The changes to health care — not just in policy, regulation, and payment but also the tectonic shifts in how we define, evaluate, report and are paid for care — can make us all feel like we’re on a runaway train.

Alongside the runaway train are the significant improvement opportunities in health care we must somehow address — less variance, improved patient engagement, coordination of care, adherence to evidence, waste reduction as well as taking on physician burnout and staff engagement, to name a few.

As we grapple with the reality and challenges that abound around our goal to “make health care better,” we have to first ask: How do we lead this kind of change? As leaders, do we broadcast a set of expected outcomes, then set goals and hold people accountable to them? Can these kinds of top-down mandates, born from policy and regulation changes, actually engage the people who are delivering care? And what about helping us each commit as individuals to the very behaviors needed to transform care: Does someone else enforcing rules create that kind of initiative?

I wouldn’t pretend to have all the answers to these questions. What I do know is this: If we are to harness the full potential of those professionals touching patients, our top-down mindset won’t cut it. Over the last 15 years, I have watched, interacted and experienced individuals and teams doing extraordinary things. I have also seen an epidemic of frustration, despair and an “I-would-quit-medicine-today-if-I-could” sentiment.

While we reflect on the goal of “making health care better” in the context of a top-down environment, let’s ponder a few questions:

How does the top-down environment impact the commitment of people called to do this intensely purposeful work?

What about its effect on innovation and team intelligence at the local, clinical microsystem level?

Does top-down change our sense of volition and ownership in what we, as physicians, want to become?

Or impact the enthusiasm, passion, and energy of those providing care?

What does top-down do to the sense of victimhood and division between “them” and “us”?

How about the effort and commitment of the very people needed to transform our health care systems?

We all know the answers. The prevailing top-down health care leadership mindset is responsible for the death of the very spirit and behaviors that are essential to its transformation.

Rather than ratcheting up regulation, grabbing another bullhorn or barking more orders, we must get better at relying on the power of teams to lead themselves, with shared simple rules and deep mutual purpose. This may sound dreamy to some, but from where I’m sitting it’s this exact “ground up” change — incubated in the clinical microsystem — that is under the hood of the many innovations that are transforming care.

Just the other day, I ran into a physician who told me about the changes he, along with his colleagues and staff, have made to the patient experience. The small changes they implemented resulted in a big impact on the patient experience, and their own. Their “what happened when …” patient stories quickly spread and their techniques have been adopted by many throughout the organization.

As he shared the story, it was clear that no person from above mandated this change. They alone decided to get better together. No “do this or else” condition existed; it was a shared commitment and true accountability for patients that fueled the effort. The changes were driven by a culture of volition established by and with the very physicians and teams that led the effort.

As we consider how best to tackle our big health care challenges, maybe we ought to start by thinking small.

Stephen Beeson is a family physician and founder, the Physician Effectiveness Project.  He can be reached on Twitter @SBeesonMD.

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