The Blunt End vs. The Sharp End

Clinician leadership. Integrated health system. Accountable Care Organization (ACO). These are the concepts and words being discussed, debated, and defined at our Winter Institute in Naples, FL over the past few days. They’re the same words and issues I heard last week at one of the nation’s premier MHA programs. We’re talking about strategies, structures, compensation methodologies, alignment challenges, and the economics of integration. Why are these topics at the “top of the charts” of what both physicians and non-clinical health system leaders are listening to, and talking about?

First, many health systems and physician groups are anticipating changes in payment that reward quality, outcomes, and safety – regardless of whether any health care legislation emerges from Washington. Clinicians with additional knowledge competencies in integration strategies, compensation methodologies, will be vital to successful implementation of integration strategies.

Second, for medical groups and health systems to be viable economic enterprises, the bottom line must reflect improvements in quality and patient safety. One of the questions discussed in the Advanced Quality course was, “What’s the cost of a Never Event?” The discussion included a financial analysis of Never Events and complications, AND how to mobilize clinicians to develop better communication techniques, and change the culture of the entire organization to address the cost of poor quality and outcomes.

The power and importance of clinician leadership can be summarized using a concept familiar to system safety engineering and accident investigation. It’s called the sharp end-blunt end model(1) of how organizations and the people who work in them interact. Imagine an inverted isosceles triangle representing an organization. The blunt end is where boards and senior organizational leaders develop missions, strategies, and goals for the organization. The sharp end is where the organization’s people, processes, and technology touch its customers (patients). In health care it’s what happens to a patient, in the ED, ICU, lab, radiology, ambulatory care, etc. When an organization’s mission, vision, values, and goals are translated into appropriate specific individual human behaviors and actions at the sharp end consistent with blunt end strategies, it’s performing at a very high level.

Clinicians are intimately familiar with activities and behaviors at the sharp end, because that’s where we’ve spent many years of our lives. We’ve experienced the frustration of inefficient work processes, and understand how harm can occur to our patients. Now imagine a clinician entering strategic and operational discussions at the blunt end. There’s tremendous insight and wisdom that can be contributed to decisions about what to improve, how to improve, and what observable behaviors at the sharp end will indicate that improvement is happening.

Just being a clinician isn’t enough to be effective in a leadership or management role. We have to learn about strategy, influence, basic health care finance, and organizational dynamics to really be effective in making change happen. Just as we have our own language and thinking styles, non-clinical leaders have theirs. Breakthrough change comes when new insight emerges from understanding how solving your problem can solve someone else’s problem at the same time. Ask yourself what value you can bring to an integrated system, ACO, clinic, business, or workplace in the health care sector. Maybe it’s traditional one-on-one patient care at the sharp end. Maybe it’s that, plus helping out at the blunt end to design a system that works first for patients, and secondarily for the professionals – both clinical and non-clinical – who care for them.


(1)Cook RI, Woods DD. Operating at the
Sharp End: The Complexity of Human
Error. In Bogner MS, ed. Human Error
in Medicine. Hillsdale, NJ: Erlbaum and
Associates; 1994:255-310.