The Guide to Integrative Performance Improvement for Healthcare Organizations:

    Healthcare providers are in a tough spot. They’re dealing with a complex set of problems: rapidly changing laws, dozens of different rulesets from insurance providers, thinning margins and increasing patient expectations for healthcare.

    Between these problems and a proliferation of different performance improvement initiatives, it can feel like there’s neither time nor energy to actually serve patients.

    As a result, being a healthcare sector manager can feel like an endless game of whack-a-mole. Each time you solve a problem, 2 new ones appear. It doesn’t help that qualified help is harder than ever to find right now.

    So what can managers and organizations do?

    Is there a way to cut costs, improve healthcare quality and free up medical and executive staff while remaining compliant?

    The answer’s simple. Yes; there is.

    An effective approach that drives positive change without relying on flavor-of-the-month initiatives and methodologies exists. Even better, it’s simple to learn and teach.

    The approach we’re talking about is extremely effective because it mobilizes your existing assets, processes and employees and helps them achieve peak performance while reducing their workload.

    I know this might sound too good to be true, but my name is Oleg Tumarkin – and as a performance improvement coach, I’ve introduced it to dozens of organizations around the world and seen it work first-hand.

    The approach is called integrative performance improvement, and it takes underperforming, overwhelmed healthcare organizations and turns them into high-performing outliers while asking management and medical staff to do less.

    If traditional performance improvement is invasive surgery than this integrative approach is a combination of effective therapy and new, healthy habits.

    The integrative approach doesn’t demand instant, radical change; instead, it slowly but surely transforms an organization from the inside out without stressing its employees or overhauling existing systems.

    In this article, I’ll introduce the integrative philosophy, explain how it’s different to other performance improvement methods, and give you a 4-step guide to making it work for your own organization.

    I’ll start by explaining why the healthcare sector is in such a bind and how the integrative approach offers a much-needed alternative to what’s happening now.

    The Current Status Quo

    Most healthcare providers deal with 4 key problems:

    Tight, constantly changing regulations. State and federal regulations change all the time. Knowing, understanding and following through on them takes effort and self-awareness, and most organizations still come up short from time to time.

    Compliance with insurance providers. Maximizing payments means complying with each insurance providers’ unique ruleset. This adds another level of complexity that’s hard to address without tight discipline and constant collaboration.

    Entry-level staff turnover and training. Non-medical personnel is often disengaged and undertrained. This means medical and administrative staff has to get involved, draining time and energy from the most qualified members of an organization. As a result, disengaged, demotivated and undertrained non-medical personnel drive up costs and employee turnover.

    Poor coordination. Most healthcare managers come from functional backgrounds and have limited cross-functional communication skills. This makes the average healthcare organization fragmented, with teams and employees that don’t understand each other.

    The overarching theme is that managers in healthcare athe lready have too many initiatives to deal with, too much change to process, and too little time to get everything done.

    Navigating these 4 problems is enough of a challenge as is; coming up with effective ways to improve internal processes is simply not realistic.

    Part of the problem is that the management skills needed to make good decisions, work in concert and organize team members can’t be (and aren’t) taught in classrooms. These skills can only be developed with deliberate practice in the workplace. Without them, healthcare organizations routinely suffer from communication issues, political infighting, misunderstandings and destructive micro-management.

    Subscribing to yet another performance improvement initiative can’t solve these negative “symptoms” because it doesn’t address their underlying causes on a practical level.

    This is where the integrative approach comes in. Instead of overwhelming team members with classroom learning, initiatives and more textbook knowledge, it helps them do better through self-observation, coaching and feedback.

    Instead of draining executives and qualified medical personnel, it empowers workers of all levels to do a better job and reinforces higher standards throughout an organization.

    Instead of being a resource drain, it helps organizations meet budgets, government regulations, insurance providers’ asks and patient expectations.

    Below, we’ll introduce the integrative approach by outlining how it works and covering the 4 steps of its application.

    Defining the Integrative Approach

    Traditional performance improvement relies on one or several tools and methodologies to improve performance inside specific functions.

