Blog: Managing the Care of Health

ANNOUNCING my new book

19 April 2017

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

In this sure-to-be-controversial book, leading management thinker Henry Mintzberg turns his attention to reframing the management and organization of health care.

The problem is not management per se but a form of remote-control management detached from the operations yet determined to control them. It reorganizes relentlessly, measures like mad, promotes a heroic form of leadership, favors competition where the need is for cooperation, and pretends that the calling of health care should be managed like a business.

“Management in health care should be about dedicated and continuous care more than interventionist and episodic cures.”

The professional form of organizing is the source of health care’s great strength as well as its debilitating weakness. In its administration, as in its operations, it categorizes whatever it can to apply standardized practices whose results can be measured. When the categories fit, this works wonderfully well. The physician diagnoses appendicitis and operates; some administrator ticks the appropriate box and pays. But what happens when the fit fails—when patients fall outside the categories or across several categories or need to be treated as people beneath the categories, or when the managers and professionals pass each other like ships in the night?

To cope with all this, Mintzberg says that we need to reorganize our heads instead of our institutions. He discusses how we can think differently about systems and strategies, sectors and scale, measurement and management, leadership and organization, competition and collaboration.

“Market control of health care is crass, state control is crude, professional control is closed. We need all three—in their place.”

The overall message of Mintzberg’s masterful analysis is that care, cure, control, and community have to work together, within health-care institutions and across them, to deliver quantity, quality, and equality simultaneously.

Some other excerpts:

In management no less than medicine, scalpels usually work better than axes.

Narrowness pervades health care, from professionals on the ground who can’t see past their specialities, to managers in the offices who can’t see past their institutions, analysts in governments and insurance companies who can’t see past their numbers, and economists in the air who can’t see past their dogma.

Reorganizing is the expected disjointed intervention for a health care “system” built on disjointed interventions.

While the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This makes the field of health care sick.

There are no management problems in health care, separate from medical problems, nursing problems, or prevention problems. There are only health care problems.

Because economics begins before medicine ends, the technocrats of health care have too often trumped the professionals.

In the name of competition, health care suffers from individualism: every patient, provider, and institution for themselves.

The field of health care may be appropriately supplied by businesses, but in the delivery of its most basic services, it is not a business at all, nor should it be run like one. At its best, it is a calling.

I can think of no field that is more global in its professional practices yet more parochial in its administrative ones than health care.

Certainly we have to measure what we can; we just cannot allow ourselves to be mesmerized by measurement—as we so often are.

Physicians who like to belittle hierarchies of authority are often slaves to their own hierarchies of status.

Who can possibly be against evidence in medicine? Me, for one, when it is used as a club to beat up on experience.

The essential problem in health care may lie in forcing detached administrative solutions on to practices that require informed and nuanced judgments.

It can be taken as almost an axiom of professional work that dysfunctional practices cannot be fixed by tighter administration. The problems have to be addressed within the work itself.

Strategy making in the field of health care tends to be about venturing more than visioning, and personal and collective learning more than institutional planning.

When we promote leadership, we demote everyone else. How about plain old management?

Instead of people pointing the finger at each other, they should be pointing their fingers together at the procedures and structures that set them apart.

Health care doesn’t need more measuring and reorganizing so much as better cultures of collaboration that open up the pathways of communication.

A systems perspective requires a focus on the person in the community, beyond a patient in a population.

There’s a massive amount of health care information out there, some of which I need to know. How much of that part am I actually getting? Is 10 percent a gross exaggeration? And how do I get even that? Haphazardly!

To find the systems perspective in health care, look first in the mirror: we are as close as we are going to get. That is because you and I are significantly responsible for promoting our own health, preventing our potential illnesses, and even treating many of our own diseases.

The invisible hand that is supposed to serve everyone by serving ourselves turns out to be a visible underhand in much of health care when it serves some users at the expense of others.

See full Table of Contents

© Henry Mintzberg 2017

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Do you run for cure? How about running for cause.

27 July 2016

You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

Part of the problem lies with medicine itself. It is mostly about treating diseases, and since physicians do so much of the research, that’s where the bulk of the funding goes. I asked a surgeon active in breast cancer research about the proportion of funding that went to finding cause. She estimated it to be 1%. (Some physicians even refer to as “prevention” stopping Stage 1 breast cancer from advancing to Stage 2. That’s like claiming that the cause of Stage 2 cancer Is Stage 1 cancer.) True there are diseases such as Alzheimer’s that do better, but how many others are like breast cancer?

And let’s not get started on pharmaceuticals, except to note that there is no money to be made from people who are well, or at least usually a lot less money from one-shot vaccines to keep them well. So developing medications gets most of the big bucks, and siphons off a great deal of the creative talent that could be looking for causes. All around, our health care needs to be better focused on the care of health.

