Hi Gray
On January 17 you wrote:
>By removing decisionmaking from the clinical interface, you are making the
>basic Taylorist mistake by saying that workers can't understand the
>economic issues, so must be dictated to. You also lead to bureaucratic
>medicine.
>Maybe it would be better to look at training, and ways in which economic
>decisions can be factored into the clinical interface, rather than
>removing decisions from the interface.
My favourite writer on management, Mary Parker Follett, had this to say
about decision-making: "An executive decision is a moment in a process.
The growth of a decision, the accumulation of responsibility, not the
final step, is what we need most to study." (from a paper written in 1926
!! and collected in "Dynamic Administration")
IMHO the emphasis on the role of managers and others as decision-makers
has not been and is not helpful toward systems thinking. It focuses far
too much attention on the individual decision-maker and their
machinations, without asking why (and whether) a decision needs to be
made: i.e. it ignores the antecedent system conditions. In fact, if in an
organization managers are continually having to "make decisions", this may
be indicative of a dysfunctional organization. It suggests that far too
many issues are reaching the status of "problems" requiring "decisions",
without being resolved on the front line at the lowest possible level. As
a result we have to put far too much intelligence into the nodes because
we can't design an intelligent network!
Decision-making is expensive! Our objective should be to minimize
conscious decision-making, so that the systems "make" them naturally. Take
the "decision" to produce more parts in the 'two palette" system in a lean
manufacturing plant using kanban, for example. The parts are produced
without the elaborate data collection, inventory controls, forecasting and
other human interventions, including decision-making, which were (still
are) typical of mass manufacturing systems.It just happens.
So I don't think it helps to argue about where the decisions should be
made in health care without understanding why the current system seems to
close off a number of apparently effective lower cost options. I don't
want to remove decision-making from the clinical interface. Decisions will
always have to be made there. But they have to be appropriate and within
the skill areas of the decision-makers -- you shouldn't have to be a
rocket scientist/polymath to make them. We cannot expect professional
health care people to solve our resource scarcity unaided: the economic
issues need to be handled within the system itself, creating a context in
which they can function effectively. I am not saying they can't understand
economic issues, just that they shouldn't have to.
In short we need to "unload" the entire system, so that fewer decisions
have to be made at every node/interface. People could then use their time
to improve their professional skills and themselves. Now that would be an
intelligent system! But it's development will not be easy -- Toyota and
Honda took years to develop lean manufacturing. And it was done in the
aftermath of a series of disasters (WWII) that destroyed their old ways of
doing things -- they had to go forward!
-- Best wishes, David Hurst Speaker, Consultant and Writer on Management dhurst1046@aol.com