Importance of Alignment in Healthcare – An Overview

It is not a rosy picture. The landscape for healthcare in the United States and many countries across the globe is in a tremendous state of stress. Inadequate access, soaring costs, and less-than-optimal quality permeate the reality of health delivery in its current state. Health systems are experiencing mounting pressures of competition and slimming margins that have been accelerating for years and are now punctuated by the impact of the COVID-19 pandemic. Workforce challenges are ubiquitous, highlighted by nursing and nonclinical worker shortages and an impending crisis of physician shortages. Healthcare consumers frequently experience inadequate preventive care, critical delays, debilitating costs, and less-than-desired health outcomes. While reviewing quality and cost, we see example after example of less than the acceptable value in the care that healthcare institutions deliver and that we, as individuals, receive.

We also see significant business changes in healthcare as we know it. New market entrants disrupting traditional healthcare models are emerging. Consolidation in the health sector is increasing, and communities and individuals are often experiencing a contraction of services. Some of this is rational and necessary for optimizing high-value care. Some of this is less than ideal, and a consequence of the longstanding poor design of healthcare delivery. For a service that is so critical to all persons, such changes in our industry are a cause for increased focus and attention.

The current state of healthcare in most locations is incredibly inefficient and not customer-focused. However, it is also true that healthcare is ripe for redesign and must change moving forward. We are indeed sitting on a precipice, and the direction that healthcare evolves will have longstanding implications. Moreover, this is an exciting time for innovation and technology in healthcare organizations as they strive to achieve higher value. It is time for the status quo to be left behind, which is happening quickly.  

For leaders of health systems, while our environment is rapidly changing and, in some cases, deteriorating, we face several imperatives. First, it is a time for courageous leadership. Addressing the day’s challenges while striving for and ultimately achieving high-value care is an absolute must. This must be done while sustaining a viable financial model to assure sustainability in our services and offerings to those we care for. The health of our communities and the financial viability of our economy both depend upon this.

As our market conditions change, we must embrace new models for care delivery, stabilize and support our people, and align payment reform with value. We need to foster courageous and committed leadership. Critical decisions of significance should arise from careful consideration and optimally with input from key stakeholders and those with direct care expertise. It is no longer acceptable to focus time on fighting fires without attention to the long term good that must arise from embracing new partnerships and opportunities. Our work must focus in order to avoid a lack of forward progress in the future. Furthermore, to succeed, we must work differently and effectively as an aligned team working towards a common goal. 

Alignment

Healthcare is an incredibly complex industry. We all work in a highly challenging environment with many players, often competing objectives and fierce competition. That which unites all of us in healthcare, both clinical and nonclinical, is the desire to help others. It is the imperative during this time of crisis that we address head-on the inadequacies present today. First, we must address absent or delayed access to care. We must improve and ultimately achieve affordability. Finally, we must pursue excellence in outcomes in every aspect.

Moreover, we must do this in a long-term sustainable manner. Our industry is about service to the patient, now much more appropriately identified as the “customer,” acknowledging that such an individual has purchased goods or services, in this case, at a hefty price. The customer must always define value and those of us in the industry must strive to provide the value defined by that customer.

Many key constituent groups dedicate their work to our delivery models. Some critical groups include nursing staff, operational leaders, and a variety of other frontline workers. These groups provide critical skilled services, are ultimately managed by the executive teams, and require meaningful support for optimal success. Other vital groups include the Board of directors, the CEO and executive team, and physicians. It is worth noting that the members of these groups who interface regularly do not always work in synchrony. At times we have found each group with important focus but with a misalignment of efforts.

The Board frequently focuses on the community and the system’s health to sustain service to the population served. The Board also has fiduciary responsibilities and seeks organizational success while assuring the highest level of achievement in safety and quality. The leadership team has a similar focus, with the additional responsibility to ensure effective execution to achieve such targets. Moreover, such leaders are frequently distracted or even overwhelmed by the challenges of everyday operations, with many obstacles to encounter daily. This includes managing an increasingly frustrated and strained workforce. Individual healthcare workers and providers are pressured to care for the person directly before them without adequate time or tools. Also added to this is the stress of work-life balance, record-high debt, and the reality of facing customers who are increasingly frustrated with their experiences while encountering our systems.

