the vision thing

“The Vision Thing”

Healthcare delivery must fundamentally change. To effectively change it, leaders need to envision the future they wish to create.

A metonym was born when the first President Bush spoke dismissively of “the vision thing”. During the 1980 primaries, George Will and others had suggested that Bush lacked the vision for the country that they perceived Ronald Reagan had, and the future Vice President understandably disagreed.

I am increasingly concerned that we have a “vision thing” in healthcare delivery, both nationally and at the level of many of our health systems.

For the first time in anyone’s life, the way care is delivered must fundamentally change. Medical practice and knowledge have reached a level of complexity at which safe and effective care can only be delivered by coordinated teams supported by smart computer systems. And the entire concept of “access” must expand to include neighborhood medical homes, on-demand telemedicine and more. The old paradigm doesn’t work today and is hopeless for the future.

I couldn’t count the number of times I hear the words “transformational change” in a month, and these overused words – though true – have lost the power to convey the magnitude of what must occur. Yet there is no national plan for transforming healthcare delivery, let alone an overarching vision from national leadership. We are haltingly and ineffectively consolidating and attempting to coordinate the world’s largest cottage industry. Other countries get better outcomes at lower cost because even bureaucrats’ plans can work out better than no plan at all.

The barriers to the development of a vision and plans for a nationwide system defy summarization. We do have plans at the health system level, though, and they are often extensive. Stakeholders – medical staffs, nurses, boards of trustees, the community at large – are overwhelmed by the prospect of all this planned change. Over and over we see the challenges of “change management” as leaders attempt to accelerate the change process as stakeholders resist.

What’s missing? That vision thing.

To me, vision is a picture of where a system will be, what it will look and feel like, at a foreseeable time in the future – after the “transformational change” has happened. And I am amazed at how rarely the stakeholders in our health systems have a clear picture from their leaders of the future they are driving toward.

The best plans, deftly implemented, will stall or fail unless stakeholders can see the future they are being asked to create. Health system leaders must paint a vivid picture of their system’s future state, and constantly reinforce that picture along with the reasons it is a better place to be than the status quo.

Pictures of the future vary, depending on local factors and the style of the painter. But I have a sketch, the faint outlines around which today’s leaders might consider laying their brush. These elements must be “in the picture” for the health system of tomorrow.


The regional integrated delivery system is the locus of care delivery for the future and we must consolidate into them. The optimal system is $1-5 billion in size, covers contiguous geography, and can meet more than 99 percent of the needs of 1-3 million people. These can be amalgamated into “polyregional” systems for various reasons, but delivery itself is regional and will be for a decade or more.


Care coordination is the cornerstone of treatment of anyone with one or more chronic illnesses. This requires working in teams, robust communications, and a comprehensive longitudinal real-time medical record that’s user-friendly for patient and caregiver. Regional systems must establish and maintain these records, in relationship with each patient.


There, let’s just use the word. We need computers, with artificial intelligence, to track patients’ progress and advances in medical science, and to enable consistent application of evidence-based care protocols. Caregiver resistance is futile.


We must dramatically expand the locations where and the means by which patients access care. The possibilities are endless.

Those are words, not a picture. But to contribute to – or even just endure – transformational change, stakeholders in a health system must be inspired by their leaders with a mental image of the future they are being asked to create. The picture must be specific to their system and community. The image must be clear, compelling, and effectively communicated through multiple channels. Each artist is unique, but failure to paint is not an option.

Mike Schatzlein, M.D.