Decisions and Org Structure LO4954 - And health reforms

Gray Southon (gsouthon@ozemail.com.au)
Thu, 18 Jan 1996 21:49:06 +1100 (EST)

Replying to LO4945 --

David

What you say sounds all very well in principle, but I am not sure how it
relates to the present where clinicians are unable to provide the care
that patients need because they are constrained by regulations made by
managed care organisations who do not know the patient.

You also make assumptions about what clinicians can handle. Clinicians all
around the world are making resources allocation decisions. They just need
to be better understood and supported.

Gray

At 02:36 PM 17/1/96 -0500, DHurst1046@aol.com wrote:
>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!
>
>David Hurst

--
Gray Southon
Consultant in Health Management Research and Analsysis
15 Parthenia St., Caringbah, NSW 2229, Australia
Ph/Fax +61 2 524 7822
em gsouthon@ozemail.com.au