That depends on the needs of the system and the vision of leadership at any given time, perhaps to increase patient safety or satisfaction or fiscal goals. It is easy to make the case that the supreme aligning focus for medical systems is quality care. After all, providing quality care is at the center of focus for all levels of medical systems from providers to government (see figure 1). The more difficult question addressed here is how to apply quality care as the organizing principle of shared alignment of administration with providers.

Let’s start with the frontline providers and their support staff. After all, they are the ones directly interfacing patients day after day and running into challenges in meeting the goal of providing quality care. For example providers may experience an additional five clicks to accomplish what one click would if programming was refined in the HMR, slowing their efficiency and draining them as a resource slowly. They may have patients who have been roomed late due to front office lack of training or system issues, patient disregard, or a combination of known and unknown challenges. They may meet a train wreck of patient concerns that challenges them professionally, tax their schedule, and not have access to the referral resources needed. All of these challenges face the provider moment by moment and they look to administration to help remove challenges that appear to be system issues.

It is true that surrounding the frontline providers are the administrators. It seems completely logical that administration is there to remove barriers the frontline experiences, take care of day-to-day business, and keep the system viable and functional into the future. And many of administration’s time is spent doing exactly this for providers and the system. Still, providers often feel that administration seems to have its eyes on a focal point beyond the frontline and the challenges they face. This is also true and predictable as providers and administrators are seeing two different views, both valid and key to quality care. Administration has the additional frontline of directives coming down from corporate and from legal and governmental levels, as well as the viability of the institution for future years. This sandwiching of administration leaves them vulnerable to challenges on both frontlines, and feeling like they are sure to let someone down all the time.

Too often, systems speak as though they need to align providers, rather than aligning with providers. The goal here is to align around the key focus of quality care for both administration and providers. Aligning vertebrae requires not just getting the bones back in place, but also soothing and strengthening the muscles and surrounding tissues that will allow the alignment and then maintain the function of the spine. In this analogy we might equate reducing inflammation with increasing trust.

The difficult part for many systems and administrators is speaking the language that communicates how longterm interests and apparent “counter commitments” (community health, system priorities, medical-legal concerns, political-national requirements) align with quality care now. And for good reason. At times initiatives do not (or do not have the appearance of nor clarity necessary to) affirm a contribution to present quality care. For example, the new technology needed is not on the purchasing order or is delayed, slowing productivity and stressing our most valuable resource, people, seemingly unnecessarily. Other times, the longterm benefit of a current action that will contribute to quality care is not communicated to the system or administration from the level above. Other times, there are just too many priorities to attend to the explanations of why we are doing what we are doing, and then the reasoning is left out. Additionally, individuals may have an old school underground belief that states that people should do what they are told without being explained as to why (not a very popular style in today’s age so it is often a covert belief).

So how do we apply quality care as the organizing principle of shared alignment with providers? As with anything lasting, we first intervene with a “soft commitment” of vocalizing our commitment to quality care, and then we embrace a “hard commitment.” A hard commitment is where we lose something if we don’t follow through with our verbal commitment. Like a camera enforced red light, we know we will pay the city if we don’t stop, even if no one is around. Perhaps for example, we articulate that ice cream will be served to all providers every time a quality care issue brought to forum is not duly considered and responded to within a week.

And here is the key to great results when aligning providers and administration. Committing to quality care with transparent and timely communication. This means that when there are questions why a challenge to quality care has not been removed after it has been expressed, that complaint is addressed specifically. This timely communication keeps issues from smoldering into flame over time, especially issues that slip between the cracks beyond sight. Being transparent, on the other hand, is a paradox. We express things that we don’t have answers to and that make us uncomfortable and we expect it to weaken our leadership and influence. But instead, our commitment and vulnerability increases the anti-inflammatory “trust,” opening the ability to align, and setting the foundation for future alignment stability.

Whichever frontline you find yourself faced with or stuck between, consider the vulnerable path that builds the foundation of alignment – trust. Commit yourself (soft and hard) to addressing quality care complaints, and ask for commitments from others to quality care as well. Follow up all quality care issues with transparent and timely communication. And then smile as each challenge to quality care “pops” into place, providing relief and functional alignment together. We may not be able to remove all quality care complaints immediately, but we can address the inflammation (build trust) and prepare for continual aligning together.

Perhaps even more important in today’s volatile, uncertain, complex, ambiguous (VUCA) practice environment, is creating the synergy between providers and administration essential to rapidly transform our systems. The speed of change requires us to quickly pass through survival fears into thriving mentality, and stay ahead of the curve continuously. This we cannot do individually. It requires us to work together with the depth of efficacy that is driven by meaning and connection.

What a burden this places on executives to cast a vision that speaks an integrated understanding of having truly heard the providers, while inspiring all levels that we can reach the goal of thriving. Of course as you read this you know this intuitively. However, the question may be, “In the face of conflict, what focus points can we use to unify providers and administration to accomplish thriving in this VUCA time?”