Given the continuum of perspectives from constituent groups and striving to achieve common ground, alignment in focus and priorities is now more critical than ever. All groups need to work together to eliminate distractions that pull away from the much-needed focus on how to serve the customer best.

In order to achieve alignment and to be able to work cohesively, a commitment to inclusivity, transparency, and effective communication is critical. Inclusivity is required for optimal engagement and, ultimately, optimal improvement. When important decisions are made, it is rarely clear that there is one right pathway. Often such decisions are made by well-intended leaders, acting on behalf of the greater good. It is also true that the expertise and perspective of those involved should be embraced more optimally. To achieve optimal improvement, it is imperative, while addressing a situation, that parties with expertise are involved in the process to improve. This is critical to achieving the best course of action but is just as crucial in establishing and feeding trust between the groups. Overall, even with added complexity and, in some cases, a delay in moving forward, the time and effort to include vital constituent groups is typically worth much more than can be measured.

Similarly, when decisions are made, it is critical to be transparent with partners. It is acknowledged that frequently a particular decision may only be popular to some or with which some may have significant concerns. The act of not sharing a necessary approach may lead to a lack of trust and active disengagement. In most circumstances, sharing transparently a plan being pursued and the why behind such decisions and approaches will foster engagement and trust, even among those who may not fully agree with such a decision or plan. Without sharing information, some will create their own narrative, which may sometimes be inaccurate and harmful to forward progress. An emphasis on effective communication and sometimes an effort to overcommunicate may be necessary or even optimal in many circumstances.

Board Role

The Board of Directors’ role is to assure sustained commitment to the community, to govern safety and quality, to support strategic initiatives, and to assure operational execution by those who have been empowered to do so. Most organizations think of the Board of Directors as being at the organization’s top. However, to be structured for success in the future, an organization should consider its Board to be in a supporting role, holding up other vital parts of the organization from below. This entity must set the stage and expectations for alignment throughout the organization.

To execute its imperative, a Board must first ensure its competency and preparation to lead an aligned enterprise. To most effectively do this, it should practice its assessment and reflections and instill its improvement process. A visible and continuously improving Board can immensely impact its organization and people. Equally important is the need for Boards to focus on assuring adequate education for its members and to set a tone and expectation for inclusivity and alignment as a focus. Succession planning for Board members ensures an opportunity to select those with attributes to enhance alignment throughout the organization and enhance the opportunities to work effectively. Such a thoughtful process is necessary because, in particular, Board member and CEO transitions may lead the organization away from previously agreed upon and carefully enacted alignment throughout the organization.

Integral to its role is the need for the Board to set aggressive achievement goals for the organization. This can be accomplished by establishing True North metrics and goals. Many in healthcare are now familiar with creating aspirational goals. One such example is the goal to achieve zero harm. After all, if anything other than zero is accepted as the goal of an organization, who should be that person to be on the receiving end of such harm? Some will challenge such goals as impractical. Others may claim that such goals are unachievable and may demoralize those doing the work.

If an engaged Board works effectively, quite the opposite may occur. Such words and actions can be impressively empowering by having an effective organizational presence and by articulating and setting the stage of alignment around pursuing perfection as the goal. Such actions lead to the realization of much needed support for those providing the care. Indeed, that pursuit motivates individuals and teams to strive for a better state. Engaging critical constituents in defining such goals can lead to impressive results and be greatly rewarding.

CEO and Executive Team’s Role

From the ground up, the next tier of support for an organization should come from the Chief Executive Officer and her/his/their team. With responsibility for establishing and deploying strategic initiatives and accountability for operational excellence, the CEO and team must work effectively with leaders and individuals in multiple realms. Such leaders have a familiar interface with the Board, their respective teams, and virtually all other aspects of the organization. These leaders play a critical role in building compelling momentum towards improvement and much needed achievement of value for the customer. In addition, most are familiar with the executive team’s role in building processes and developing and empowering people to help deploy effective strategic initiatives and improvement. Finally, the CEO and team must focus on aligning the organization across levels of engagement to achieve optimal success. 

