Reframing the managing and organizing of health care—toward a system

This is the third in a set of three TWOGS based on a book I am completing called Managing the Myths of Health Care. The first TWOG introduced two myths: that health care is a “system” and that it is failing. In fact it is succeeding, astonishingly (at least where it chooses to focus its attention, namely on the treatment of acute diseases rather than chronic conditions). It’s just that this is expensive, and we don’t want to pay for it. So we intervene with all kinds of administrative fixes, that were the subject of the second TWOG: measures, markets, and mergers, heroic leadership, relentless reorganizing, and making health care more like a business. Arguably, these are the causes of the perceived failures. In this TWOG I discuss some basic ways to reframe certain key practices of health care, to render it more like a system.

Clearly we need administrative engineering to keep the lid on the costs of health care. But that does not mean, to quote from a flamboyant article in the Harvard Business Review, that hospitals need to be seen as “focused factories”, doctors as “industry players”, and patients as “customers” and consumers” who carry out “one-stop shopping” for their services.

Beyond being a patient, I am a person. Beyond being part of some population, we are members of communities. Practiced properly, health care is not a business at all, but a calling. Can anyone possibly believe that most physicians, nurses, and other professionals would work as conscientiously as they do, in the face of so much pressure and frustration, in order to maximize the  “value” of some shareholders they never met?

There is thus a compelling need to proceed differently in health care, with scalpels instead of axes, out of the administrative offices and into the operating rooms, of all kinds. What looks good on paper can wreak havoc in practice because administrative prescriptions are often simple and reality is often complex. So ways have to be found to combine the efforts of dedicated professionals with those of engaged managers.

In the final section of my book Managing the Myths of Health Care, I discuss reframing across various key aspects of health care. Those concerning managing and organizing are discussed here. We do not have the space to get into three others: Reframing Scale—to make the default position human scale rather than economic scale; Reframing Ownership—to recognize the key role that common ownership has to play in this field beside public and private ownership; and Reframing Strategy—as venturing, not planning (which is touched upon here). I may discuss these in later TWOGs.

Reframing Management: as distributed beyond the “top”

Most everywhere, an essential problem in health care lies in forcing detached administrative solutions on to practices that require informed and nuanced judgments. In a 1994 article on health care reform, Donald Berwick put it: “Only those who deliver care can, in the end, change care…. The outsider can judge care; but only the insider can improve it.” Clinicians should, therefore, “stop feeling battered” by the reforms and begin to do something about the problems. Bear in mind that it was clinicians who developed day surgeries: one of the great advances of health care in recent times, that both cut costs and improved qualities dramatically.

In fact, eliminating the word “outsider”, as well as the vocabulary of “top” and “middle”, would also help, by challenging the artificial gaps between levels of administrative authority as well as those of professional status. Everyone who works in this field contributes and therefore deserves the full respect of everyone else, so long as they return that respect.

There are three ways to close the artificial gaps between administration and operations: One is to bring “down” this “top” by wooing those people concerned with administration―managers, administrative engineers, government officials, and so on―off their hierarchical pedestals and into more direct contact with the operations. A second is to bring the base “up” by involving the providers of the services in the administrative practices (without necessarily having to become managers). But most important may be eliminating the formal levels between administrations and operations—for example by favoring smaller institutions and regions in the first place.

Concerned and committed people in all kinds of unexpected places can improve the practice of health care, much as so many people are changing Wikipedia every day. (Think of this as open source strategizing.) A policeman in receipt of dialysis treatment helped reorganize the scheduling for everyone’s benefit. “Let a thousand flowers bloom” could thus be the motto for driving effective changes in health care.

Reframing Organization: as collaboration transcending competition

There is no doubt that we are all competitive beings, from which can spring good and bad. But we are also cooperative beings, from which can spring a lot more good, especially in health care, where we already have too much competition. In the name of that competition, health care suffers from individualization: every recipient, every provider, every institution for him, her, or itself. So enough of professionals grinding in their own mills, apart from managers who try to remote control them, let alone apart from each other who believe they can coordinate everything on automatic pilot. There are no management problems in this field, separate from medical problems or nursing problems or prevention problems, etc. There are only health care problems. 

Reframing the Practice of Managing: as caring before curing¹

Instead of leaders who don’t manage, health care needs managers who lead. Such managers are part and parcel of their institutional community; they do not sit “on top” of it.

In response to a newspaper commentary I published about heroic leadership, a retired manager of nursing wrote to me about her experiences with people “not skilled in understanding the work of front-line staff… [they] managed from a meeting, from their offices, or from their home computer”:

In health care today, the vertical monopoly structure is leaving the front-line point-of-care team questioning where is the support, where is the leadership, where is the inspiration, where are the coaches, who really cares? I do not believe there is a shortage of staff; there is a lack of retention of staff. The idealistic, intelligent, youth are not satisfied with mediocre leadership and turn to other professions to have their dreams fulfilled.²

Health care institutions—and businesses too these days—need something quite different: managing as convincing more than controlling, demonstrating more than directing, inspiring more than empowering, above all managers who engage themselves in order to engage others. Put differently, in health care managing itself should be about dedicated, continuous, holistic, and pre-emptive care more than interventionist, episodic, narrow, and radical cures.

How to get to this? Managers can start by purging their organizations of the corporate vocabulary—“CEO” and all the rest. On the ground, they can experience people beyond patients, providers beyond professionals, communities beyond populations. And by the same token, the providers can be reaching out sideways, to communicate with each other more effectively for the sake of continuous care.

As discussed in the TWOG of the week before last, a cow is a system: its parts function harmoniously. Why can’t health care work like that?

© Henry Mintzberg 2015, Have a look at our International Masters for Health Leadership (mcgill.ca/imhl), where mid-career people from all aspects of health care the world over get together for five 11 day modules to consider all this and much more.