Formalizing The Way We Work — An Organized Way of Working

For at least the last decade — perhaps longer — companies have been explicitly trying to adapt to a VUCA world.





Volatility refers to the speed and turbulence of change. Uncertainty means that outcomes become less predictable. Complexity refers to the growing interdependence of social and economic forces. Ambiguity indicates the haziness of reality.

These are the general conditions of our industry (professional services) and the industry we serve (healthcare delivery).

In short, it’s crazy and uncertain out there.

Awareness and readiness become paramount when VUCA is the prevailing reality. Awareness and readiness allow a company to respond to problems and take advantage of opportunities, both of which are in abundance in a VUCA world.

To respond to problems and take advantage of opportunities a company must be organized.

Being organized becomes essential to existence and scaling.

Being organized is a competitive advantage. That’s the key to existence.

Being organized allows more work to be completed. That’s the key to scaling.

Being organized allows decisions to be made by the most appropriate employee. That’s the key to creating a responsive company.

Responsive to customers. Responsive to the market. Responsive to each other.

To become organized, we must:

  1. Share, process, and make as much information available to as many people as possible
  2. Turn knowledge into learning and improvement
  3. Encourage everyone to contribute

With the goal of creating reliable, repeatable, and adaptable ways of working.

Reliable, repeatable, and adaptable ways of working provide exponential benefits.

All of them can be summarized with the “Beamed to Mars” principle. It asks, if a co-worker happens to be beamed to Mars tomorrow, could someone in the organization step-in and fulfill their current responsibilities?

Sadly, Mary was beamed to Mars.

Mars excursions happen all the time: weeks of vacation, a series of sick days, family emergencies.

The red planet is not a lonely place.

Perhaps the greatest benefit of organization is that which rolls up to the individual employee: it allows for greater autonomy and creativity by routinizing the work that can be routinized and creating slack to work on more interesting and difficult problems.

That’s our operating goal. To organize the company, the work our employees do, and how that work is informed and created.

Becoming organized starts with the company’s intention:

  • Help middle manager administrators transform healthcare delivery.

It continues with outlining our company’s principles, the foundational beliefs that drive our behavior and reasoning:

  • Start Now. Go Fast. — as in moving appropriately quickly and efficiently with a willingness to experiment our way to the best solution
  • Know-How — as in expertise and skill in everything that we do
  • Execute. Start Again. — as in getting things done is our ultimate outcome

Then it continues with our performance expectations of every employee:

  1. Be Curious — to explore, to learn, and to improve.
  2. Be Flexible — in your approach, acceptance of responsibilities, and in providing assistance.
  3. Be Ready — be prepared, be responsive, and be aware.
  4. Take Initiative — to get started, to communicate effectively, and to make things better.
  5. Contribute to the Whole. The responsibilities specific to your role are important. We also request that you contribute to building a company.
  6. Commit to the Approach. We have designed a way of operating. Follow along or help us find a better way as everything is open to improvement.

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Here comes Peter…

Just saying (Laurence Peter, Peter Principle):

Peter pointed out that in large organizations where these practices are used, it is inevitable that individuals will be promoted until they reach their level of maximum incompetence. The unavoidable result is the runaway spread of incompetence throughout an organization.

Now Pluchino and co have simulated this practice with an agent-based model for the first time. Sure enough, they find that it leads to a significant reduction in the efficiency of an organization, as incompetency spreads through it. That must have an uncomfortable ring of truth for some CEOs.

Solution?  Two show promise:

The first is to alternately promote first the most competent and then the least competent individuals. And the second is to promote individuals at random. Both of these methods improve, or at least do not diminish, the efficiency of an organization.

Or a third, luck?


Heterarchy: “an organizational form somewhere between hierarchy and network that provides horizontal links that permit different elements of an organization to cooperate whilst individually optimizing different success criteria.”

A potential solution to flattening hospitalsThis paper says that collaboration is the key; and what do we need more in health care given the multiple professional groups, support units, employment structures and tripartite missions (patient care, education, research)?

The email conundrum

Incessant email, ugh.

The misuse of email is tremendous.  Clive Owen at Wired writes, “Everyone complains about ‘e-mail overload’ — getting so much stupid corporate e-mail that you miss out on important messages.”

Two solutions.

The more practical and organizationally implementable makes email gamelike, from Wired:

Every employee is given virtual tokens — say, 100 a week, — that they can attach to e-mail they write. If you really want someone to read a message now, you attach a lot of tokens, and the message pops up higher in your correspondent’s Outlook inbox.