As an individual leader, the CEO must seek inspirational leadership and set a goal of alignment throughout the organization. Many actions are needed in order to be successful in achieving this. First, they must establish and maintain communication and relationships with constituents, including the community, the staff, the Board, and physician groups. Building effective engagement and establishing trust is critical for success moving forward.

People innately want to make a difference, succeed, and feel pride in engagement and achievement. Therefore, the CEO also must set a clear direction and empower people with confidence and support to move towards improvement. Emphasizing support for individuals and teams and working to remove barriers so that progress can transpire is critical. In many cases, a successful approach is for leaders to create such conditions and then get out of the way.

Complex organizations frequently have numerous critical efforts, each requiring resources and focus. Therefore, the organization’s operational leaders must work to triage the prioritization of work efforts in an aligned fashion. To effectively achieve agreed-upon goals, a process of deselection of projects and efforts can be liberating and accelerate progress towards improvement. Such a process can assure proper alignment and create focus toward progression in pursuit of agreed-upon organizational goals. Without this, well intended efforts may not yield movement in the prioritized direction.

A multitude of tools can be used to assure inclusivity and alignment. One example is utilizing a tiered huddle system spanning various levels of groups within the organization. Such a process can improve communication of current conditions and situations to optimally engage those in the appropriate roles to address a current imperative or situation.

Executive presence is also critical to ensure the ongoing assessment and assurance of alignment and effective engagement. This is true throughout every level of an organization. The incredible effectiveness of being present to experience the reality of those working within the organization and seeing the product delivered keeps leaders in touch with the people and the organization. Formal and informal opportunities to be present can yield tremendous value. For example, effective rounding with appropriate leader support can deliver a glimpse into the pulse of the people and the organization as a whole and help executives understand current conditions. Additional opportunities, such as structured listening sessions, can also be an effective tool for optimally connecting and aligning. 

Leaders come with inherent skills and attributes, and only some individuals may possess all desired or much needed skills. Coaching can be an effective tool to help optimize the engagement of every leader. Also, the power of a CEO receiving coaching and openly sharing the humility of such an experience can permeate an organization positively. A key champion for supporting people and processes, the CEO must lead effectively and play a critical role in establishing focus and alignment to lead a highly effective organization.

Physicians’ Role

Physicians and providers are a critical constituent group of all healthcare organizations. It should also be noted that the current state of healthcare providers includes such significant realities as burnout, moral injury, financial stressors, and in many cases, immense personal strife. The difficulty and impact of these conditions deserves acknowledgment to honor our physicians’ and providers’ commitment and sacrifices. The stress of malalignment in focus and goals can add to this burden for physicians and health systems. Investing time and effort toward understanding these factors is rewarding and supportive.

Conflict at various levels is a seemingly universal feature of the relationship with physicians. Achieving alignment with this critical group is incredibly important for successful progress in improving the healthcare delivery system. Many organizations greatly value and, at the same time, struggle immensely with their physician partners. Pressures of a variety of sorts are a reality for physicians. In some cases, this drives oppositional directions of focus and objectives. It is well established that a health system not working effectively and in concert with its physicians will have difficulty establishing necessary progress. Given the pressures on the healthcare industry, and the imperative to improve, this relationship requires attention and focus. With such effort, achieving success in such imperatives as achieving high-value care is likely to be successful. 

