In this sure-to-be-controversial book, leading management thinker Henry Mintzberg turns his attention to reframing the management and organization of health care.
The problem is not management per se but a form of remote-control management detached from the operations yet determined to control them. It reorganizes relentlessly, measures like mad, promotes a heroic form of leadership, favors competition where the need is for cooperation, and pretends that the calling of health care should be managed like a business.
“Management in health care should be about dedicated and continuous care more than interventionist and episodic cures.”
This professional form of organizing is the source of health care’s great strength as well as its debilitating weakness. In its administration, as in its operations, it categorizes whatever it can to apply standardized practices whose results can be measured. When the categories fit, this works wonderfully well. The physician diagnoses appendicitis and operates; some administrator ticks the appropriate box and pays. But what happens when the fit fails—when patients fall outside the categories or across several categories or need to be treated as people beneath the categories or when the managers and professionals pass each other like ships in the night?
To cope with all this, Mintzberg says that we need to reorganize our heads instead of our institutions. He discusses how we can think differently about systems and strategies, sectors and scale, measurement and management, leadership and organization, competition and collaboration.
“Market control of health care is crass, state control is crude, professional control is closed. We need all three—in their place.”
The overall message of Mintzberg’s masterful analysis is that care, cure, control, and community have to work together, within health-care institutions and across them, to deliver quantity, quality, and equality simultaneously.
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Managing the Myths of Health Care
Bridging the Separations Between Care, Cure, Control, And Community
By HENRY MINTZBERG
Berrett-Koehler Publishers, Inc.Copyright © 2017 Henry Mintzberg
All rights reserved.
We have a system of health care.
I haven't noticed. Mostly we have a collection of disease cures, or at least treatments, often the more acute the better. Overall, "health care" favors cure over care, acute diseases over chronic ones, and the treatment of diseases in particular over the prevention of illnesses and the promotion of health in general. As for research, development of cure receives much more attention than the investigation of cause.
Calling something a system does not make it a system where it needs to deliver. A system is characterized by natural linkages across its component parts. As we shall discuss later, a cow is a system, since its organs function together naturally. You and I are systems like this, too, at least in how we function physiologically, if not socially. About how much of the field of health care can we say that? What happens when all we individual physiological systems get together in a social context? Even the various medical specialties often have difficulty working with each other, let alone with nursing, community care, and management. As for the inclination to treat diseases instead of preventing them, let alone promoting health, see the box on "Health Promotion over the Cliff." It is not quite an allegory.
Health Promotion over the Cliff(from Robbins, 1996: 1-2)
Once upon a time, there was a large and rich country where people kept falling over a steep cliff. They'd fall to the bottom and be injured, sometimes quite seriously, and many of them died. The nation's medical establishment responded to the situation by positioning, at the base of the cliff, the most sophisticated and expensive ambulance fleet ever developed, which could immediately rush those who had fallen to modern hospitals that were equipped with the latest technological wizardry. No expense was too great, they said, when people's health was at stake.
Now it happened that it occurred to certain people that another possibility would be to erect a fence at the top of the cliff. When they voiced the idea, however, they found themselves ignored. The ambulance drivers were not particularly keen on the idea, nor were the people who manufactured the ambulances, nor those who made their living and enjoyed prestige in the hospital industry. The medical authorities explained patiently that the problem was far more complex than people realized, that while building a fence might seem like an interesting idea it was actually far from practical, and that health was too important to be left in the hands of people who were not experts. ...
So no fences were built, and as time passed this nation found itself spending an ever-increasing amount of its financial resources on hospitals and high-tech medical equipment. ... As the costs of treating people kept rising, growing numbers of people could not afford medical care.
The more people kept falling off the cliff, the more a sense of urgency and tension developed, and the more of the country's money was poured into the heroic search for a drug that could be given to those who had fallen, to cure their injuries. When some people ... questioned whether a cure would ever be found, the research industry answered with a massive public relations campaign showing men in white coats holding the broken bodies of children who had fallen, pleading, "Don't quit on us now, we're almost there."
When a few families who had lost loved ones tried to erect warning signs at the top of the cliff, they were arrested for trespassing. When some of the more enlightened physicians began to say that the medical authorities should publicly warn people that falling off the cliff was dangerous, representatives from powerful industries denounced them as "health police." ... Finally, after many compromises, the medical establishment [issued] warnings. Anyone, they said, who had already broken both arms and both legs in previous falls should exercise utmost caution when falling.
