What it needs is great microsystems (units and practices).  What I’ve observed is that mesosystems are often workarounds. They are created when the macrosystem fails to or can’t support the development of microsystems (units and practices) in such a way that they are high functioning, effective learning, and capably connecting units.  Mesosytems take many shapes [separate business entities or divisions, service lines, discipline silos (e.g. nursing services and medical staff), middle managers, committees, work groups, etc.].  Special effort needs to be taken to not create too much waste when putting a mesosystem in place.

How the mesosystem is set up and structured is important. Many children’s hospitals within a hospital are set up as a mesosystem. It make sense, because the business of children’s hospitals is different from the business of adult health care units. However, the children’s hospital needs to be big enough to warrant the investment of its mesosytem.  Supporting functions that become mesosytems are also typically not lean and create significant waste.  The best example of this in health care organizations is the separation of nursing services and medical staff into large mesosystems.  It often creates waste.  This isn’t to say that creating connections among disciplines isn’t helpful, but it needs to be done in a way that limits waste and maximizes the functioning of the microsystem.

The question for every health care organization ought to be: what does it take to have high-functioning, effective learning, capably connecting units or microsystems?  At the microsystem level is where the output and performance of the organization matters the most.  The manager(s) and leader(s) of those units need to be effective at managing processes and leading people.   They need to be good at connecting with the leaders and managers of other units, and they need to be good at managing up to their bosses. They need ready access to and processes that effectively connect them to support systems (e.g. HR, Finance, IT, facilities, etc.). They also need to connect well with other units or microsystems where they share patients and critical interdependencies. And finally they need to be well connected to the macrosystem leadership. Achieving this isn’t easy, but creating a complex set of mesosystem workarounds isn’t the leanest approach.  So, it needs to be deployed carefully, and in some cases not deployed.

Good managers and leaders of microsystems are capable of driving continuous improvement and adaptation through team learning and robust quality improvement. Learning takes transparency, a just culture, and coordinated teamwork. Processes have to be mapped out, visible and constantly scrutinized through daily management.   Robust quality improvement processes and tools need to be in place with skills and knowledge of quality improvement integrated throughout the team. The ideal would be to embed these attributes into the microsystem, not leave them up to a mesosystem to do them.  Support services are just that.  They are there to help the microsystem and are embedded in the microsystem as much as possible.