ICEBERG Metaphor – A Tool for Healthcare Quality Management Systemic Structure
Keywords:
Iceberg, Healthcare Quality, Systemic Structure, Mental Model, WaterlineAbstract
Like an iceberg, where nine-tenths of the iceberg’s mass is underwater, the essence of an organization’s makeup is not visible to most observers. Those forces that cause an organization to function the way it does and the people in the organization to behave the way they do may not be readily observable. The tip of the iceberg represents the events that occur daily in the organization. The middle layer of the iceberg represents a deeper understanding of the organization as a system by linking events into patterns of behavior. The bottom level of the iceberg, which is underwater, represents the deepest understanding of the behavior of the organization as a system. This level represents relationships among variables in the system that causes the events and patterns to occur. The mental model of “clinical guidelines are used to control physician behavior” encourages organizations to adopt top-down mandates for “cookbook” processes. Alternatively, the mental model of “using evidence-based clinical guidelines to standardize steps of care can actually save physician time on routine interventions so that more time can be spent on the unique needs of the patient” encourages organizations to support and foster clinician involvement in evaluating, selecting, adapting, and implementing clinical guidelines. The concept of systemic structure in organizations and explores lessons and strategies for managers. If managers and organizations are to achieve new levels of performance, managers must begin to integrate double-loop learning into their philosophy and approaches. When managers realize that individual mental models and the organizational context surrounding the concepts described influence how quality management is operationalized in an organization, they may gain a deeper appreciation for the value of teams as systemic structures. This article is an attempt to explore how a systems perspective can help managers improve the quality of organizational interventions.
References
Armenakis, A. A., and A. G. Bedian. (1992). The Role of Metaphors in Organizational Change, Group and Organizational Management 17 (3): 242–48.
Cabana, M. D., C. S. Rand, N. R. Powe, A. W. Wu, M. H. Wilson, P. A. Abboud, and H. R. Rubin. (1999). Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement, JAMA 282 (15): 1458–65.
Clearly, C., and T. Packard. (1992). The Use of Metaphors in Organizational Assessment and Change, Group and Organizational Management 17 (3): 229–41.
GLACIER. (2003). [Online information; retrieved 2/16/03]. www.glacier.rice.edu.
Gordon, S. (2005). Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes and Medical Hubris Undermine Nurses and Patient Care. Ithaca, NY: Cornell University Press.
Hanna, D. P. (1988). Designing Organizations for High Performance. Reading, MA: Addison-Wesley Publishing Company.
Innovations Associates. (1995). Systems Thinking: A Language for Learning and Action. Participant manual, version 95.4.1. Waltham, MA: Innovations Associates.
Institute of Medicine. (1999). To Err Is Human: Building a Safer Health System,edited by L. T. Kohn, J. M. Corrigan, and M. S. Donaldson. Washington, DC: National Academies Press.
Kelly, D. L. (1999). Systems Thinking: A Tool for Organizational Diagnosis in Healthcare. In Making It Happen: Stories from Inside the NewWorkplace, compiled from The Systems Thinker Newsletter, 1989–97. Waltham, MA: Pegasus Communications.
McCormack, B., A. Kitson, G. Harvey, J. Rycroft-Malone, A. Titchen, and K.Seers. (2002). Getting Evidence into Practice: The Meaning of ‘Context’, Journal of Advanced Nursing 38 (1): 94–104.
National Institute of Standards and Technology. (2006). Baldrige National Quality Program Healthcare Criteria for Performance Excellence. [Online information; retrieved 1/2/06.] www.baldrige.gov/Criteria.htm.
Pierce, J. C. (2000). The Paradox of Physicians and Administrators in Healthcare Organizations, Healthcare Management Review 25 (1): 7–28.
Randolph, G., and C. Lannon. (2001). Advanced Access Scheduling: Doing Today’s Work Today, American Academy of Pediatrics News 19 (6): 266.
Senge, P. M. (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday Currency.
Shortell, S. M., and A. D. Kaluzny. (2000). Healthcare Management: Organization Design and Behavior. Albany, NY: Delmar Thomson Learning.
Solberg, L. I. (2000a). Incentivising, Facilitating and Implementing an Office Tobacco Cessation System, Tobacco Control 9 (Suppl 1): i37–41.
Tumolo, J. (2002). Open-Access Scheduling, Advanced Nurse Practitioner 10 (5): 25.
Weisbord, M. R. (1987). Productive Workplaces: Organizing and Managing for Dignity and Community. San Francisco: Jossey-Bass.