The French word for a surgical operation is intervention. Using the word in English, that is significantly what happens in health care: intermittent and disjointed interventions, whether in primary, secondary, tertiary, or so-called alternative medicine, as well as in public and community health. We need more systemic practices in health care, especially to reconcile the delivery of quantity, quality, and equality.CHAPTER 2
The system of health care is failing.
If there is one area of agreement in this field, this may be it: these "systems" are failing, all over the world. Users and providers alike complain bitterly about their health care.
At a party in Montreal a few years ago, I got into a conversation with a young radiologist who went on and on about how bad health care was in Quebec. "You did your residency in the United States," I finally intervened. "How about that?" She threw her hands in the air: "Don't get me started on the American system!" Sometime later I was in Italy, with people in the field who were likewise putting down their health care. So how does Italy compare with other countries, I asked. Oh, they replied: in the last ranking by the World Health Organization (2000), Italy ranked second best in the world behind France. Is second best still bad?
SUFFERING FROM SUCCESS
Quite the opposite: I believe that second best and much else is actually rather good — as far as it goes. In most places in the developed world, the treatment of disease is succeeding, often rather dramatically. The trouble is that it is doing so expensively, and we don't want to pay for it. In other words, where it focuses its attention, health care is suffering from success more than from failure.
And where it focuses less attention — in preventing illness in the first place — there have still been remarkable improvements, for example, in vaccines and the promotion of better eating and more exercise. It is just that here the pace of improvement is slower, and the efforts and resources expended are less — and no match for the commercial interests that promote poor eating and sedentary living.
On some of the broadest measures of life expectancy, infant mortality and others, performance in most countries has been steadily improving. A World Health Report in 1999 reviewed "the dramatic decline in mortality in the 20th century." To take one of its examples, Chilean women in 1998 could expect to live to age 79 on average, which was not only 46 years longer than their predecessors of 1910, but also 25 years longer than women of 1910 whose countries had the 1998 Chilean income level. The report attributed a part of the reduction in mortality to "income growth and improved educational levels — and consequent improvements in food intake and sanitation" but concluded that access "to new knowledge, drugs, and vaccines appears to have been substantially more important" (1999: 2).
Don't get me wrong about this claim of health care succeeding rather than failing, as did the head of an ICU who attended our International Masters for Health Leadership program (imhl .org). When he heard me say this, he became angry: he had to live with the errors, the distortions, and the other failures of health care. I could not argue with him about any of this, only to reply that I use the word success to mean getting better, not being perfect. Health care has its problems, to be sure, but it has been making remarkable progress where it focuses.
How about being offered this choice: (1) Health care circa 1960: when you feel chest pains, your GP comes to your home, gets you straight into a hospital, where you get attention from many doctors and nurses, who eventually send you back home to rest and hope for the best. You have received state-of-the-art health care. Or (2) health care now: no doctor comes to your house — you may even have to get yourself to a hospital, there to wait in an overcrowded emergency room until you get to cardiac surgery, where a stent is inserted, so that you can be sent home the next day, in rather good shape. You have received rather ordinary 21st-century health care.
Medicine has been particularly brilliant at developing expensive new treatments. Who among us is prepared to forego one of these to save our life? So we live longer, although sometimes more expensively sicker.
But not always: Consider a 90-year-old man in Vancouver who demanded an expensive hip replacement so that he could keep running. He was intent on maintaining his lifestyle, at the expense of the taxpayers of British Columbia. Could they fault him?
Pharmaceutical companies have had their expensive successes, too, except that these have been far too expensive in those countries disinclined to control the exorbitant pricing by this industry. (Bear in mind that these companies depend on state-granted monopolies — namely, patents — to charge what they do. When in the recent past has any country ever granted monopoly rights on necessities of life, such as electrical power or fixed-line telephone services, without seriously controlling prices? Being allowed to charge "what the market will bear" [a term used in Businessweek by Carey and Barrett in 2001] is simply patent nonsense. [See my article by this title, Mintzberg, 2006b.])
MORE FOR LESS?
Of course, while the costs of treatments go up, so too must the budgets to cover them, whether they are paid by taxes, insurance premiums, or personal payments. If we want more, we have to pay more. But in this age of consumptive greed, we want to pay less — or at least not that much more.
For the most part in the field of health care, we are not buying services so much as the possibility of needing services (i.e., insurance). Why, then, should I pay for you, who is sick, while I am healthy and probably invincible at that? In other words, while the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This is not a happy combination: it makes the field of health care sick.