Turns out, it works.  “When a work group at IBM tried [it], messages with 20 tokens attached were 52 percent more likely to be quickly opened than normal. E-mail overload ceased to be a problem.”

The second possibility is one that has been visited before, from Edward Gottesman at Prospect:

The time has come for a public sector remedy: a tax, perhaps no more than 2p, or 3c, on every email sent. Opponents will argue that collecting the tax is impossible or unfair. Yet the status quo is unworkable.

Has your organization thought about trying to reduce the amount of email?  It needlessly keeps people behind their desks or inattentive on their Blackberrys/iPhones.

Organize around the patient

Vineet Nayar at Inverted Wisdom (a Harvard Business Publishing blog) asks an intriguing question:

As time passes by, people and things change. Now, what if time passes by and people change, but things that should change, don’t?

Health care is steeped in tradition.  While other businesses have flattened their organizational structures and empowered front-line workers, on the whole health care has grown more bureaucratic.  Actually, health care has approached this issue in an almost completely opposite fashion.  Remember the empowered country doctor?  I don’t either, but I have read that they existed at one time.

Mr. Nayar continues:

It is not a stationary relic I’m talking about. I’m talking about the brand new dinosaur on the block – the classical management pyramid. Time has come to dismantle it and adapt to a new evolutionary and unstructured model that leverages the team effect to ensure that companies can lead change rather play catch up or be left behind.

The prevailing notion is that health care is constantly changing, that’s true.  But backward incentives have mucked up our ability to respond.  The reality is that the majority of stakeholders in our industry have become reactive to change instead of leading it.

Again, Mr. Nayar:

Yes, the traditional pyramid management structure needs some unstructuring. Flexibility is the key to survival in the 21st century, and organizational structure is no exception. It needs to be open to change, to take any shape that’s best suited to the organization.

Leadership would do well to shun the ‘Me’ approach and deregulate, decentralize and transfer a substantial part of the organizational control to the frontline.

Logically, the health care organizational structure should be devised so that the complete focus is on the patient’s needs.  The Cleveland Clinic is trying by integrating its service lines into institutes dedicated to health care conditions.  Cleveland Clinic CEO Dr. Toby Cosgrove:

I think the model where we bring together all the expertise (cardiologists and surgeons under one roof, for example) will be a tremendous benefit for clinical care. You get wonderful things from proximity (conversation and innovation). The line between medicine and surgery is blurring. Innovation takes place on the borders of disciplines.

Delivering health care requires a tremendous amount of organization.  The complexities of this industry (uber regulation, 24/7/365 operation, numerous specialties, etc.) make it difficult for executives to let go of their control.  But the complexities also make it that much more important that control is released to the talented workers on the front line. Mr. Nayar:

Simple as it may sound, the truth is that this is a very tough task. The question we must ask ourselves is whether we have within ourselves the fortitude to deconstruct the traditional power centres so that more emphasis is placed on the troops instead of the General.

Difficult it is, but necessary.  Quality would improve if it were released to the people who truly understand quality and can provide it its necessary attention.  Technology may reach its full potential if the people who use that technology become the decision makers on implementation.  Services would benefit the patient if we organized around the patient’s health care needs.  We need to stop building barriers and start tearing them down.

We should organize around collaboration and continuity and integration.

Maggie Mahar at Health Beat Blog recently wrote about the high level of care delivered at the Mayo Clinic and the power of integrated delivery systems:

The variation suggests that it may not be the Mayo “system” that lifts Mayo’s flagship Minnesota hospital above the tide. Rather, some observers suggest, it may be the highly egalitarians and collaborative “culture,” which puts patients ahead of everything and everyone else, that makes the Mayo Clinic in Rochester, Minnesota so special.

Nevertheless, the 2008 Dartmouth Atlas does provide sufficient data to support the thesis that integrated delivery systems are likely to provide the most efficient high-quality care. And the report makes it clear that Mayo is not the only integrated system that stands as a benchmark for excellent collaborative care. Both Intermountain Healthcare (IHC) in Utah and the Sutter system hospitals in Sacramento are singled out for praise.

One last time, Mr. Nayar:

So, do we have the vision to look upon our organizations as collaborative and evolutionary life forms that must keep changing along with the marketplace? Do we have the humility to step out of our egos and hand over the mike to our subordinates? Do we possess the courage to unstructure an existing, rigid regime that we have known to work in the past?

We often accept the verdict of the past and slumber into the cushioned inertia of best practices, until the need for change cries out loudly enough to stir us out of our comfort zones. It is time.

Embrace change, lead change.  It is time, indeed.