#futureofmeded: The ITSO model to optimize systems-based medical education and patient care

By: Dan Dworkis (@TheEmergMind) and Felix Ankel (@felixankel)

The Case Part I

You are an associate dean for medical education at an integrated academic health system. At an all-hands retreat earlier in the year, operational leaders identified the delivery of time-sensitive cross-disciplinary care as a key opportunity for improvement in cases such as acute stroke and myocardial infarction management.  Where multiple services were involved, there seemed to be a lack of “systemness” when different departments needed to work together under time and resource pressure.  As these clinical services have a high concentration of learners you are asked to develop a process of improvement for learning and clinical care.

You enthusiastically take on the challenge, as you have previously advanced the concept of “graduate medical education as a strategic asset” to the health system.  You believe that this patient centered focus among training programs will help promote system wide competencies such situational awareness, transprofessional collaboration, and “teaming behavior”.  You optimistically set out plans to train medical staff and learners in their piece of the puzzle. A quarter or two later, however, your system is no closer to meeting pre-defined metrics, fallouts are common, morale is sinking, and friction within and between departments is increasing.

Looking through the data, you confirm that each department has done a great job with training modules for every involved individual. So, what is the problem? Why is your system not getting any better despite individuals receiving high-quality training? How should you guide medical education in your health system?

To better understand the strengths and weaknesses of your current approach, you look at the challenge from a systems lens.  You see that to have true systems thinking, you need to build antecedent disciplines (personal mastery, mental modes, shared vision, and team learning.  You realize, that in your case, although there is personal mastery, a mental model to facilitate a shared vision and team learning is missing.   To plan your next steps, you turn to a mental model called the ITSO Matrix developed by The Emergency Mind Project and start mapping out what’s happened so far.

Background: Systems and Performance Under Pressure

The way any organization performs under pressure depends not only on the components of that organization, but also on the complex, multi-level interactions between them. Systems are more than just the sum of their parts.

Unfortunately, medicine and healthcare systems tend to take a narrow view of performance under pressure that is overly focused on individual level behaviors and temporally at the moment of action. In this world view, success or failure of the system tends to rest on what one person does at the moment of performance: did Dr. A perform critical Task B well and quickly enough when called upon to do so? The reality of organizational performance, however, is much broader and more complicated.

To illustrate this, consider a different type of high-performing organization: a top-level basketball club. Obviously, the club’s success or failure depends in part on how much the team’s captain scores during, say, the 3rd quarter of a particular game. But to say that the captain’s ability to score during that quarter is the only thing that matters to the overall performance of the club that season is too simplistic. It ignores the work of the rest of the team on the court, the performance of the team on defense, what the team did to recover from their game yesterday and prepare before the start today, the work of the coaching staff in selecting a balanced group, how the culture of the club is expressed in making decisions or handling mistakes, and a host of other factors.

Understanding and evaluating the performance of a system under pressure requires looking at that system across multiple levels that includes but goes beyond just individual performance. It also requires looking at the system across multiple points in time that includes but goes beyond the exact moment of performance.

The ITSO Matrix

The ITSO Matrix is a mental model in the shape of a 3×2 matrix that serves as an organizing device to help you see this broader picture.

The matrix’s three rows frame the structural levels of organization within which medical care (or another skill like basketball is delivered, starting with the Individual (I), then the Team (T), and finally the System (S) or overall structure.

The two columns split time into either “On-the-X” or “Off-the-X” (O), where “the X” is the moment of critical impact during which your system needs to perform.

A few examples to help illustrate this: identifying a potential acute stroke at triage is an individual, on-the-X skill, so would fall in the top left of the matrix. Completing a training module to help identify acute strokes is an individual, off-the-X skill, placing it in the top right. Undertaking a morbidity and mortality (M&M) conference when an acute stroke is missed is a team level, off-the-X event, so middle right.

Unfortunately, those three activities are where many health systems currently stop in their medical education, leaving significant holes in the matrix where no medical education programs exist. An example of a system level, off-the-X event would be diversity, equity, and inclusion work designed to select and hire exceptional candidates to multiple positions across teams that strengthen the culture and function of your whole organization.

Elite organizations understand that high-level systems performance requires training, action, and reflection in all parts of the ITSO Matrix, not just in the obvious sections on individual behavior at the moment of performance.

Applying the ITSO Matrix

The ITSO Matrix can be applied analytically to map existing strategies for medical education and performance, or prospectively to explore and contextualize potential future strategies and interventions.

