CHAPTER 1

Leading Healthcare Transformation from the Middle

The Covid-19 pandemic only made what has long been apparent to all even more obvious: modern healthcare is in desperate need of reform. Books, articles, and academic papers typically begin with the same refrain: health care is expensive, hard to access, difficult to navigate, and prone to failure. Despite years of policy and operational changes aimed at improving quality and reducing cost, healthcare systems all over the world are swamped with demand and are short of resources.

In part, the current predicament is the result of past successes creating new problems. Decades of medical innovation have helped grow the aging population and increase the numbers of patients living well with multiple complex conditions. Rapidly advancing science has caused an explosion in medical knowledge. At the same time, increasing subspecialization fragments patients’ care across multiple doctors and offices and fractures the clinician-patient relationship, which has been the bedrock of healing practice and a key source of clinicians’ job satisfaction for centuries.

Although past successes have increased demand, past failures have worsened supply. Quality remains an issue despite years of academics’ and practitioners’ work to reduce waste, delay, unwarranted variation, and harm. Uneven spread of resources and quality of care reinforce inequality and are part of a long-standing pattern of structural racism in healthcare delivery.¹ Providers’ unrelenting hunt for efficiency has contributed to worsening patient experience. The pooled labor models used in urgent care centers and inpatient hospitalist staffing often mean patients can no longer expect to see the same doctor twice.

Healthcare delivery organizations are under constant pressure to deliver more care at lower overall cost. They have responded by growing, to spread their fixed costs over a larger patient volume, and increasing productivity, to deliver more care with the same resources. Recent decades have seen a wave of mergers, acquisitions, and partnerships of delivery organizations, the substitution of cheaper clinicians and care sites for more expensive ones, and analytic and communication tools that help spread the existing workforce around a larger patient population. On both sides of the Atlantic, healthcare delivery organizations have been driven by performance targets imposed by governments (in the United Kingdom) or insurance contracts (in the United States), typically focused on maximum waiting times or minimum patient volumes and aimed at wringing every ounce of productivity from existing human, technological, and spatial resources.

Unfortunately, many of these responses have only worsened the situation by alienating staff. Clinicians, who have been called upon to do more with less, see their work reduced to a series of isolated transactions and administrative tasks. A deep sense of disenfranchisement and loss of control are contributing to the burnout that is exacerbating workforce shortages. Doctors and nurses are leaving their professions early because they feel they are no longer respected independent professionals but instead are cogs in a machine. Burnout is both a cause and a symptom of health system dysfunction.²

But the common narrative of demand and productivity risks missing a deeper secular trend that is pushing delivery organizations to rethink the fundamental models on which they are based and the way they are managed. Healthcare is, at its heart, the organized delivery of science to the patient. Care underpins human compassion with social, psychological, biological, and engineering sciences and brings this all to bear on patients’ health problems. As the science changes, so too must the organization of its delivery.

New information, decision support, and diagnostic and communication technologies are changing who can deliver care, and where and how it is delivered. They also enable more precise targeting of care to the unique needs of smaller patient subpopulations. Such new technologies are already allowing a new generation of clinical operating models, such as self-care, virtual consultation, supermarket-based services, health coaching, and disease-specific smartphone applications.

Less obviously, these technological advancements are also forcing delivery organizations to reconsider both how they design new models of care and how they manage change. Although large-scale interventions such as mergers or electronic health record implementations create the essential infrastructure of a modern delivery organization, they are insensitive to subtle differences in the clinical particularities of different patient disease or risk groups. Organizations have to become more operationally diverse as they deploy different models of care to target the needs of different subpopulations, each of which may need a different blend of technology, staff, and site of care to meet its particular needs. If existing organizations are to cope with upcoming technology, they will need to redesign the front line of care at their many locations.

To be successful, redesigning the front line of delivery organizations must occur in ways that are sensitive to needs of patients suffering with specific diseases, respectful of their cultures and values, feasible given current technology, and implementable in the context of existing organizational, regulatory, and financial structures. This requires merging the science of clinical medicine with the disciplines of organizational design and managerial control. For organizations to transform, clinicians and managers working in thousands of inpatient and outpatient units will need to apply managerial insights to medical, nursing, and therapy practice. In other words, clinicians will need to think like managers and managers like clinicians. Furthermore, organizations will have to develop and support a generation of clinical change leaders.

