The Forum

A roadmap for achieving ‘systemness’


In an ideal world, health care providers would work collectively and collaboratively to meet patient needs, with minimal fragmentation or redundancy across the system. Systems would be constructed—and reconfigured as needed—to allow for swift adaptation in response to external pressures such as demographic changes and decreasing budgets.

Sadly, this is seldom the case. What we most often see is tremendous redundancy in the system, which often leads to poor patient experiences and outcomes—which makes sense since provider incentives have historically emphasised volume over value. However, we also see that governments and payers are increasingly stepping in with mandates and reforms that attempt to 'unfragment' the system. Some common mandates include:

  • Reallocate services across a geography
  • Meet minimum volume thresholds
  • Assume greater financial risk
  • Partner across the continuum
  • Standardise clinical services
  • Implement system-wide IT solutions

This work is important, but often overwhelming. Any CEO tasked with one or more of these directives can be left asking: What is the end goal of what I'm trying to achieve here? Which project do I attempt to tackle first? And how do I know if I'm on the right path?

As we have researched best-in-class systems—Intermountain, Ribera Salud, Gesundes Kinzigtal, and others—we have found that they each unlocked considerable benefits by staging out the level of system cooperation over time and building on work streams in a particular sequence that progressively gains political buy-in. This path is a journey towards 'systemness,' where every partner, facility, and staff member that the system interacts with is harmonised such that when combined, they operate as more than the sum of their parts.

Distinct and staged benefits of working as a system

First, systems start by working together to achieve an operational benefit. These are the gains realised by centralising business functions such as procurement, HR, and finance. Most systems understand that this is a smart first step to reduce redundancy and begin collaboration. For that reason we think of this as a baseline—the bare minimum on your systemness journey.

The next step is where we see many systems currently focusing their efforts: clinical benefit. Here the focus is on working with clinicians to create, communicate, and adhere to mutually agreed upon system-wide clinical standards. This work is much more complex and often more contentious than back-office consolidation, but gains are more persistent. Pursuing a clinical benefit is helped by first demonstrating success through back-office consolidation.

The third step is working together for structural benefit, which refers to the gains associated with footprint rationalisation and effective allocation of capital. The benefits from rationalising your fixed cost base can be sizeable. But this work is far more politically contentious, so it's important to have achieved buy-in from doctors through clinical standard creation before attempting to reconfigure services.

Finally, this preceding work positions systems to work towards true transformational change, and reap the corresponding benefits. This is achieved when you've ensured that every component of your health delivery model—the staff, the operations, and the footprint—have all been optimised and harmonised. It's here that you're ready to transition your collective effort towards new objectives.

In today's health care environment, we most frequently see this transformation as one of assuming greater responsibility for population health management. The transformational benefit—where you and your partners have to become adept at managing collective risk—is optimised only when you've unlocked all of the preceding benefits.

Now what?

This roadmap captures the 'what' of systemness and gives a sense of the path you should take to achieve it. Yet we often hear from our members that the 'what' becomes clear long before the 'how.' Regardless of where you are along the journey, we see three consistent areas where you should focus your time and energy—determining who has the authority to do what, engaging and enfranchising key stakeholder groups, and ensuring your system wide information is maximally usable.

These three areas have been the focus of the Global Forum's research this year. Over the next few months, through Chief Executive Roundtables, onsite presentations, research briefings, and blogs, our team will share our insights on these three areas, as well as case studies of groups that have done it the best.

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