Scientific Management, Systems Thinking and Evidence-based Practice

It is Friday evening. I am studying for a first set of questions in the course I am taking at Georgia Health Sciences University. The material involves an overview of the challenges of healthcare management and healthcare policy in the United States. At the moment I am wondering if evidence-based management (and evidence based clinical practices) are only new labels for the old scientific management. When Frederick Taylor calculated the optimal size of a shovel for a particular purpose was he not collecting evidence to be used in practice? And in a way were not his instructions to "Schmidt" (so as to get him to handle 47 tons of pig iron per day) somewhat analogous to telling instructing a manager or a physician in the one best way to do something, as derived from evidence? Is it a surprise that physicians resist systems by which they are evaluated upon compliance with procedures, especially when there are conflicts between the interests of particular patients and the financial interests of organizations?

http://www3.niu.edu/~td0raf1/labor/Story%20of%20Schmidt.htm

Evidence-based clinical practices are based upon observations of outcomes in large populations of patients. But physicians face their patients one by one. It is the particular patient that a physician is trying to understand so as to diagnosis and treat correctly. Under DRG's (diagnostic related groups), for example, the patient becomes a diagnosis. The correct evidence-based process is based not on the patient as a person but on a diagnosis. Many patients have multiple chronic conditions. If we go to evidence-based practice are we assuming that physicians lack the ability to use his or her systems thinking skills (informed by the evidence of personal experiences) to assess the needs of this patient. Does process ultimately replace cognition? Is the use of professional discretion something to be driven out of clinical processes as is variance in industrial processes?

I value evidence, process, efficiency and economy. But I hope that we are not driving good physicians out of the profession by constraints that may in a way reduce the profession to something of an industrial profession in which obedience is more highly valued than personal insights. Physicians rightly value professional discretion and autonomy. If we come to no longer trust physicians as human beings with advanced knowledge and cognitive skills, can we substitute a trust in evidence-based processes?

Reflecting on An Information Technology Implementation Challenge

This is an initial reflection upon an assigned reading by Ann Scheck McAlearney in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The title of the case is, "An Information Implementation Challenge." The focal character is Dr. Dan Johnson who has been appointed CEO of a hospital system. Johnson favors the adoption of new information systems including a computerized provider order entry (CPOE) system and or a more comprehensive electronic health record (EHR) system. The hospital system presently runs on paper-based systems and those systems are working. Dr. Johnson, a physician, is getting push-back from physicians and the supervisor of the medical records department. He has done his homework and can cite evidence that automated systems are better once through the period of deployment and transition. The case sets up a discussion of the challenges of transformational leadership. Those who are resisting a change have also collected "data" indicating that early adoption is problematic. Dr. Johnson favors early adoption and is planning his next steps carefully. He wants this to happen sooner rather than later. He realizes that if he pushes too hard he risks alienating good people whose work the success of the hospital system depends upon. He is inviting people to become part of a working group, but the key players he needs on board have strong reservations.

What is at stake is the future of the hospital system and the future of Dr. Johnson's career as an administrator. While some younger employees and physicians appear open to use of electronic devices the culture of the organization is not aligned with Dr. Johnson's plans. I see problems with all the "obvious" solutions. A likely future scenario is that he pushes forward quickly, the plan fails, the hospital system falters, and Dr. Johnson is forced to leave. The incremental approach (what Charles Lindblom termed, "muddling through") is not likely to be acceptable to Dr. Johnson. Sometimes you can't get from "here" to, "there" incrementally, and moving slowly becomes an excuse for not moving. Johnson should look for allies in other high places in the organization but he may not find any. It would be better if the energy for this initiative had emerged from within the organization and he had been "recruited" by others to become a sponsor. So far, his attempts to reason with people appear to not be successful. He is apparently not working from an external mandate that requires this change at this time. He is likely to call a meeting and find himself the lone voice in support of this idea.

I think Johnson has to assess the situation and consider that this fight may not worth the effort. Dr. Bernadine Healy, former president of the Red Cross, took on the culture of that organization trying to make needed changes and wound up sacrificing her career. If Johnson is indeed a lone voice in the culture of this hospital system he may be best for him to find another professional opportunity now. When reason is pitted against fear reason is likely to lose. The people who resist change are not bad, selfish or dumb. They prefer the known to the unknown. We all have a natural attachment to known ways of doing things, even if we realize that the status quo is not ideal. Concerns about job loss or spending less time in direct patient care are realistic concerns. Automation involves process reengineering which often results in reducing the number of employees and modifying the responsibilities of those who remain. Physicians rightfully value their autonomy and resist changes that may force them to explain some of the decisions they make regarding their patients. Transformation is costly and requires faith that the gain will ultimately be worth the pain.

