The Roles and Responsibilities of Managers

Our reading assignments this week in the class at Georgia Health Sciences University regard the role of managers in healthcare organizations, including aspects of control, design, professional integration, adaptation and accountability. One of the points made by the authors of our textbook (Kovner, McAlearney and Neuhauser) is that the measurement of aspects of processes and outcomes is important in assessing quality of care provided. I have no doubt that Lean Six Sigma, the Toyota Way, balanced scorecard and other similar management tools are valuable. But there is also a lot to be said for just good old common sense. I wonder if managers don't sometimes become so detached from what is really happening in the organization that they miss the obvious. Bureaucratic and highly regulated organizations can create people so fixated on rules and procedures that they can miss what is obvious and common sense.

I am remembering the statement of "Dr. Leonard McCoy" in Star Trek IV: The Voyage Home as the crew is pondering what their next ship will be. "The bureaucratic mentality is the only constant in the universe. We'll get a freighter." My point is that the foundation of good management is good sense. If someone steps forward and identifies a problem or an opportunity there are probably many others who share the observation and for whatever reason have not expressed the obvious. In my opinion, good managers do not thrive on rules. Over time, they shape the culture of an organization in such a way that that common sense and shared values reduce the dependence on rules.

There is a Taco Bell store in Albany that I like. The people are friendly and the food is good. But there is one light fixture that customers are always bumping into. Its placement is a design flaw. It is suspended at a height of less than six feet. It is in the exact location that people walk to get to a table and then to place used cups and papers in the waste can. Many people bump into it. It is so obvious that it needs to be either raised or removed! There is no need for a customer satisfaction survey asking whether you enjoyed bumping your head into a light fixture today. I have asked managers at the Taco Bell store at least five times to either raise or remove the light. I have sent e-mail to "Taco Central" with the same plea. Nothing happens. Either the local managers don't care or they are powerless to take such a radical initiative as to raise a lighting fixture.

I bet there are plenty of situations like that in hospitals that managers miss because they are watching the numbers rather than looking up and seeing the obvious.

Anticipating "Black Swan" events

Nassim Nicholas Taleb's best-selling book, The Black Swan: The Impact of the High Improbable(now in its second edition) regards the anticipation of low-probability, high consequence possible events. Managers generally focus their attention on the crisis of the day and on likely near-future scenarios. There are so many low-probability possible scenarios that it may not be a productive investment of time and attention to give them much thought. It is difficult to plan for a radical change in circumstances. And an executive or manager is not likely to be faulted for failing to anticipate an event that was very improbable before its occurrence.

But medical insights are evolving rapidly. For example, the discovery of a cure for aging, resulting in radical life extension, would certainly have huge consequences to medical institutions and societies at large. It would probably result in a large increase in numbers of people with chronic medical conditions and would surely lead to substantial population growth, further taxing the limited resources of the earth. It could happen. Many unlikely things of high potential consequence are possible. Some of the work being done in theoretical physics would surely have dramatic consequences if radical new ideas could be implemented.