Scope of a Miracle

It is good to see photographs of U.S. Rep. Gabrielle Giffords that became available to the public today. Few people know all the details of the kinds of care she received that made possible the near miracle of her survival and recovery. There are surely many physicians, surgeons, nurses and others who together made this possible. She is alive and recovering today because of the coordination of the efforts of many professionals. In other words, it was not only the skills of individuals who saved her life and promoted her recovery. It was the timely coordination of those efforts. In this case, the "system" of care worked. I want to believe it would have worked as well for any person who suffered her injury.

As I read some of the comments received by HHS regarding proposed rules for implementation of ACOs I see the strong expressions of good people who simply do not want government agencies to attempt to rationalize the healthcare delivery system. Some people are simply opposed to "socialized medicine" and/or define the proposed changes as a loss of freedoms won on battlefields around the world. Others are open to change but do not believe that the new law and the proposed rules will work. Rep. Giffords' recent experiences with the system could be cited either as evidence that what we already have can work; or to say that we can do better. I want to believe that we can do better for at least all American citizens, including the large numbers of people entering the Medicare program. I believe that the rationalization of medical processes can reduce costs and produce more consistent quality outcomes for all patients.

It is a safe guess to say that the implementation of the new law will produce unintended behaviors among providers. The system that produced the law is a political system. Democratic political systems cannot produce scientifically rational policy designs, as in the context of operations research which is rational in a more objective way. Politics is the art of what is politically possible. As we pray and hope for Rep. Giffords' continued recovery let us continue to hope that the new law which she supported in Congress with her vote backed by her courage can be implemented successfully. "Bureaucrats" have to run with what they are handed by others.

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.