Additionally, the engagement vehicle between physicians and health systems has changed immensely. Traditionally, physicians have been financially independent of hospitals and health systems, often with a disparate business model from such entities. Many physicians have previously aligned into single and multispecialty partnerships or groups. For years, large-scale change has occurred in this model of provider business arrangements. With generational changes, there has been less desire for physicians to engage in the business of medicine and an increasing desire to focus solely on clinical medicine. In many instances, there is also more emphasis and focus on balancing time spent between work and personal commitments. These factors have given way to the increasing presence of employer/employee engagements with larger organizations. The employment model has flourished with health system employers and increasingly competitive groups such as private equity-owned or other healthcare industry-owned practices. Frequently this has also been accompanied by an increase in competitive objectives that threaten health systems.

Hospitals and health systems now employ greater than 50% of physicians. Many health systems have utilized employment in an attempt to establish alignment with groups of physicians. In reality, employment does not equate to alignment, and in many cases, care and nurturing are even more critical to those now employed.

This relationship presents an evolving dynamic, with many moving parts and some potential changes forthcoming. For example, the Federal Trade Commission has proposed a new rule to eliminate non-compete clauses in employment contracts in the United States. If approved, this action may impact physicians frustrated with their current arrangements and potentially threaten organizations’ investments in employing such physicians. As a result, formal attempts to authentically seek alignment with physicians are now more critical than ever.

Additional factors involved in the healthcare employment landscape have also evolved. In some cases, highly compensated and highly valued physicians are now exploring representation through unionization, a concept virtually unheard of until recently. In addition, group advocacy actions, tense negotiations, and even strikes have been on the table. When trust between physicians and their employers is in a state of stress and flux for many, we need partnership and collaborative efforts more than ever. Now is the time to focus and work on engagement, inclusivity, and alignment with physicians. 

In many instances, a tremendous gap in trust exists between healthcare institutions and physicians. The trust gap primarily comes from a need for more understanding of positions, stressors, and imperatives that impact both. To achieve better alignment, keen attention much be paid to the importance of understanding objectives and perspectives and sharing and discussing goals with key constituent groups of physicians. Working towards alignment is critical to enable forward movement. There is ample room for common ground with physicians and clinical partners in the journey toward improvement, and the effort is worth it. This must start with conversations, building relationships, and establishing trust.

An essential tool in pursuing alignment is the mechanism by which conflict is identified and addressed. In healthcare, there is no limit to the interfaces in which this occurs. We frequently see the conflict between physicians and health systems, but also frequently between physicians, between physicians and their groups, between different groups, etc. This reality of our complex environment can be an immense distraction. However, conflict areas can be a nidus for dialogue, problem-solving, engagement, and alignment. It is worth the effort to invest in this upfront and to commit to the ongoing identification of significant conflict so that it can be addressed openly, respectfully, and collaboratively. When managed well, conflict can create incredible opportunities for partnerships and combined efforts to improve care, reduce waste, and improve the bottom line, for all parties.

Additionally, effort and investment must be made toward developing clinical leaders. Like many professionals, physicians desire to be led by those with similar training and experience. Furthermore, it is an amazingly unique and critical position for physician leaders to be managers responsible for the big picture while continuing to practice as frontline caregivers. There is an inherent trust in those who deeply understand or have experienced the world that physicians work in. For this reason, investing in developing physician leaders is critical to establishing much-needed improvement efforts. Support for physician leaders navigating the challenges of their work should be recognized. It is frequently beneficial in optimizing their effectiveness and engagement, and alignment with the critical groups they lead.

Summary

It is essential for all healthcare leaders and frontline caregivers to strive for common ground and to establish a unified focus. An opportunity to share, learn and understand is critical to an environment where we can work together effectively. The commonality that unites us is the desire to serve and help those in need. Building upon this commonality and establishing a focus for improvement is necessary to thrive in our environment while transforming and achieving our imperative to improve value.

Establishing and understanding the critical aspects of our goals can bring us together. Effective alignment is critical to ensure focus and success in today’s ever-changing healthcare landscape. Moreover, to improve alignment, we can agree upon where to apply our energy and where to manage our risks and distractions to serve together better. This requires focus with intention and a commitment to the hard work ahead. Such efforts’ success can significantly improve an organization’s culture and those who interface with it. Such efforts and the ripe environment for improvement will yield a much healthier tomorrow.