ALL HEALTH CARE IS LOCAL

It is becoming increasingly clear that simply doing more of the same, only faster and cheaper, will be insufficient to address the issues of demand and productivity, the impact of novel diseases, and evolving technology. A more fundamental transformation is necessary. Thinkers from different disciplines tend to offer solutions framed in terms of their own specialty: economists propose market and payment reforms, such as value-based contracting, and management scholars focus on alternative organizational forms and philosophies, such as focused factories, integrated practice units, and lean manufacturing.

Indeed, many argue that the answer lies in management models drawn from other industries. After all, they reason, healthcare is not the only high-cost, high-risk industry where the cost of failure is measured in human lives. Other dangerous or complex industries have dramatically improved their performance over the years. Landing a jet on an aircraft carrier deck, operating a nuclear power reactor, and flying in a complex air traffic system have become cheaper, safer, and more reliable. Moreover, many of these industries have published their methodologies for all to see, such as High Reliability Theory (nuclear power), Crew Resource Management (airline industry), and the Toyota Production System (manufacturing).

Yet uptake of workable solutions and validated approaches has been uneven. These managerial approaches are still not routine in healthcare, and in some quarters they are still viewed with suspicion. Individual examples of successful system and institutional improvements abound, but there are fewer examples of systemic, systematic, and sustained change. Failure to implement proven innovations, from electronic health records to clinical practice guidelines and checklists, is a familiar complaint.³ The lag between proof of efficacy and widespread industry adoption can be measured in decades.

Nonetheless, some organizations have managed a significant transformation. They are the subjects of numerous publications and talks and are well known to many, including Intermountain Healthcare, Salford Royal NHS Foundation Trust, and Virginia Mason Medical Center. Yet even the best institutions have failed to scale or spread. Kaiser Permanente, once the darling of health reformers, is a real presence in only a few markets. Many internationally recognized brands, such as the Mayo Clinic, Cleveland Clinic, Massachusetts General Hospital, and The Royal Marsden, have largely remained in their original markets or made only limited investments elsewhere.

Why, then, in the face of such clear advice and compelling exemplars, has change been so slow, localized, and inconsistent? Why have validated models and best practices failed to transfer? The structure of healthcare systems can certainly hinder spread. The balkanized nature of specialist medicine and nursing tends to fragment the organizational structure of delivery systems into independent institutions and departmental silos. Each usually has its own budget and revenue source, and consequently they tend to function as profit-maximizing independent businesses acting in their own interests, not the system’s, with few incentives to collaborate.

Beyond this, the uncomfortable reality is that health care is obstinately local. Societal and community values, individual patient preferences, patterns of disease, capital and real estate resources, institutional history, and staff numbers, skill sets, and work preferences vary from one region to the next. Although leading organizations’ methods or organizing principles may be taught, their foundational histories, organizational cultures, and passionate local change leaders are harder to transport across state or national boundaries. For example, Toyota gladly teaches its methods to other car companies, but many competitors trying to emulate Toyota have been challenged to replicate its success.

System transformation is ultimately effected through unit-level operational change. To transform, individual institutions and delivery systems must each select from among a diverse set of tools, exemplars, and approaches those that resonate most with their local communities of patients and staff. Lessons may surely be taken from innovations in other healthcare delivery organizations or imported from management models applied in other industries, but ultimately each must be implemented locally in the institution’s own wards, operating rooms, clinics, and consulting rooms. Most important, these approaches must be adapted to meet local conditions. The questions each delivery organization must answer are not just, What should we do?, but also, How do we do it here?

Unfortunately, there is no magic bullet, no single dominant model that can be “rolled out” or franchised. On the contrary, transformation requires local redesign and change at each of its myriad delivery units: local change at global scale.

TWO KEY TRENDS DRIVING CHANGE IN DELIVERY ORGANIZATIONS

Short-term market pressures compel delivery organizations to address productivity and demand-supply mismatch by delivering care that is faster, better, cheaper, and, nowadays, remote. Beyond this, two longer-term trends are changing the fundamental nature of healthcare delivery. Both have a significant impact on the way professionals work together, and both are forcing delivery organizations to change.

The first is a continuing transition from an individual-based to an organization-based enterprise. For centuries, health outcomes were driven by individual clinician excellence. Accordingly, clinicians were trained, recruited, regulated, and managed as individuals. In the modern era, however, health outcome is equally a function of organizational and team excellence. To be sure, individual skill and training are still necessary, but they are now no longer a sufficient condition for the best patient outcome.