    The problem is that healthcare organizations’ needs run across functional boundaries. Just as a human is not a collection of independent body parts, so an organization is not just a set of functions and departments.

    This is why it is important to look at the organization as a whole, without being biased towards any one particular methodology that addresses a specific function. Function-oriented methodologies can’t and don’t address this – but the integrative approach can.

    Specifically, integrative improvement helps unlock organic processes inside an organization, rather than imposing new rules and procedures on it. It relies on non-invasive techniques and new behaviors and systems to create healthy, vital organizations that are capable of peak performance in the long run.

    Of course, if we discover acute problems that can benefit from a specific process improvement methodology, we address them as well – but only with the big picture in mind.

    In short, the integrative approach to organizational improvement and management:

    • Treats each organization like a complex ecosystem that has to work in concert.
    • Empowers employees by giving them the skills, knowledge, and motivation they need to do well without distracting them from their day-to-day work.
    • Equips all workers, including entry-level medical and admin staff, to overcome minor problems on their own, and to collaborate with others in ways that are helpful to the overall organizational performance.

    The integrative approach goes beyond reaching a specific goal or fixing a single problem. It strives to create an organization that works effectively, spearheaded by leaders who consistently drive better results, processes and team habits.

    It’s like treating obesity and heart problems with a combination of walking, healthy eating and yoga. It’s slow, it’s tough, but it works. The traditional approach, in comparison, is like going through quadruple bypass surgery – then celebrating with bacon and cigarettes.

    Now that we’ve defined the integrative approach, let’s take a look at how it actually works.

    Step 1: Daily Check-Ins/Touches/Pings

    Many healthcare organizations are fragmented and dysfunctional to the point that their employees and departments neither work in concert nor understand how they’re supposed to.

    If information is the life-blood of the organization, we can honestly say that most organizations have a weak, arrhythmic pulse that does not even reach many of its extremities.

    You can quickly see how well an organization fares by walking into any department and asking anyone what their teammates’ priorities are right now.

    Even better, ask what the organization’s overarching goals are. For best results, start by quizzing functional executives about what another executive’s priorities for the week are – and work your way down the hierarchy.

    In the overwhelming majority of healthcare organizations, you’ll find that management sometimes gives meaningful responses. Still, by the time you go to middle-management and client-facing personnel, most people struggle to formulate their goals, let alone those of their colleagues or the organization.

    That’s why the very first step of integrative performance improvement is to improve information flow by making sure an organization’s disparate parts are connected and in sync. The simplest way to achieve this is with brief daily check-ins within and across teams.

    Daily check-ins:

    • Connect employees and teams
    • Help employees and teams relate to and understand each other
    • Make it easy to spot other problems

    Many managers fret that daily check-ins are painful, difficult and/or inefficient. The common stereotype is that of a long unproductive meeting.

    This is a misconception. Daily check-ins don’t have to be long or cumbersome.

    And if you really think about it, you’ll realize that all effective organizations already practice them. From family dinners to morning roll calls to water cooler conversations, check-ins are a natural part of any team or organization, and that’s exactly how they feel when implemented correctly: organic and highly effective.

    The key is to find non-obtrusive ways to make daily check-ins work for your organization. Employees can make their daily check-ins in small, cross-functional groups; they can do them digitally; they can pick check-in times that are convenient to the team.

    What matters is that daily check-ins are implemented, because they set the stage for integrative improvement with 3 major benefits:

    Improving performance. Daily check-ins encourage employees to plan ahead, analyze completed work and share it with their colleagues. This promotes continuous improvement, discipline, and understanding: key ingredients of peak performance.

    Promoting learning. Daily check-ins give everyone an opportunity to ask questions, communicate with others and receive feedback on past performance. They naturally lead to knowledge transfer and co-learning.

    Building trust. A linear approach to management can make employees feel isolated and managers scrambling for feedback. Daily check-ins reveal what’s really happening at any given time, building trust and rapport while highlighting problems employees are dealing with.

