What is the right amount of management.

I loved reading the article on Paul Levy's blog a few back on "is your organization too flat?"  Throughtout my career, when faced with a management challenge I have tended to want to bring more management attention to it and provide them with enought room to be thoughtful about their approach.  However, every tie I have been confronted by management "experts" in the form of national management consulting gurus, I have found that they demand a flattening of the organization, relying on the advice and analysis of the most junior advisors to the point where it seemed not only counterintuitive but down right wrong.  What I also found is that it was impossible to ever buck that common wisdom without looking like you were completely out of touch and even though the Board would have given you your walking papers when the proposal to flatten came along if you had objected, they always agreed to add those people back in 18 to 36 months later usually lamenting that we never ever got the marketing or whatever off the ground and that was what was holding us back.    http://runningahospital.blogspot.com/2010/05/is-your-organization-too-flat.html .

The thinking of the study authors that Paul Levy quotes is just that, that at a time with difficult challenges and cost or quality problems, is flattening the best solution.  Might the situation need more managment and not less.  Might the span of control lend itself to change better with greater hands on supervision and role modeling. Might the operating results be better in the short and long term by keeping good managment in place and seeking moe good management. 

I have recently adviced clients that had alot of management to streamline.  Why?  Because the accountability was poorly defined, the roles were poorly defined and the managment culture was weak.  They need more managment but not on top of what they had but instead of.

I had another client that was getting limited results from management.  It was not because there were not enough, or that they were not competent, it was about the expectations and the QI processes in place to getthat team into a innovative mode.  They were so bogged  down by bureaucracy and history that they could not see their way out.  Leadership needed to change as much as the management resources in order to move the organization at hte pace required.

The obvious morale of the story:  You can have too much management, if its not managing, leading and innovating.  But you can easily have to little that will assure that you are ineffective in all of the above. 

AHA new direction.....1944 ...not so far off

Interesting reprint in the AJN from 1944 on the "aims of the AHA". I wonder if the interest in covering everyone regardless of cost was the direct result of wanting to care for each other after the war. (More on that later). The one thing that is bothersome as you read this article is the mention of state planning commissions.  Since the 1980s the push for competition has crippled planning.  It seems almost counterintuitive today to promote state based planning.   But also, it is a missing link until Boards really represent communities needs.  (I think I wrote about this last year).  I don't see the individual hospital's incentives changing enough to drive them to change.  I see the disincentives may...

oil spills

I hate to ask.  Not only am I related to an employee at BP (its the only thing Sarah Palin and I have in common) but I can barely watch the news on the Horizon oil spill.  But it seems to me that there are lessons beyond BP and the oil industry.  Why?

According to everyone I talk to at BP, "safety is the top priority".  They keep hearing it over and over.  Now, of course they had some high profile problems at Texas City (think the Duke medical center safety issue) that have caused multiple deaths and an inescapable need to take ownership for safety.  So how did this happen if safety was the priority?

Can it be as simple as "show me the money" or testosterone as one 60 minutes interview suggested (I'm the boss was the example); it seems that efficiency and cost and timing issues (read cost) were weighing heavily on project that was taking too long.  Or is it as we know in healthcare that the work of safety is never done.  And people lose sight of the fact that the disasters are ever so overwhelming that they are rarely fixable.  And the costs of a breech are enormous. 

So are there lessons to be learned? 
1. People at the sites seem to have had concerns that may have not triggered an automatic "abort" as is suggested in the military and aviation.
2. What are the adequate response mechanisms for disasters.
3. Should we be doing certain procedures or are they too risky.
4.What are the oversight/monitors on management
5. Have we codified procedures checklists and processes to the max?
6. What are the incentives for safety vs cost and efficiency.
7. And worst case, how well do we take responsibility and are transparent when we have a mishap.

We have learned these lessons before, have signed on to quality and safety, but are we moving to zero defects fast enough?. 

I beg your pardon if I have stretched this to healthcare where it doesn't belong...but I am the wife of a BP employee...so everything is seen in the context of the spill.  I think the spill has meaning to healthcare other than the fact that it finally got reform off the front pages of the paper and the cable news channels.

Quality of the Board

Okay, I am curious how much Boards are being prepared for the challenges of health reform.  Besides an advocacy role trying to divert the worst from coming your way, there are a number of strategic issues that only the Board can wrestle.  The question across the country these days is "How big is too big" but for healthcare, the question may be "how small is too small".  For community hospitals or rural or even inner city hospitals, do you have the capacity to change.  Do you have the size to restrict inpatient capacity in favor of outpatient and make the transition from current fee for service to bundled payments.  How big do you need to be?  How much competition will really matter in the future - can you be a one hospital town?  Will the competition for beds be the issue or the competition on price and quality.

I'd say that the new guidelines in some states for formal Trustee education may be the opportunity not the threat.  So the question of the day is how much should CEOs try to control or tailor their trustees education and how much should the Education become apart of the norm.  Strategic systems thinking and the ability to be opportunitistic and evidence based in the near future could be a strategic advantage.  We might start evaluating excellent hospitals on the quality of their boards not just their medical staffs.

TMI....or too little?

As my daughter says with her fingers crossed in the shape of a T, TMI Mom!  Translation: Too Much Information!  As I read the breaking news, blogs, updates, mobile news services, paper management journals, it just feels like too much information - TMI, for gosh sakes!  However the frustration is that it is really possibly too little information, alot of speculation and opinions and not refined, and defined adequately for action. 

Busy executives need to understand, as do their boards, the actions that are coming around the bend and the actions that are part of a longer term plan.  The reform agenda will roll out overtime but that does not mean that hospitals, doctors and healthplans can wait to see what emerges with a few brief comment periods.

This blog intends to breakdown the timelines and opportunities that doctors, hospitals and systems should be considering as the reform rolls out and to interpret some of the options. 

TLGI.  Too little good info is creating a combination of head in the sand and mistaken cues.  There are finally some opportunites for good ideas to get funded but you have to be prepared.