In some quarters, this transition is controversial. As healthcare becomes increasingly “corporatized” and doctors become employees, some argue that a consequent loss of physician independence not only contributes to burnout but also harms quality. This view holds that independent nursing and medical professionals who advocate in their patients’ best interests are at the heart of high-quality care. Its advocates fear that individualized and compassionate care risks being lost in the organizational machine.

Nonetheless, the ascent of the organization and its dominance over the individual are the modern reality of healthcare, for good and bad. There is some advantage to a focus on the organization. Many of the most egregious failures in patient care have their roots not in the failure of individual professionals but in poor delivery system design and function. How we structure and manage groups of individual caregivers matters, in large part because of the key role now played by teams. The challenge of modern healthcare is to develop better organizations capable of delivering compassionate and individualized care on a grand scale while preserving the personal relationship between clinician and patient and clinicians’ sense of control over their working environment.

The second trend is a more fundamental, science-driven change in the core processes of preventing, diagnosing, and curing disease. Advances in biology, analytics and machine learning, and communication technology are changing the way in which healthcare’s core activities of disease finding, diagnosis, treatment, and prevention are undertaken. Wearable technologies, population analytics, and personal health record algorithms can identify at-risk patients long before disease is manifest and the patient typically presents. The Covid-19 pandemic has reinforced the way in which modern communication technologies and point-of-care and noninvasive testing can allow diagnostic hypotheses to be formulated and even tested at a distance, often without recourse to a specialist or the need for an in-person visit. Expert treatment advice is moderated by patient-to-patient interaction via social media and patients’ and nonmedical professionals’ access to digitized algorithms, and therapies are increasingly targeted to smaller populations based on genetic profile. Rules-based systems guide the activities of health coaches with no medical or nursing training. Many interventions, previously considered hospital only, can now be safely delivered in distant outpatient settings or the patient’s own home.

These trends have the potential to fundamentally change the nature of healthcare delivery as technological advancement enables less expensively trained staff to make more sophisticated decisions. Those without medical training can now make decisions that used to wait for medical professionals. Technological advancement tends to distribute decision authority, and as a result teams become more diverse and geographically distributed.

The primary impact is on how we work. Better supported and easier decision-making changes who can or should perform the work of care, where and how that work can be undertaken, and what kind of organization is needed to support it. We are seeing this effect already. Teams now comprise individuals who are increasingly working across organizational boundaries in interprofessional groups that combine clinicians, managers, and, most important, the patient. Medical decision-making regarding an individual patient’s care is increasingly based on large data sets, and expert systems make recommendations based on the aggregated experience of thousands of like patients.

However, traditional healthcare delivery organizations evolved to support an entirely different style of care. When general practitioners and hospital specialists treated patients with only one disease and when treatments were fewer and less well targeted, the independent, lone doctor was the primary decision maker. When consulted, he (and it was usually “he”) saw the patient in person and was supported by a suite of nursing and technology services that were centralized around his work and overseen by a hierarchy of lower-status professional managers. The hospital and consulting room were the doctor’s servants. In the modern era, this classical model of the delivery organization as the doctor’s workshop is no longer fit-for-purpose. Increasing patient complexity and technological capability are mirrored by increasing size, diversity, and distribution of the care team, and previously stand-alone institutions are becoming part of integrated regional networks.

These two trends are forcing the widespread operational redesign of existing organizations to create institutions and systems better suited to new ways of working. Moreover, operational and organizational redesign is unlikely to be a one-time occurrence: more likely it will be an ongoing necessity because the nature of new technology is to constantly drive changes in the operations of healthcare delivery. As a result, we will always be rearranging the tasks and decisions of care, reallocating roles and decision rights, and resituating care as pharmaceutical, device, digital, and communication innovations make new alternatives feasible. To this extent, the ability to repeatedly transform—to restructure organizations and revise clinical and operational processes—is becoming an essential long-term organizational capability: a way of being rather than an event.

IMPACT OF THESE TRENDS ON DELIVERY ORGANIZATIONS

The new ways of working enabled and forced by technological evolution have two important and often underappreciated organizational implications. The first of these relates to the structure and operations of delivery organizations.