    In the short run, daily check-ins give an organization a “pulse”, building the foundation of a healthy organization.

    Over time, daily check-ins help teams understand workloads; improve cooperation; build trust and cohesiveness. They create a solid foundation for an effective, self-improving organization.

    Once daily check-ins have been implemented, the next step is to diagnose what’s holding performance back, and what can be done to improve operations.

    Step 2: Identifying Key Performance Drivers and Constraints

    Daily check-ins highlight the teams, processes and practices that most need improvement. They can also reveal the drivers and constraints affecting an organization’s performance.

    This is important, because it helps us precipitate and pre-empt information inversion: a problem wherein we focus on easy-to-measure but irrelevant variables over important ones that are hard to measure precisely.

    Here’s a real-life example of information inversion to explain what we mean. A clinic’s manager received a number of complaints from patients who said that they felt lost while at the clinic. She decided to fix this by having staff check in on patients more often.

    By asking nurses to approach patients more often, she achieved her goal: the number of complaints plummeted. This made sense. An increase in the number of employee-to-patient touches is easy to measure and monitor. This quantity of communication metric, however, was not the best proxy for making sure communication happened.

    What the manager didn’t consider was the cost. Now nurses had even less time to fulfill their other duties and constantly complained about being understaffed.

    The number of touches increased and patient complaints decreased, but only at the cost of an important performance driver: the availability and energy levels of the nurses.

    A simpler solution that the staff identified, once they got involved, started with identifying the real problem: not communicating key information in a way that addressed common questions patients had.

    To address this problem, the team developed a quick communication checklist that reminded all staff to do two things:

    1. Brief patients about the clinic’s processes immediately upon their arrival.
    2. Remind staff to keep patients updated on what’s next, advising on wait times and steps to follow after every interaction.

    With a bit of practice, patient feedback actually improved while the number of touches dropped. Employees provided better directions, which in turn meant patients knew what to do at any given moment without further instructions.

    This made patients happy and freed up the nurses from constantly having to check in on them. In other words, there were less employee-to-patient touches, fewer complaints and smaller wait times – a win-win-win for everyone. It however, relied on shifting focus from a very easy metric – quantity of communication, to the much harder to measure quality of communication.

    This, in a nutshell, is why all process improvement needs to focus on salient performance drivers and constraints. Once these have been identified, they need to be made visible to all organization members – for example, by:

    1. Making key metrics top-of-mind through discussing them in meetings; covering them in daily check-ins; focusing on them during performance reviews.
    2. Helping each individual employee understand and spell out how their performance contributes to an organization’s key metrics. The idea here is to make it easy for employees to have people take pride in their work, understanding how their contribution helps drive overall success.

    Once we’ve identified an organization’s key metrics and made them a part of operations, it’s time to move on to our next step.

    Step 3: Developing Internal Champions

    With the integrative approach, the end goal is to bake continuous and breakthrough improvement into the organization on all levels. This means developing internal champions and giving them the tools, knowledge, and power they need to drive more positive change going forward.

    Two kinds of employees are perfect candidates for this. The first category is managers with prior experience in Lean, Six Sigma, Operational Excellence and other frameworks who just need to develop their communications and human relationship skills and adjust how they do their work slightly.

    Giving these people the freedom to improve operations, as well as developing their coaching and cross-functional skills, is a powerful way to improve organizational performance.

    Another approach is to take existing staff eager for more responsibility and orient them towards performance improvement.

    Some will take on PI tasks as an added responsibility; others will turn into informal leaders; a third category may switch to a completely new role, e.g. an administrator becoming a patient advocate that bridges the gap between patients and medical staff.

    Key processes of this step are:

    • To involve people across all hierarchy levels and roles;
    • To identify improvement opportunities and direct employees towards them;
    • To motivate employees with rewards and extra responsibility, e.g. by fast-tracking internal champions to management positions;
    • Guiding internal champions using outside coaching, internal reviews and mentorship.

    Once we’ve identified key performance drivers and constraints, made them clearly visible across all levels of an organization and developed internal champions, integrative organizational improvement becomes a matter of habit.