Twenty years ago the answer to this question and the ongoing objective was expressed as providing access, availability, and cost effectiveness. Sometime later, quality of care was added as a focus point. In 2008, Berwick, Nolan, and Whittington published their answer to this question with what is now widely known as the triple aim of healthcare. This triple aim includes the experience of the individual patient, the health of a defined population, and the per capita cost for the population. In 2014, Bodenheimer and Sinsky added the work-life health of providers to the mix, as widespread burnout is associated with reduced patient satisfaction, health outcomes, and an increase in costs. More recently, true efficacy and communication have been added in The Bridges Lens model (2015).

As with any quality study of causation in our complex world, more and more variables show up having significant influence on our success. The interdependent and symbiotic cycle of life on our planet and in our healthcare systems continue to train us to increase our perspective and see all of the moving parts. More on this another day, as today we are looking for a focus point that unifies providers and administration in achieving resolution to conflicting priorities.

On a practical level we are seeking a unifying principle across the board, a birds-eye perspective that simplifies the message. One that when we hear it, it sounds so familiar, like we have known it forever, or déjà vu perhaps. The objective here is not to invent something new, it is to recognize what has been here the entire time. A unifying principle that facilitates an executive’s ability to cast a vision that reflects having deeply heard providers and that is responding to complex provider concerns. A unifying principle that inspires engagement together.

When asking providers, quality care is the one focus point that has providers responding with nodding heads of agreement regularly. Could the unifying factor in medicine be quality care? Providers satisfaction is clearly linked to being able to provide quality care, and patient satisfaction has been tied to provider satisfaction (Haas et al. 2000).

If quality care is a unifying principle, how wide would our perspective of quality care need to be to be efficacious? Is it just something that a provider provides according to their medical training? Is it something that is built into each active system we promote or role out? Is it part of recognizing the most success in reaching every socio-economic population we serve?

For the immediate private engagement between a provider and patient, quality care means being seen in a timely manner, heard and understood, developing a path toward increased health, and effective follow through. For administration, quality care may mean seeking to remove frontline challenges to quality care, while also responding to system demands and keeping the doors open for the longterm. Quality care is found in parent systems that seek to bring consistency and accountability to updated legal implications and system wide improvements. Furthermore, doesn’t the principle of quality care reach all the way to the government systems that look to protect people and provide the population with, well … quality care? In truth, perhaps our difficulty has not been finding the unifying principle to focus us on what really matters. Perhaps the difficulty has been leading our systems to recognize the full breadth of what quality care really has the potential to be, and bringing quality care to life at each level of leadership.

Quality care when looked at from various perspectives reveals that attending to quality care from the individual, through our systems, to the population, can be the integrative principle. Perhaps the challenge is that the various people tasked with their part of the system typically address only their singular view. The provider does not have enough time to address the full quality care complexity of the patient in the office in 10-15 minutes. Administration must attend to keeping the doors open and directives from parent organizations. And the government enacts laws that are often not closely connected to meeting the complexity of the quality care required.

Quality care means a professional and satisfying eye to eye connection between provider and patient that addresses the concerns of the patient. Quality care means that access is available not just theoretically, but actually to each of the social-economic abilities or inability to arrive in the providers office. Quality care means quality and balanced care for the providers and administration, that sustains future care for everyone. Quality care means having and attending to laws and principles that increase true efficacy of quality care.

Under the VULA life we live, natural differences in priorities lead to conflicts between providers and administration. Perhaps the unifying factor for solving these differences has always been right under our noses, attending to quality care. Not just at the provider level, although removing the challenges to achieving quality care at the provider level is the first key. Additionally, identifying the widest perspective of what quality care means at every system level, and making a case to hold quality care at each level as the principle of effective medicine.

Could it be that taking increasingly larger perspectives on providing quality care could be employed as the unifying focus point between administration and providers? If so, lucky for us, quality care is also the path of least resistance with providers.

Berwick D, Nolan T, and Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June; 27(3):759-769.

Bodenheimer, T, and Sinsky, C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med 2014 Nov/Dec; 12(6):573-576.

Dreussi-Smith T, Payne R, Young J, and Shaw L. 2014. Bridges to health and healthcare: New solutions for improving access and services.

Haas J, Cook E, Puopolo A, Burstin H, Cleary P, and Brennan T. Is the professional satisfaction of general internists associated with patient satisfaction? J of Gen Intern Med. 2000 Feb;15(2):122-8.

That depends on the needs of the system and the vision of leadership at any given time, perhaps to increase patient safety or satisfaction or fiscal goals. It is easy to make the case that the supreme aligning focus for medical systems is quality care. After all, providing quality care is at the center of focus for all levels of medical systems from providers to government (see figure 1). The more difficult question addressed here is how to apply quality care as the organizing principle of shared alignment of administration with providers.