When task responsibilities and decision rights are redistributed among professionals and institutions, these groups are forced to redefine their relationships and ways of interacting. In practice, this means developing new ways of working within a team and smoothing patients’ passage from one team, unit, or organization to the next as they traverse a system or network to receive their care. Smooth passages through complex systems are not accidental. Other industries devote substantial resources to ensuring that customers do not experience the complexity of the systems developed to serve them, but healthcare all too often makes the navigation of our complexity the patient’s responsibility. The pathways that complex, multi-comorbid, or chronically ill patients take through delivery systems with multiple organizational boundaries need to be specifically designed to be simple and navigable.

In effect, this requires redesign in two dimensions: the configuration of people, technology, and routines within each unit and the relationship of multiple units and organizations that contribute to a patient’s care. Complex patients interact with multiple organizational subunits, each delivering a portion of the care and contributing part of the value that patients receive from their care. Each ward, clinic, operating room, doctor’s office, or pharmacy must be specifically configured internally to be capable of reliably delivering the portion of care for which it is responsible. At the same time, the transitions across the delivery system’s multiple organizational and departmental boundaries must be redesigned to coordinate the patient’s overall care.

The focus of this redesign is the local operating system: the fundamental unit of any delivery organization. An operating system is made up of the care process and its associated business processes, the staffing model used to implement these processes, the medical and information technologies and physical infrastructure that support staff in their work, and the data systems, metrics, and mechanisms of behavioral influence that are used to exercise operational control. These elements must be aligned and made fit-for-purpose at each of the many organizational and system units with which the patient comes in contact. The need for operating system redesign occurs whenever previously standalone institutions coalesce into networks, existing networks take on the challenge of population health, or organizations adopt new technologies that change work patterns. In all these situations individual and institutional roles and responsibilities may have to be redistributed and multiple local subsystems reconfigured.

Who is to do this work, and how? The second organizational implication of the changes described previously relates to the model of leadership and control within a delivery organization. Over the course of the twentieth century, the model of centralized hierarchical managerial control initially advocated by Frederick Taylor and the “scientific management” movement in the late nineteenth century has given way to a model of decentralized operational control and frontline leadership. This transition has already occurred in many service and production industries that have moved away from command-and-control hierarchies toward individual self-management and self-managing teams.⁴ Centralized expert problem-solving resources have been replaced by frontline staff who are skilled and authorized to identify and solve problems then and there and are empowered to redesign systems and structures in the longer term. Decentralized problem-solving authority was one factor that helped organizations successfully respond to the early challenges of the Covid-19 pandemic.

However, in healthcare, in spite of increased recognition of the importance of clinician engagement and leadership, key frontline workers, especially doctors, continue to hold themselves apart. They often view the delivery organization more as the context for their individual professional practice than as an essential part of the overall mechanism by which they achieve a positive patient outcome.

Yet transformation depends on the clinical staff. Structural, operational, and managerial change is required to bring organizations together at the highest level and to redefine operations, behavior, and working relationships at the lowest. This work needs the involvement of clinical staff and depends on clinicians and managers working together. It is the clinicians who have the scientific knowledge and operational control required to effect meaningful change at the unit level. Therefore, transformation is also the work of identifying, developing, and supporting a group of people within the delivery organization who understand the work of taking care of patients, can lead operating system redesign, and can undertake ongoing oversight and control of improved units and systems.

Unfortunately, those key frontline workers who are interested in transformation face an uphill battle. Healthcare delivery is a particularly difficult setting in which to bring about change, in part because of the difficulties of exercising operational control in this context.

THE CHALLENGE OF IMPLEMENTING LOCAL CHANGE

Why is changing the way we work within units and relationships among units so difficult? Three characteristics of healthcare make this work challenging and affect the way management principles developed in other settings can be applied in healthcare.

The first of these characteristics relates to the nature of the science underpinning healthcare delivery. Despite dramatic advances in our understanding, the medical science base is far from complete and care remains an uncertain business, a fact starkly demonstrated by the emergence of a novel disease in 2020. Unlike in many production industries, causal relationships in medicine are probabilistic, not deterministic. Medicine is based on biology, not Newtonian mechanics, and accordingly its “rules” and “standard operating procedures” are incomplete, evanescent, and rarely universally applicable.

As a result, many patient-clinician interactions are still empirical: we try something and see what happens. A “best practice” does not guarantee an outcome; it simply makes it more likely. Scientific advances improve our probability estimates, but even after the unwarranted variation resulting from inadequate systems is removed, a significant level of variability and uncertainty remains. Patients simply do not respond to therapy with the same reliability that metal forms in a press or that meat cooks on a grill.

