Domains 2018-02-21T11:03:02+00:00

Keeping it simple

‘Transformation’ suggest, by definition, that almost everything is changing, simultaneously. That’s what makes healthcare transformation so ‘wicked’. There is simply no single ‘tame’ solution for it and because of the multifaceted social complexity, many will have to contribute and to collaborate to create adequate solutions. 

At DIRMI we think this multitude of interests, perspectives and possible choices is a great challenge. To keep things simple, we focus on just a few interrelated domains, which we think are highly relevant. At least for an effective START of healthcare transformation processes.

These domains were chosen based on (a) significance in terms of potential effect, (b) alignment with current science and practise and (c) inclusion of as much stakeholders as possible.

Interprofessional practise

Healthcare is a product of collaboration. In the face of increasing complexity, growing demand-supply-imbalance, quality, safety and other issues, effective collaboration in healthcare has gained in attention. Moreover, based on 20+ years of experience we know now that sustainably implementation system change (e.g. integrated care), a culture of safety, innovations like e-health, or any other change of scale, all require health and care providers to interact more effectively.


From safety to connectivity

Mainly ignited by the disclosure of severe patient safety issues, as of the end of the 20th Century, the science of team work and interdisciplinary collaboration gained greatly in attention. Furthermore, current generation of IT innovations creates unprecedented possibilities. However, their implementation are accompanied by so-called disruptive change, entailing impact-full re-alignment of and shifting between tasks and responsibilities within and between professions.

While intra-team effectiveness is just becoming standard a topic in most health and care organizations, inter-team and -professional issues within complex networks emerge as a next frontier. These developments impact the way things are -or should be- done with such speed, that even more unknown territories emerge, like: complex adaptive systems, inter-professional training, virtual teams, etc.

New ways

Transformation requires adapting every-day working habits of professions that have been trained and matured the ‘old-fashioned way’. This includes the new-be in the team: the client/patient and informal caregivers.

At DIRMI we collect and synthesize expertise, old and new, to explore new avenues of collaboration between people. We ask ourselves:

  • Providing care in and across continuously changing teams and networks: how does that work?
  • How can we create, sustain and measure effective integration of inter-professional work at regional, population management based, level?
  • How can we help change deep-rooted professional cultures of relatively silo-ed autonomy into new, agile e-health assisted inter-professional teamwork?
  • What skills, competencies and knowledge does the 21st Century healthcare workforce need?
  • What existing science and best practises in transforming towards network-based collaboration, which have proven to be effective in other industries, COULD be effective in healthcare?

Our aim is to create insights in dynamics of re-designing professions and their interconnecting boundaries, as well as best ways to do accomplish this.


Leading yourself, change and people. More and more this is what is expected of professionals in healthcare. The meaning of ‘leadership’ has evolved far away from its authoritarian definition, and is currently even beyond the relatively modern construct of ‘transformative leadership’. Working in ever changing networks, enabled by information and communication systems with unprecedented capabilities, professionals, informal carers and clients/patients as well as intelligent and learning machines are working continuous simultaneously side by side. Being effective in modern healthcare teams requires ‘leading in-the-moment’ skills, on top of profession- and specialty-specific competencies of most, if not all, professionals.


Medical ‘leadership’

Historically, healthcare is organized ‘around’ the work and role of physicians. Despite the various changes and even rapid innovations across the healthcare arena, the much contested position of the medical profession is often discussed when it comes to determinants of sustainable innovation. Institutional agency to adapt to the current shifts between professional boundaries, have resulted in the trend of ‘medical leadership’ in several countries. Not surprisingly, the two topic within these new competencies of physicians, entail ‘collaborative skills’ and ‘personal development’.

Against all odds?

A new generation of professionals, innovative content in training curricula, the modern patient and more external societal trends strongly influence healthcare professional’s make up in terms of attitude and behaviour. Unequivocally, research, field experiences and society urge us to start rethinking the modern healthcare professional. Working in an ever-changing patient-centred setting, she/he must be skilled in continuously adapting to the challenges of effectively working with a high paced stream of all kinds of people, while adequately using information and intelligent systems.

In this perspective we enter relatively new terrain of professionalism mainly based on taking initiative, speaking up and listening simultaneously, organizational sensitivity, and other social skills, while the majority of the contemporary professionals has been educated the ‘old’ way.

New Professionalism

Ancient professional culture and various unwritten rules often still dominate healthcare practise. Moreover, in general proven, evidence based healthcare innovations takes up to 15 years to be sustainably implemented. Hence, a power-contest between doing things the ‘old’ and the ‘new’ way. To overcome this impasse, change should also come from within professions itself. Maybe, physicians have taken the lead, lately, with their attempts to ‘rewrite’ their historical dominant, autocratic position, into ‘medical leadership’ (although the literature suggests that ‘nursing leadership’ appeared several years earlier).

At DIRMI we investigate novel ways to influence and facilitate modern professional agency, possible one of the most important institutional building blocks to sustainable healthcare transformation.

Collaborative governance

Collaborative transformation, in a collaborative practise, with collaborative people , collaboratively leading themselves, change as well as others? It all sounds like a fanciful, unrealistic fairy-tale. That is: if we forget to think about new ways of governing the entire transformation process as well as the foreseen ‘new’ paradigm of continuous change. Governance, as we see it, relates to processes between all thinkable institutions in healthcare. Including interactions between various field-actors involved in boundary-crossing leading us to those new set of norms, institutions and how-we-do-things-here in healthcare. We like to think of ‘collective governance’ as the framework that helps to keep it all together. Collectively.



At any point in time, an overarching set or principles, rules and regulations must be in place to maintain the highest possible healthcare quality. Currently, dynamics of healthcare transformation require regulators, managers and administrators to find novel routes, unchaining the potency of innovations and new ways of working across various domains and professions, while maintaining high levels of trust between them. However, while healthcare is increasingly becoming more complex, the current generation of well-meaning and often also overworked ‘regulators’, in their attempts to regulate, operate ‘high-speed regulation production lines’. This all evolves into a field of over-administrated and -regulated professionals. Burn-out and even worst is trending in healthcare. Unfortunately. This should change. Rapidly. However, who knows HOW? How to BEND the rules without those MAKING and MONITORING them?

Actors in Governance

Historically, in general, those ‘governing’ healthcare have not always been necessarily the ones also ‘making’ healthcare. This principle is shifting – a sign of transformation itself? For example, scientific research has shown the benefits of medical representatives at board level of hospitals, resulting in significantly higher effective organizations. Similar research in the field of change management is repeatedly suggesting that taking a collaborative approach, including having employee and patient/client representatives on board, results in much higher success rates of (e.g. e-health) and other innovations.

Principles of governing is increasingly characterized by a narrowing of the former top-down and bottom-up division of stakeholders. Nevertheless, we will always need people governing as well as we need people with ‘boots-on-the-ground’. And everything in between we cannot do without.

Top or bottom

Although it is not easy to recreate reality, at DIRMI we do fancy the idea of a total recall of old governance principles in healthcare. All this will impact our ways of thinking, acting and reacting. In particular at board-level, in healthcare human resource, and within our politics, professional organizations and regulatory organizations. We think that top-down and bottom-up speaking and listing holds the magic of collaborative governance. Are you listening?