John Robbins has written a wonderful allegory about a cliff that people kept falling over. There thus developed a highly sophisticated effort to treat the injured, involving physicians, ambulances, and hospitals with the latest technological wizardly. Efforts were even undertaken to develop drugs to cure the injuries of the fallen. When some people suggested building a fence atop the cliff, they were ignored, or else dismissed: what did they know about health care?1

Dr Jonas Salk didn’t buy any of this. He never cured any child of polio. Instead he ensured that no child ever had to be cured. His laboratory developed a vaccine that eradicated the disease. We need more money and talent dedicated to stopping diseases, including studying the toxic effects of what we inhale, ingest, and absorb. And by the way, Dr Salk refused to patent his vaccine, with the comment that “Who owns my polio vaccine? The people. Could you patent the sun?” He could have made a great deal of money by ensuring at the outset that only the children of rich parents could get the vaccine. Instead children all over the world became protected rather quickly.

Researching cause can be quite different from researching cure. It is often more like detective work, where samples of one can be perfectly appropriate. After all, find the cause in someone and you may be on your way to finding the cause in everyone.

A 2003 poll by Hospital Doctor named Dr John Snow the greatest physician ever. Partly he earned that with a sample of 2. When an outbreak of cholera exploded in London’s Soho District in 1854, believing that the disease was water-born, even though the physicians who mattered were convinced it was air-born, he plotted the locations of the recent victims on a map. They clustered around one well, all except two, who lived miles away. Like a good detective, Dr Snow visited the home of one of them. A relative told him that she liked the water of that well and had someone fetch it for her. Her niece also liked that water, he was told, and she died too. And where did she live? There was sample Number 2. Finally Dr Snow’s colleagues listened to him. (Sewage seeping into the well—i.e., toxin—was later found to be the cause of the outbreak.). The handle of the well was removed—that was the cure! (for this well at least)—and the epidemic ended.

Some years ago, I heard about an astonishingly high incidence of certain cancers among children in Alexandria. So for this TWOG I went on the internet and found one related article, in the Journal of the Egypt Public Health Association, 2002, under the title “Patterns in the incidence of pediatric cancer in Alexandria, Egypt, from 1972 to 2001.” The article concluded that “The trends in some cancer types suggest the need of a closer examination of the underlying factors and environmental contaminants leading to the disease in children.” Yes indeed, and what a perfect place to research cause. But who is to do that: where is the constituency for cause?2 In other words, where are the Dr Snow’s when we need them now?

If you have lost a cherished member of your family to a dreaded disease, I can well understand your wish to help find a cure for it.  But cannot this emotion also be directed into helping avoid the suffering of others? So please, the next time you run for a disease, or fund a research chair, or just donate a few pennies for health care, consider cause. Invest in health.

© Henry Mintzberg 2016. HM is the Founding Director of the International Masters for Health Leadership (imhl.org) and author of the forthcoming Managing the Myths of Health Care (Berrett-Koehler, 2017). Follow this TWOG on Twitter @mintzberg141, or receive the blogs directly in your inbox by subscribing hereTo help disseminate these blogs, we now also have a Facebook page and a LinkedIn.


2 I found no follow-up study, nor any comments on that one.

 

Who can possibly manage a hospital?

6 January 2016

Great debates continue as to who should manage hospitals and other health care institutions. For example, should the head be a physician? a nurse? a professional manager? The physicians know cure, the nurses know care, the professional managers know control. But who knows all three? Is there thus good reason to reject all these candidates? I reject the question itself.

Professional managers so called, namely people who believe they are qualified to manage everything because they sat still in an MBA or MHA classroom for a couple of years, have been the target of several TWOGs here. Being educated in the abstractions of administration prepares no one for the cauldrons of practice.

Great debates continue as to who should manage hospitals and other health care institutions. For example, should the head be a physician? a nurse? a professional manager? The physicians know cure, the nurses know care, the professional managers know control. But who knows all three? Is there thus good reason to reject all these candidates? I reject the question itself.

Professional managers so called, namely people who believe they are qualified to manage everything because they sat still in an MBA or MHA classroom for a couple of years, have been the target of several TWOGs here. Being educated in the abstractions of administration prepares no one for the cauldrons of practice.

Management, unlike medicine, uses little science: hence it is not a profession. Or to put this another way, because illnesses in organizations, and prescriptions for their treatment, have hardly been specified with any reliability, management has to be practiced as a craft, rooted in experience, and an art, dependent on insights. Visceral understanding counts for a lot more than cerebral knowledge.