Second, this uncertain science is in the hands of a group of independent professionals. Physicians remain highly autonomous, largely a result of the way they are recruited and trained. As the volume of medical knowledge has increased, training programs have become more specialized. This has resulted in a generation of doctors trained to focus on that component of the patient’s care for which they are responsible, not the broader system of care of which that component is a part. Other health professions are equally independently minded. Because it takes a wide and sophisticated skill set to cure disease and relieve suffering, nurses, doctors, therapists, and social workers have each been deliberately trained to focus on a different aspect of the overall value the health system creates for the patient. Although they share the same broad goals of preventing disease and returning ill patients to health, they legitimately differ in their approaches to achieving them.

Even when they are paid employees of a healthcare delivery organization, doctors and nurses maintain a strong allegiance to their professions, professional organizations, and professional peers. Correspondingly, they identify less with the delivery organization and its managerial staff. This is particularly true for doctors who have an independent revenue source, as under the fee-for-service reimbursement system in the United States or from private practice in the United Kingdom or other national health systems. The strong value set already in place before joining a delivery organization only further supports their independence. Professionals will rebel if an organization’s goals are not perceived to be consistent with these values, a discrepancy often at the heart of the persisting conflict between clinicians and managers.

Third, patients are equally autonomous. In most service industries, customers interact with a service “wrapper” that is highly responsive to their preferences, but the creation of the core product, such as the cooking of the fast food or the safe piloting of a plane, remains exclusively in the hands of the professional. Customers are excluded from these operations. But in healthcare, patients genuinely are “coproducers.” They are constantly making medical decisions—if, when, and how to intervene—often over long periods of time. These choices have a significant impact on exactly the same outcome the professionals and delivery organization are trying to influence (and for which they are being held accountable). In few other settings are service providers as vulnerable to the customer’s failure to use that service appropriately or correctly. In other words, if you miss your flight, it is your problem, not the pilot’s, but in healthcare, if the patient does not take the medication, the system is nonetheless accountable. The patient is, in effect, part of the professional team.

What these three factors—an incomplete and dynamic knowledge base and the pivotal roles played by independently minded doctors and patients—have in common is the behavioral variability they create at the front line of care. They make it challenging to exercise operational control and implement innovations and operational change. These factors help to explain why inflexible mandates from the top often tend to be controversial and unsuccessful.

These characteristics also mean that clinicians and patients necessarily have a central role in the transformation of care systems. Only they have the requisite knowledge to confront the complex interaction between personal and community values and the nature of a disease, the current state of medical knowledge and technological capability, and the ideal local and regional organizational arrangements for delivering care to patients suffering from that disease. Only they have the final control over care choices and how they are executed.

In sum, clinicians at the front line need to be involved in unit-level operational redesign for instrumental reasons. It is they who have the knowledge and ability to exercise control. But they also need to be involved for therapeutic purposes. Returning to clinicians’ control over their local environment is a way of addressing one of the causes of burnout, what Eisenstein has called “an act of self-care.”⁵

LEADING FROM THE MIDDLE

The idea that clinicians should have an enhanced role in the design and management of delivery organizations is by no means a new one. There are numerous papers, talks, and blogs on clinician engagement and leadership. However, the now-popular term “physician leadership” is often used to refer to leadership at the chief executive and senior decision-maker level. By “clinical leaders,” we usually mean those in named leadership positions. But the need for reform at the unit level—the ward, operating room, clinic, or practice—requires the engagement of a larger group of practitioners working with patients day to day. These are leaders in the middle of the organization working in patient-facing operating systems several layers below the senior leadership. It has become increasingly clear that, despite well-intentioned efforts, top-down implementation of the rules and protocols of “evidence-based medicine” is not sufficient to transform a system of care or practice at the unit level. MIT’s Ed Schein is popularly quoted as observing that “you can’t impose anything on anyone and expect them to be committed to it.” Nowhere is this truer than in healthcare, where no one can impose a course of action related to patient care on the professionals who provide that care.

Unfortunately, clinicians are often schooled in perspectives and skills that run directly counter to those that are needed to effectively lead change and exercise control of the local operating system in which they also practice. They are not well prepared for a change leadership role. Both the new ways of working in the future, enabled by new technology, and the leadership skills to help a team learn and implement them (that is, to lead their colleagues in a clinical team through change) are unfamiliar to many clinicians. The approaches and language common to the management models drawn from other industries can clash with core values and behaviors of clinical practice.