Analytically, the ITSO Matrix functions like a multi-dimensional analysis of strengths and weaknesses, allowing your team to examine your existing strategies across levels of organization and points in time. Essentially, it’s asking the question: “What do you currently do at the Individual, Team, and Systems levels, on and off the X to improve performance?”

If most of your organization’s energy is focused on the upper left of the matrix (a common situation in medical systems), then additional work on team and systems level interventions might yield improved results. Conversely, if your organization is overly focused on the bottom right of the matrix (perhaps with multiple corporate retreats and planning meetings but no focus on implementation), you run the risk of setting lofty priorities that might be impossible to accomplish.

The ITSO Matrix can also facilitate comparisons between organizations for idea generation. Does another hospital in the health system have a vastly superior myocardial infarction program than your team does? What does their ITSO Matrix show they’re doing differently than you are? Is there a program or programs you could learn from and adopt?

Prospectively, the ITSO Matrix functions like architectural plans to guide a common vision of where your organization is going. Identifying holes or areas for improvement in your current educational strategy provides options on potential paths forward beyond more of the same actions. Are more online training modules to help triage staff identify acute strokes the answer? Perhaps not if you’re already maxing out the upper left of the matrix and ignoring the rest of it.

In this way, you can leverage the ITSO Matrix to provide crucial context for your choices and improve your organization-level communication. Rather than simply announce a new educational directive, framing your path forward within the ITSO Matrix allows you to explain the why behind your choices to your staff, your funding organizations, or both.

The Case Part II

Applying the ITSO Matrix to the problem set facing your organization, you look at the challenges and your existing resources to address them. So far, each department seems to be focused on the upper left part of the matrix, in the individual-on box with training modules and certifications for providers. Each group does have existing morbidity and mortality (M and M) conference, so there’s some existing structure in the middle right / team-off box. Additionally, your organization identified provision of time-sensitive cross-disciplinary care as a priority. That’s a system-level process, but does simply identifying a priority really count as a resource? You hesitate to put it in the system-off box at the bottom right.

What is clear is how empty the rest of the matrix seems, and how much room for improvement there is. Bringing together the heads of each department, you use the ITSO Matrix as a tool to non-judgmentally start a conversation around how to improve as an entire system.

As a challenge, you ask them to think about what you could do collectively to improve and meet your common objectives without any more effort going into the individual-on box. Where else could you be focusing your educational efforts? Inspired by a new way of approaching the problem set that goes beyond more mandated modules, the department heads lean into the task and focus on the empty parts of your ITSO Matrix.

Three priorities emerge: first, communication within a treating team and between different treating teams during the actual medical care needs to be improved. Poor communication hampers multi-disciplinary action, while good cross-team communication amplifies the success of individual actors. Training this type of communication sits on the bottom left of the matrix, spanning the team and systems level on boxes.

Second, to accomplish this cross-team training, your department heads realize they need to build a cross-team working group that meets regularly to identify needs and set priorities that go beyond traditional team boundaries. Since this working group would span multiple teams, it sits in the system-off box on the bottom right of the matrix.

Finally, the department heads suggest trialing a multi-group M&M conference instead of multiple individual M&M conferences for cases that involve time-sensitive cross-disciplinary care, effectively growing M&M beyond the team-off box to include part of the system-off box as well. This new type of M&M (and the other interventions the department heads identified) will require new ways of thinking and acting, and the heads turn to you as the dean of medical education to help them learn how to execute these strategies.

Armed with these new ideas and priorities, your system and the teams and individuals it’s comprised of look ahead to a better and more-productive second half of your year. Morale is improved, educational objectives are set, and it’s time to get to work.

Final thoughts

  1.  #Meded is a complex adaptive system.  Use systems-thinking to grow and build graduate medical education (GME) as a strategic asset for health systems.
  2. Although personal mastery is foundational for #meded leaders, applying and sharing mental models facilitates a shared vision, team learning, and system growth.
  3. There are many forms of mental models (see here and here for two examples). We have described the ITSO mental model to catalyze systems-based education and practice.


1. Dworkis D. The Emergency Mind: Wiring Your Brain for Performance Under PressureSangfroid Press. 2021

2. Edmondson A. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge EconomyJossey-Bass Pfeiffer. 2014

3. Senge P. (revised 2006)The Fifth Discipline: The Art and Practice of the Learning OrganizationDoubleday.

4. Warm EJ, B Kinnear, S Lance, DP Schauer, J Brenner. What Behaviors Define a Good Physician? Assessing and Communicating About Noncognitive SkillsAcad Med. 2022;97(2):193-199.

Photo Credit: iStock

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