It appears from the case study that Johnson has the ability to listen. It is necessary to listen in order to gain empathy for others. The key is to create an alignment of interests if possible. I am not recommending a political approach such as Nancy Pelosi collecting Congressional votes for healthcare reform one deal at a time. But I question that Johnson can win this one based on evidence-based management alone. He must address peoploe's fears, including possible job loss and possible reductions in professional autonomy. The external environment of healthcare organizations is changing rapidly. Organizations must adapt. By adapting they have some ability to affect environmental changes. A failure to adapt is risky. I am remembering the movie, "Other People's Money." Clinging to a dying organization is futile. As a physician Johnson had to make difficult decisions involving the best interests of patients. Now as an administrator he must make difficult decisions involving the best interests of a hospital system. He has to assess what is possible and what may not be possible. He has to assess how important the future of this particular hospital system is to him. It is not selfish to walk away from one situation to join another organization more ready to accept one's heart-felt beliefs. I believe Johnson needs some internal allies to be able to make this change.

There is an episode of the original Star Trek series in which Captain Kirk materializes in some strange parallel universe by a malfunction of the transporter. Spock and other team members in that other universe are evil deriveratives of the characters we know. Spock of the other university figures out what has happened and arranges for Kirk and others to return to the right universe. The following dialog is part of this episode named, "Mirror, Mirror."

KIRK: You're a man of integrity in both universes, Mister Spock.
SPOCK: You must return to your universe. I must have my captain back. I shall operate the transporter. You have two minutes and ten seconds.
KIRK: In that time I have something to say. How long before the Halkan prediction of galactic revolt is realised?
SPOCK: Approximately two hundred and forty years.
KIRK: The inevitable outcome?
SPOCK: The Empire shall be overthrown, of course.
KIRK: The illogic of waste, Mister Spock. The waste of lives, potential, resources, time. I submit to you that your Empire is illogical because it cannot endure. I submit that you are illogical to be a willing part of it.
SPOCK: You have one minute and twenty three seconds.
KIRK: If change is inevitable, predictable, beneficial, doesn't logic demand that you be a part of it?
SPOCK: One man cannot summon the future.
KIRK: But one man can change the present. Be the captain of this Enterprise, Mister Spock. Find a logical reason for sparing the Halkans and make it stick. Push till it gives. You can defend yourself better than any man in the fleet.
SCOTT: Captain, get in the chamber!
KIRK: What about it, Spock?
SPOCK: A man must also have the power.
KIRK: In my cabin is a device that will make you invincible.
SPOCK: Indeed?
KIRK: What will it be? Past or future? Tyranny or freedom? It's up to you.
SPOCK: It is time.
KIRK: In every revolution, there's one man with a vision.
SPOCK: Captain Kirk, I shall consider it.
(He beams them away.)

http://www.chakoteya.net/StarTrek/39.htm

Cultures change slowly, but they can change. One voice can possibly initiate a change if joined by other voices. In the case study, Johnson may find a way to change the culture of the organization he leads. Johnson has power but his power is derived from the support of those he leads. He appears to have the sensitivities needed to understand the situation in a systematic way. Logic may gain its end and his vision may be realized.

Reflecting on Evidence-based Management

This is an initial reflection upon an assigned reading by Kovner and Rundall in our textbook Health Services Management, Cases, Readings and Commentary (9th) by Kovner, McAlearney and Neuhauser. The essence of the reading is that healthcare managers should make decisions based upon evidence just as physicians should practice evidence-based medicine. Basically this means there should be close ties between scholarly research and managerial practices. My approach to this is shaped by my experiences as a academic person who teaches public administration.

If there is a disjoin between scholarly research and managerial practice the easy explanation is to fault practitioners for not reading academic journals. It is not that simple. Even in public administration (PA), which is an applied field of study and practice, there is a substantial divide between scholarship and practice. The best practitioners were often not outstanding students. Successful PA scholars are not necessarily able to make a transition to successful practice. Success in scholarship requires a deep, narrow focus. Success as a practitioner requires a wide variety of interests and abilities. Scholarly journals are much more geared toward the needs of academic persons than practitioners. Even in PA, an article seldom includes an "executive summary," to clearly identify the relevance of findings to practice. Getting a paper published in a scholarly journal often requires the use of advance mathematics in the data analysis. Few practitioners have either the need or the interest to work through the mathematics. The bottom line is that practitioners are more likely to learn through informal communities of practice than by reading articles written by academics as required to advance their academic careers. Peer-review does not usually include practitioners as reviewers and what is required by peer-review to get work accepted for publication is sometimes not as rational and scientific as the public may assume. Assuming that what I have observed in PA applies to healthcare management the status quo does not favor greater use of evidence based management practices. As indicated by Kovner and Rundall, healthcare managers claim to practice evidenced-based decision making but do not cite scholarly research as the evidence they draw upon.