What appears obvious to management consultants and academics is foreign to clinicians for at least four reasons. First, doctors in particular often have limited experience operating in a team of equals that includes those skilled in management, finance, or process engineering. Clinical training is still based on the presumption that individual action “causes” a good (or bad) patient outcome. It emphasizes individualism and a strong ethos of personal accountability that is reinforced by the medicolegal code. In usual group settings, such as the emergency room, operating room, or catheterization lab, the doctor is typically the high-status content expert in a hierarchical team. Even in those multidisciplinary meetings where the status differentials are not so overt, participants are frequently all health professionals who share some core values and perspectives.

Second, they are not trained to have an enterprise focus or mindset needed to design patients’ paths through complex organizations or regional systems. One effect of increasing sub-specialization is that individual clinicians increasingly focus on the small portion of the patient’s overall care that is their responsibility (and specialty), a focus that is reinforced by the transactional way in which their activities are measured and reimbursed. In other words they preferentially concern themselves with their portion of the overall value chain, not the wider chain or longer patient journey.

Third, clinicians are often naturally averse to risk. The principle of primum non nocere (first do no harm) makes clinicians reluctant to perturb the current system without strong evidence that to do so would be safe and effective, even when that system is clearly underperforming. Such a mindset not only tends to preserve the status quo but also makes clinicians suspicious of the kind of rapid cycle experimentation that is at the heart of modern approaches to improvement and innovation. Interestingly, clinicians and organizations did, at least temporarily, embrace rapid experimentation as they responded to the 2020 Covid-19 crisis.

Finally, clinicians are only too aware of the uncertainty that underlies much day-to-day clinical practice. This tends to make them prefer to maintain flexibility and unwilling to “lock in” practices lest they be inflexible later. It makes them wary of any standardization that could limit their ability to respond rapidly to evolving clinical situations. Standard care is frequently dismissed as “cookbook medicine.”

These aspects of clinical practice do not align well with the recommendations of the formalized approaches to management and performance improvement common in other industries. In fact, those approaches are typically based on completely opposite behaviors. Other industries measure performance through compliance with an invariant standard. They aim to reduce ambiguity through high degrees of specification and standardization and exploit any remaining variance as a mechanism of learning. Such industries encourage innovation by exploiting the diversity in team skills, and to this end they deliberately flatten hierarchies and create groups of equals with unusual skill combinations. Notably, nonmedical industries promote experimentation, not in the controlled environment of a lab or under the oversight of a rigorous clinical trial review process, but in real time, on the shop floor, with live customers and small sample sizes.

Given the clash between the culture and practices of healthcare delivery and those approaches to improvement and innovation that are common in other industries, it is little wonder clinicians are often slow to adopt well-accepted management methodologies into healthcare and are thus dismissed as impediments to change.

Herein, then, is the challenge. The changes healthcare delivery organizations must make to accommodate current demands and future innovations require rebuilding unit-level operating systems and developing new relationships among individuals, units, and organizations working together in a wider system or regional network. This requires engagement of front-line clinicians who have both the local knowledge and access to the levers of control over unit-level operating systems that are necessary to make change. To effectively exercise this control and develop systems that are more fit-for-purpose, however, clinicians and managers have to learn new behaviors and skills. They must work together within and across organizational boundaries in interprofessional and multidisciplinary teams, planning systems to support the management of at-risk patient populations as well as individual patients, overseeing the day-to-day performance of these systems, conducting experiments and making necessary midcourse corrections, and, of course, leading change among their colleagues. Yet the very people needed to lead local change in their units and organizations are not just ill prepared for the task, they are likely trained in a set of skills that are contrary to the ones they will need to bring about these necessary changes. On top of that, the management principles and tools they are offered seem insensitive to the clinical context with which they are familiar. If we are to engage clinicians in change leadership at the front lines of care, we will need a model of management and innovation that addresses these clashes in perspective and accommodates the particularities of the healthcare context.

This book aims to do just that. Chapter 2 begins a discussion of what the work of managing care is and how leaders in the middle of delivery organizations can do it: how they can establish its goals, design the necessary operating systems, lead change, exercise daily oversight, and routinize ongoing refinement and constant innovation. It starts with identifying the purpose of the enterprise. Care is managed to achieve a goal, and the nature of that goal will shape how we manage care. Chapter 2 considers that guiding goal.