will give you a much better understanding of how your organization does its work and delivers value to your customers.

Why You Should Care

Understanding key work systems and placing ongoing performance improvement efforts into them is important for several reasons. First, work is dynamically changing, and senior leaders must keep abreast of changes that affect organizational function. Second, most errors in health care are the result of process errors.7 Work systems are composed of interrelated and, in many cases, simultaneously functioning work processes. Understanding your work processes can reduce patient errors, improve efficiency and cut costs.8

Another significant reason is because approximately 85 percent of variability — and therefore the potential for error that occurs within these processes — is because of the system itself.9 Variability has the potential to create latent and actual errors in patient care. This is not only a safety issue but also an efficiency issue, which can result in lost profits.

With the concept of key work systems now framed, physician leaders can begin the process of “system thinking.” That’s a way to view the interrelationships between the various processes of care and the functioning whole.10

In many respects, it’s how humans have interacted since the dawn of mankind. For example, system thinking is required to figure out the complicated relationships that exist in families and communities. Over time, system thinking also has become an important and sophisticated approach to the management of modern organizational life.11

In health care, systems of care are complicated. Yet, in many cases, these systems are loosely linked and are dynamic in nature because they are rapidly changing. Physician leaders who use system thinking and frame their organizations using key work systems will benefit their employers in ways that markedly improve efficiency and promote safety.

Eugene Fibuch, MD, CPE, CHCQM, FACPE, FABQAURP, was professor emeritus at the School of Medicine and co-director of the physician leadership program at the Henry W. Bloch School of Management at the University of Missouri in Kansas City.

Jennifer J. Robertson, MD, MSEd, FAAEM, is an assistant professor in the emergency medicine department at Emory University in Atlanta, Georgia.

REFERENCES

1. Guralnick S, Ludwig S, Englander R. “Domain of Competence: Systems-based practice.” 2014. Academic Pediatrics. Vol. 14 (2S), March-April. pp. S70-S79.

2. Hertz H. A Reflection on Work Systems. nist.gov/baldrige/publications/archive/insights_0812.cfm .

3. Senge P. The Fifth Discipline. Doubleday. New York, NY.

4. Alter S. “Work System Theory: Overview of core concepts, extensions, and challenges for the future.” 2013. Business Analytics and Information Systems, USF Scholarship Repository. Vol. 14 (2), pp. 72-121.

5. Hurta D. “Managing Changing Projects, Processes and People.” 2007. Advanced Manufacturing Specialist Training Program. Rolla, Missouri.

6. Holden RJ. “Lean thinking in emergency departments: A critical review.” 2011. Ann Emerg Med. 57 (3): pp. 265-78.

7. Russell JP (Ed). The ASQ Auditing Handbook. 4th ed. 2013. American Society for Quality. Milwaukee, WI.

8. Nolan TW. “System changes to improve patient safety.” Br Med J. Vol. 320 (7237): pp. 771-3.

9. Reid PP, Compton WD, Grossman JH, et al., editors. “A framework for a systems approach to health care delivery. Building a better delivery system: A new engineering/ health care partnership.” 2005. National Academies Press. Washington, DC.

10. Waissi G. “On healthcare reform — A system engineering approach.” 2010. Decision Sciences Institute Conference Proceedings. San Diego, CA.

11. Trochim WM, Cabrera DA, Milstein B, Gallagher RS, Leischow SJ. “Practical challenges of systems thinking and modeling in public health.” 2006. American Journal of Public Health. 96 (3), pp. 538-546.