Let’s start with the frontline providers and their support staff. After all, they are the ones directly interfacing patients day after day and running into challenges in meeting the goal of providing quality care. For example providers may experience an additional five clicks to accomplish what one click would if programming was refined in the HMR, slowing their efficiency and draining them as a resource slowly. They may have patients who have been roomed late due to front office lack of training or system issues, patient disregard, or a combination of known and unknown challenges. They may meet a train wreck of patient concerns that challenges them professionally, tax their schedule, and not have access to the referral resources needed. All of these challenges face the provider moment by moment and they look to administration to help remove challenges that appear to be system issues.

It is true that surrounding the frontline providers are the administrators. It seems completely logical that administration is there to remove barriers the frontline experiences, take care of day-to-day business, and keep the system viable and functional into the future. And many of administration’s time is spent doing exactly this for providers and the system. Still, providers often feel that administration seems to have its eyes on a focal point beyond the frontline and the challenges they face. This is also true and predictable as providers and administrators are seeing two different views, both valid and key to quality care. Administration has the additional frontline of directives coming down from corporate and from legal and governmental levels, as well as the viability of the institution for future years. This sandwiching of administration leaves them vulnerable to challenges on both frontlines, and feeling like they are sure to let someone down all the time.

Too often, systems speak as though they need to align providers, rather than aligning with providers. The goal here is to align around the key focus of quality care for both administration and providers. Aligning vertebrae requires not just getting the bones back in place, but also soothing and strengthening the muscles and surrounding tissues that will allow the alignment and then maintain the function of the spine. In this analogy we might equate reducing inflammation with increasing trust.

The difficult part for many systems and administrators is speaking the language that communicates how longterm interests and apparent “counter commitments” (community health, system priorities, medical-legal concerns, political-national requirements) align with quality care now. And for good reason. At times initiatives do not (or do not have the appearance of nor clarity necessary to) affirm a contribution to present quality care. For example, the new technology needed is not on the purchasing order or is delayed, slowing productivity and stressing our most valuable resource, people, seemingly unnecessarily. Other times, the longterm benefit of a current action that will contribute to quality care is not communicated to the system or administration from the level above. Other times, there are just too many priorities to attend to the explanations of why we are doing what we are doing, and then the reasoning is left out. Additionally, individuals may have an old school underground belief that states that people should do what they are told without being explained as to why (not a very popular style in today’s age so it is often a covert belief).

So how do we apply quality care as the organizing principle of shared alignment with providers? As with anything lasting, we first intervene with a “soft commitment” of vocalizing our commitment to quality care, and then we embrace a “hard commitment.” A hard commitment is where we lose something if we don’t follow through with our verbal commitment. Like a camera enforced red light, we know we will pay the city if we don’t stop, even if no one is around. Perhaps for example, we articulate that ice cream will be served to all providers every time a quality care issue brought to forum is not duly considered and responded to within a week.

And here is the key to great results when aligning providers and administration. Committing to quality care with transparent and timely communication. This means that when there are questions why a challenge to quality care has not been removed after it has been expressed, that complaint is addressed specifically. This timely communication keeps issues from smoldering into flame over time, especially issues that slip between the cracks beyond sight. Being transparent, on the other hand, is a paradox. We express things that we don’t have answers to and that make us uncomfortable and we expect it to weaken our leadership and influence. But instead, our commitment and vulnerability increases the anti-inflammatory “trust,” opening the ability to align, and setting the foundation for future alignment stability.

Whichever frontline you find yourself faced with or stuck between, consider the vulnerable path that builds the foundation of alignment – trust. Commit yourself (soft and hard) to addressing quality care complaints, and ask for commitments from others to quality care as well. Follow up all quality care issues with transparent and timely communication. And then smile as each challenge to quality care “pops” into place, providing relief and functional alignment together. We may not be able to remove all quality care complaints immediately, but we can address the inflammation (build trust) and prepare for continual aligning together.

As you know well, there are stages of childhood development. For example a time when a baby does not sustain interest in the toy after you place a blanket over it. Or a time when a child looks down from a tall building and believes that there really are miniature people and cars moving below.

As it turns out, adulthood has its own phases of development in the levels of perspectives your colleagues, your superiors, and your direct reports are able to see and consider. Ways they are captured, and currently unable to see past.

Getting clarity about what we ourselves and others around us are capable of perceiving eliminates some of the guess work and disappointment we experience as we lead upwards and lead direct reports. Have you wondered why your colleague continues to say one thing as you two make a plan together, but then not follow through with your agreement? Perhaps he or she is right on the line between being able to see your point (when you are together focused on it), but after leaving your office cannot continue to hold that advanced concept (without you bridging it). No that you know, what are your options?

What are these phases of adult development that are so powerful? Check back to find out! But if you just can’t wait for applications to medicine, search “Robert Kegan Adult Development.” He is a longterm professor at Harvard and has published many fascinating books on our adult capacities and those around us.