If a disjoin exists between research and managerial practices I believe the scholars must accept at least part of the responsibility for closing the divide. Academic cultures are probably among the most durable of all organizational cultures. It is unlikely that in the near future tenured or tenure-track faculty members will be rewarded for their abilities to span related areas of knowledge or to contribute to successful practice. If this is correct, this is sad. There is a degree of distain for academic "ivory towers" among some practitioners. And there is a degree to which some scholars look down upon successful practitioners. It is cause for concern when former students who did not display advanced cognitive skills as students sometimes move quickly into high-paying positions with major responsibilities. While evidenced-based management practices are surely important they are probably not highly correlated with successful careers as practitioners. "Success" of course can be defined in different ways, but that is probably more evident to scholars than practitioners. If the major institutions of society were ever managed by persons with the most advanced cognitive abilities it appears that those entering the systems now may be less well prepared to practice evidence-based management. If there is a gap between research and practice it is the responsibility of all concerned to try to address that divide.

Evidence Based Management?

It is the Christmas break. I am scheduled to take a course at Medical College of Georgia (online) beginning in January and have been reading the textbook as a way to prepare. One think in particular caught my eye. It is the idea that because evidence-based clinical practices have proven to be valuable that evidence-based managerial practices are also necessarily a good thing. The first thing that comes to mind is Herbert Simon's paper on the Proverbs of Administration. What seems like a "sure bet" may not be. Some people swim upstream and get awards for doing so. Others just swim upstream.

I believe that there are some fundamental differences between clinical practices and managerial practices. Assuming evidence-based clinical practices are a good thing I question that that necessarily implies that evidence-based managerial practices are necessarily always good. For the moment, let me reflect on just one difference. Clinicians are not in the business of designing the systems that they seek to heal. The basic design of human bodies is pretty much what it is. Strategic level managers, however, do design organizations. Making a decision regarding whether or not to merge two existing provider-organizations is not something with a parallel in the clinical world at present. And to say that two hospital systems should not have been merged because there was some prior evidence of failures does not require a new term such as evidence-based management. We have always known that it is good to learn from history while realizing that history is a guide rather than a set of deterministic rules. In clinical practices there are usually large numbers of prior cases from which to observe outcomes. The variations tend to smooth out individual differences. In strategic management there are usually fewer cases upon which to ponder.

But to return to a previous observation, in high-level management decisions are being made about the design of things. Organizations are more fluid in prospective designs than organisms. I certainly do not oppose the application of critical thinking skills to strategic management. I am only questioning what is gained by the introduction of the phrase, "evidence-based management" and the assumption that because evidence-based medicine is a good thing that the association to management adds anything to the fact that we already accept that managers should learn from experiences, have a systems perspective and anticipate the range of possible consequences of their decisions.

What is a Physician to do?

I am recoving for nasal surgery this holiday season and preparing to be both a teacher and a student this spring semester. I am thankful for the opportunity to become a student at Medical College of Georgia while continuing to teach at Albany State University.

In reading about ethics as related to medical care I read recently that ultimately decisions are to be made by the patient and the physician is responsible to fully inform the patient regarding all available options. But if I recall, physicians are also responsible to practice evidence-based medicine in order to do those things that have been shown to be be most effective given the diagnosis. Forgive me if I am missing something, but if the patient chooses the treatment how can the physician be responsible for the patient making choices that are not evidence-based? I have no problem with patients participating in decisions about their treatment. But is it realistic to hold the physician responsible to explain every option and every possible consequence of every option? Given the power of suggestion, is it really in the interest of the patient to be told every awful thing that might possibly be the result of a medical decision? And must a physician identify treatment options that are clearly far beyond the patient's scope of options for reason of cost? Might doing so be said to be unethical behavior? Under some form of managed care, telling the patient want is technically possible but not financially feasible is not going to earn the appreciation of the physician's employer and/or partners.

To me, a professional relationship involves agency and trust. Agency does not require a blind trust. Patients certainly should participate in their care and be as alert as the situation permits. But how can a physician fully inform patients of all choices, follow patients' choices, and also be held accountable to practice evidence-based medicine? We are going to need all the good physicians we can find in coming years. Let's define the practical and ethical responsibilities of physicans in reasonable ways in order not to cause good physicians to seek other lines of employment.