On April 13 and 21, we are hosting our Systemness 2.0 workshop for international chief executives, and as we approach these sessions, we take a look back at some of the key insights learned from our previous workshops in 2017. This gives us an idea on what has changed, what hasn't, and how far systems have come along the systemness journey. Back in 2017, we saw a few common themes emerge.
1. Don't run too far too fast.
Perhaps the most discussed section was about the different benefits that accrue by pursuing systems initiatives.
Best-in-class systems pursue integration efforts in stages, and efficiencies increase as they work through the stages, which are increasingly contentious and complex. It is understandable that we gravitate towards steps that have the potential for greatest efficiencies—for example, the "structural benefits" achieved by efforts such as rationalizing services. As such, many systems, payers, and governments run to these structural benefits first.
But our research shows that there's more to "systemness" than paring down your footprint. Our members saw the importance of fully investing in operational and clinical efficiencies, rather than jumping straight to structural efficiencies. This approach builds political capital and trust through less contentious initiatives, setting you up for greater success when you do move on to more complex and contentious initiatives.
2. Determine governance structure based on decision making, not reporting.
When determining governance for a systems initiative, many ask the question, "Who needs to report to whom?" So, they develop an org chart—but while org charts can be helpful, they don't get at the core need: to make decisions. A different approach is needed.
The most critical step is to first inventory the decisions that need to be made for your systems work. Then you can delegate authority based on who is best situated to make each decision.
One helpful way to think about this approach is to allocate decisions related to direct patient care to those closer to patients, while allocating decisions related to strategy to those closer to the system. Said differently, give the operational power to those closer to the local level and the planning power to those closer to the system level. In short, make your governance about the work you're trying to accomplish together, and allocate authority accordingly.
3. Identify opportunities for sweeteners before jumping to penalties.
Because network integration efforts are often politically contentious—not to mention genuinely complex—we need tools to encourage progress in the work. If we believe or know that we will face pushback to the work, we tend to run straight to penalties or "sticks" to enforce change.
However, best-in-class systems use penalties sparingly, instead utilizing "sweeteners" or "carrots." We see this succeed through a variety of tools, such as developing shared principles to guide the work, or extending shared resources. Many of our members gravitated toward the idea of encouraging participation by first identifying what their partners might need that they could provide. Such "sweeteners" range from donating staff (e.g., senior clinicians who would be valuable to the project) or giving free rent, to providing back-end office support or lab services.
Get to know what your network partners need and entice their participation by sweetening the deal.
What systemness looks like today
Now, four years later and in the throes of a pandemic, systems-level thinking has gone from a "nice-to-have" to a "need-to-have." Our current research cycle finds executives focusing on hardwiring new and beneficial ways of working to sustain systemness gained during 2020 into their day-to-day operations.