#MEQAPI – Tweetchat June 8th 2017 3:00ET: Tribes and Silos in Healthcare

Topic:  “Tribes and Silos, and, Tribes VS Tribes in Healthcare”

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.


This week we are discussing silos and tribalism in healthcare. The chat is based on the excellent blog “Tribes and Silos, and, Tribes VS Tribes in Healthcare” by Dr. Bernadette Keefe, MD.

Bernadette describes how tribal and siloed behavior plays out in healthcare:

… many errors and misunderstandings in healthcare are, at their core, communication issues  arising from stakeholders speaking and acting from isolated positions.

Since this often leads to waste and error, it is important that we address tribal or siloed behavior and structures in healthcare.

Bernadette covers a wide range of the causes, processes, and effects of siloed and tribal behaviors and structures, but I would like to dwell on one specific area, the patient perspective.

Here is what Bernadette states about the patient experience:


Patients are experiencing multiple pain points, including:

  • Often limited access to data
  • Inadequately represented in research endeavors
  • Lack of time with and incomplete communication with physicians
  • Not enough shared decision making or, often patients are not given enough data or tools to make effective shared decisions. This results in incomplete buy-in and, what is inaccurately termed, non-adherence.

How to improve?

  • Release data from data silos
  • Involve patients in more research AND have transparency of their data and study results.
  • Provide better educational materials for patients online to enable more effective self care between healthcare provider contacts.
  • Create patient care teams to expand the healthcare provider network on behalf of patients, as described in, “Cowboys and Pit Crews” – Atul Gawande MD.
  • Additionally both patients and physicians might appreciate this post.

From a quality point of view this is critical, since we must shape all processes and workflow with the customer outcome in mind. If the structures and processes are not leading to quality and value as seen from the perspective of the patient, then we have failed.

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.


Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Workload: demands of the job, and whether they exceed the resources and ability to meet the demand.
      • Human Resources Policies
      • Traditions and memes
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
      • Access Control
      • Interoperability
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance, bullying, supporting
      • Fatigue (especially alert fatigue)
      • Values and traditions
      • Friends and family
      • Role Models
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Internet sources
      • Employment Handbook
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Incentives and rewards
      • Adverse Effects reporting
      • Disruptive Incidents reporting
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Architecture: location of work areas, gathering places, shared areas

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.


  1. What METHODS increase or reduce silos or tribal behavior
  2. What MACHINE factors increase or reduce silos or tribal behavior
  3. What PEOPLE issues increase or reduce silos or tribal behavior
  4. What MATERIALS increase or reduce silos or tribal behavior
  5. What MEASUREMENT factors increase or reduce silos or tribal behavior
  6. What ENVIRONMENTAL factors increase or reduce silos or tribal behavior


meqapi numbers jun 8 2o17


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.






Published by

Matthew Loxton

Healthcare Analyst using Lean Six Sigma, Knowledge Management, & Organizational Learning to improve healthcare http://linkedin.com/in/mloxton

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