One thing that business and healthcare continuous improvement leadership have to contend with, in many ways, is balance. For example, manufacturers try to strike a balance between having just enough inventory to meet customer needs without having too much inventory that would possibly become obsolete. Healthcare leaders can't waste money on overstaffing, but don't want patients to wait too long, either.

We need to find balance, also, in when we employ “top-down” management practices and when we encourage “bottom-up” ideas or decisions… or sometimes we can do both at the same time.

Use Bottom Up Management When …..

• You are looking to innovate – Innovation can come from any person or part of the organization, but it is difficult to produce on demand. Setting up a culture and the tools to support employee generated ideas for innovation is an effective bottom up approach to continuous improvement.
• You need to reduce complexity – It is very difficult to recognize unnecessary processes, procedures, and products from the board room. Front line employees, however, fight complexity every day and are in the best position to point out where it can be reduced.
• Employee engagement is a priority – Employee engagement should always be considered important, but, in many organizations, there are particular times when it is critical to get the most discretionary effort out of every single person. When faced with this situation, bottom up management can help employees feel empowered, and invested in the success of the company.
  
  

Use Top Down Management When ....

• Setting strategic direction – While leading organizations ask employees to solve problems in a bottom up way, it's still appropriate and necessary for leaders to set direction and strategic goals. Leaders might help define what goals need to be met, while asking employees to figure out how to meet them.
• An immediate decision is required and the situation is critical – While bottom up management has many advantages, it is not appropriate for critical, time-sensitive decision making.  When a threat, risk, or opportunity requires speedy action, the decision should come from the top.
• People can’t reach an agreement – Managers shouldn’t step in to settle every dispute, but once in a while, it is necessary to break a log jam of disagreement that is preventing forward progress for the organization. Certainly people should be given the opportunity to develop their negotiation and persuasion skills, but there should be a limit on how much time they get before management intervenes.
• There is a need for reassurance – When organizations go through very difficult times or disruptive change, top down management can provide a sense of security and reassurance to the organization. Some situations simply call for strong executive leadership to overcome employees' fear, uncertainty, and doubt. 

Striking the right balance between bottom up and top down management is tricky, but not impossible. Smart leaders are able to recognize the situations that call for each and adjust accordingly. Doing this well can make the difference between being a great boss and a former boss.