    At this point, it’s time to move onto the last stage of the integrative approach.

    Step 4: Continuing to Improve

    The integrative approach may be simple, but it’s not easy.

    Like integrative medicine, it’s less of a finite system and more of an ongoing commitment to peak performance and excellence. It is not a quick-fix solution. Once implemented, it shows superior results – but sustaining and improving on them takes time and patience.

    What does this mean in practical terms?

    For starters, as internal champions continue to evolve, organizations need to support their development. This means training them in coaching, opportunity assessment, continuous and breakthrough improvement. This means guiding them to develop cross-functional relationships and support others in the performance improvement.

    Second, the management needs to constantly encourage various feedback mechanisms. By ensuring that the information flows freely throughout the organization, they can enable everyone to participate in ongoing improvement.

    Third, it’s important to dedicate resources to integrative organizational improvement. It’s a strategy that works in perpetuity once implemented. Yet, like any deliberate effort, it needs a bit of time, energy and budget to deliver consistent results.

    The reason is that while Integrative performance improvement works very well on its own, it works even better with external support. Specifically, there are several things that are difficult or impossible to do without an outside observer.

    The Value of an Outside Observer and Expert

    The first and most important thing an observer does is is hold up a mirror to the organization, helping it become aware and eventually self-aware.

    This is possible thanks to structured observation and feedback. Internal managers, especially ones with limited cross-functional and cross-organizational experience, don’t always notice what their organization can do better, or understand how the changes they introduce will impact other parts of the organization. They’re also often overwhelmed to the point where they can’t tackle the problems that they do understand.

    An outside observer can step in, helping internal staff calibrate their performance assessments and taking pressure off management. He or she can also move up and down hierarchies easily, connecting with workers on all levels of an organization: something that internal employees can only do once a very high level of trust has been developed internally.

    The second thing an outside observer does is bring in a new set of skills and competencies. They can give employees and managers a new, fresh look on operations and existing systems. They can also help the organization develop awareness of methodologies that would otherwise be unavailable.

    Perhaps more importantly, outside observers are uniquely placed to offer short-term impact and guidance in long-term organizational improvement.

    With the former, they can apply their expertise to quickly fix important, pertinent problems. With the latter, they can help management identify and develop internal champions with new frameworks and processes by:

    • Offering individual coaching and skill development
    • Providing methodology-specific training across methodologies
    • Enabling and guiding practical, on-the-job learning

    Most importantly, an outside observer is just that: an objective, neutral, qualified outsider. Doctors see other doctors to get treated, even if the help they need falls under their own expertise. Using the same logic, it makes sense a healthcare-sector manager to rely on external consultants and managers to give their organization the perspective on the care it needs.


    At this point, we’ve set up all the processes and functions we need for an organization to improve its own performance on a consistent basically. Specifically:

    1. We’ve created a cohesive, coordinated organization with daily check-ins.
    2. We’ve diagnosed our key performance drivers and constraints, as well as how we can improve them.
    3. We’ve started identifying and developing internal champions that will galvanize other team members and drive improvement on an ongoing basis.
    4. We’ve devoted resources and time to making sure there’s room for integrative organizational performance to keep moving forward.

    As far as fundamentals go, that’s all there is to integrative performance improvement. Once these elements are in place, a healthcare organization will offer better care; find that its members are more cooperative and fulfilled; have an easier time complying with federal, state and insurance provider regulations while cutting costs.

    The best part is that any integrative performance improvement effort drives better results from inside the organization, rather than through an invasive corrective effort. This means that initiatives based on these principles work better, stick for longer, elicit less internal resistance and leverage existing assets.

    At this point, I’d like to thank you for reading this guide to integrative organizational performance improvement through the end. You’ve just learned a broad range of tools, methods and strategies – and I’d like to hear about your own PI journey, challenges and all. What have you tried so far? What will you do differently having read this article? What did you learn? Let us know; your thoughts are valuable to us.

    Oleg Tumarkin