Well then, if not professional managers, how about physicians? Surely they have the visceral understanding of the operations, plus the status to be heard. Moreover, are hospitals not fundamentally about medicine? Yes to all of the above questions. But there is a lot more to managing health care than knowing medicine. In fact, there are reasons to believe that the practice of medicine is antithetical to the practice of management.

Physicians are trained mostly to act alone, individually and decisively. Every time one sees a patient, an explicit decision is made, even if that is to do nothing. Decision making in management is not only more ambiguous, but also more collaborative. A cartoon appeared some years ago showing several surgeons around an anesthetized patient, over the caption: “Who opens?” In management, that is a serious question! Add to this the facts that medicine tends to be interventionist, mostly about episodic cures, rather than continuous care; that it usually focuses on parts, not wholes; and that it strives to be scientific and evidence-based, and you have to worry about physicians running hospitals.

This leaves the nurses. Their practice is often more visceral, more engaging, and arguably closer to concern about the whole patient. Moreover, their jobs are ones of continuous care more than intermittent cure, plus they are inclined to engage in more teamwork. So some nurses at least should be rather more suited to managing hospitals.

Sure―but how to get the doctors to accept management by the nurses?

So the conclusion appears to be evident: no-one can possibly manage a hospital! Running even a complicated corporation must seem like child’s play compared with managing a general hospital: the strident doctors, the beleaguered nurses, the sick patients, the worried families, the demanding funders, the posturing politicians, the escalating costs, the accelerating technologies―all embedded in cases of life and death.

Yet people do manage hospitals and other health care institutions, sometimes with rather astonishing effectiveness. So beyond the evident answer to our question is the obvious answer: People, not categories, have to manage health care institutions. I have encountered physicians who were renowned as heads of hospitals. (One of Montreal’s most respected hospital directors was an obstetrician with an MBA.) Likewise have I seen some awfully impressive nurses managing hospitals―and imagine how many more there would be if given the chance.

My own preference is for people who have worked in the operations before moving into the management, whether that be in nursing, medicine, physiotherapy, or social work, etc. In fact, the wider the net is cast, the greater the chances of success.

That is not to conclude that training in management is irrelevant, only that it should follow experience on the job, and build on it. That is what we have been doing at McGill since 2006, with great success and delight, in our International Masters for Health Leadership (imhl.org), for people from all aspects of health care all over the world.

Now for the ultimate bit of administrative engineering

In a recent TWOG on managing the care of health, I discussed a number of dysfunctional forms of administrative engineering—mergers, measures, reorganizations, etc.—that are meant to fix health care where it is not broken. Some weeks ago I underwent a bypass operation in a Montreal hospital that had been administratively engineered in a particular way.

Our hospitals in Canada are mostly non-owned―they are independent trusts. But that has not necessarily stopped the provincial governments that provide most of their funding from treating them like government departments.

Last year in Quebec, the prime minister and his minister of health, both physicians, solved the problem of who should manage hospitals by deciding that no one should. They eliminated the positions of director general—head of the hospital--and indeed of most of the health care institutions in Quebec. In effect, they fired them all, and combined all these institutions into regional agglomerations, each with its own single président-directeur général (the French term for CEO).1

This is not Alice in Wonderland. In the teaching hospital where I was treated, with its 637 beds, there is no longer anyone in charge. The former directeur général was kicked upstairs—transformed into a PDG―to manage the whole agglomeration. This comprised nine (yes 9) separate institutions, across acute, community, rehabilitative, palliative, and geriatric care, etc. Think of all the money our government has saved. Think too of all the chaos that is to come.2

So I have a terrific idea. Do we really need all those government ministers? Health, Justice, Culture, Finance, Education, Agriculture, Mines, and eighteen or so more. Why don’t we just agglomerate them all, and have the prime minister run the whole works himself. Think of how much more money we could save.

© Henry Mintzberg 2016. Partly drawn from my forthcoming book Managing the Myths of Health Care.

Follow me on Twitter @Mintzberg141. You can also receive the blog directly in your inbox by subscribing to mintzberg.org/blog.


1 This is an unfortunately excellent example of ignoring the importance of the plural sector in society. Because of its power over funding, this government has in effect nationalized the hospitals. (The chart it drew even shows a solid line from this PDG to the minister of health, and a dotted one to the board of directors of the hospital. Dots have deep significance for bureaucrats.) As I argue in my book Rebalancing Society, professional services often attain their high levels of quality by functioning with a certain degree of independence in the plural sector, rather than the public or private ones. So much for that idea in this case.

2 Their timing might just prove to be impeccable—for the opposition parties. As I noted in my TWOG on efficiency, the cost savings of such administrative engineering show up immediately; while the negative impact on services appear later—perhaps just in time for the next election.