Reconciling Supply and Demand
Before considering the obvious consequences of this, let me mention two other myths related to this one. The first is that we cannot afford the escalating costs of our health care services. Of course we can: it's a question of choices, individual and collective — really individual or collective. When we spend on cars and computers, we get instant gratification. How is health insurance, public or private, to compete with that? It offers no fun! In the case of the United States, while health care costs far exceed those anywhere else, the very rich pay low taxes, and some major corporations hardly any taxes, while many Americans have long suffered for want of basic services.
The other related myth is that the demand for health services is insatiable: provide more and we shall consume more. I don't know about you, but going to the doctor is not my idea of a good time (although I do like to chat with my particular GP): the waiting room, the needles, the prostate examination — no, thank you. I don't even cherish being admitted to a hospital. "Medical procedures are not hotcakes. People aren't going to line up eagerly demanding heart transplants just because someone else is paying" (CHSRF, 2001, citing Robert Evans of the University of British Columbia).
For every hypochondriac, how many other people avoid health services like the plague (so to speak)? Even that 90-yearold in Vancouver was not being unreasonable. Put yourself in his running shoes: this was truly a question of health care. So excessive demand for health care services is not the problem so much as reasonable demand for services that are in short supply, thanks to our collective reluctance to pay for them. (An exception can be noted here for the proclivity to order too many tests, especially in the United States, where there is so much litigation.)
Of course, there is a supply side to this issue. Give some physician the time and the fees for some treatment, and he or she may find lots of illness in need of it. Or give some hospital more beds and it will fill them. Is this a bad thing? Only if the added services are unnecessary or, worse, lead to the diagnosis of conditions that are better left untreated.
So what are the consequences of all this? Quite simple: The field of health care is being squeezed on all sides, by governments and markets, demanders and suppliers. As a result, many users are justified in feeling that they are not getting the services they need — not fast enough, not good enough, or just plain not enough.
Rationing is a taboo word in much of health care. In Canada, governments go to great lengths to avoid mentioning the R word, let alone facing decisions about it. Yet rationing is an intrinsic part of health care, everywhere, all the time — for example, when a night nurse has to decide which of two beeping monitors to attend to first, or a physician has to determine who is to get a kidney that has become available for transplant, or a government or HMO has to specify the age at which people can no longer get some expensive treatment. The only alternative to this rationalizing is that everyone gets everything to cover every possible contingency. That is hardly feasible, at least if you are not Michael Jackson — and look what happened to him. people who avoid health care services may just be increasing the costs, since problems caught late can be much more expensive to treat.
Sometimes medicine strikes back. A surgeon called the executive director of his hospital: "I have a heart. I have a patient. I have an operating room. I have no budget." What is any manager who has a heart to do? This is rationing reduced to a game of Ping-Pong. Hit the problem back to someone else. Is the "system" failing, or are we failing in how we make choices, or refuse to?
We turn now to what have been the main administrative interventions applied to deal with this ostensible failure of health care: heroic leadership; administrative engineering; categorizing, commodifying, and calculating; increasing competition; and running health care like a business. I shall argue that, in some significant ways, much of this has delivered conspicuous failures.CHAPTER 3
Health care institutions, not to mention the whole system, can be fixed with more heroic leadership.
Leadership is all the rage today, especially in business, but well beyond it, too, and the field of health care is hardly immune. Count the thousands of books about leadership on Amazon, and then try to find the few on followership. Are we so obsessed with leadership because we get so little of it? Or, do we get so little of it because we are so obsessed with it?
Of course leadership matters. The problem is the elevation of leadership to heroic status, as if leaders on "top" are superior to "human resources" below. Such leaders are supposed to drive others to participate, for example by "empowering" them. Go tell that to professionals in hospitals, even to bees in a hive. They know what they have to do and just get on with doing it — unless, of course, they have long been disempowered by their leadership.
The queen bee knows better: what she does is facilitate the worker bees' ability to get on with it, by emitting a chemical substance that holds the whole hive together. In human organizations, we call this culture. We human beings could use more leadership like this, especially in professional fields such as health care, which needs leadership to facilitate communityship. (I'll get back to this idea later.) Problematic can be the position of heroic leadership as well as the person in that position.
THE POSITION OF HEROIC LEADERSHIP
Jean-Louis Denis has written that "a very individualistic and grandiose vision of organizational leadership ... appears ill-suited to the workings of complex organizations marked by a fragmented authority structure" (2002: 17).
Managers and Leaders? Making matters worse is the currently widespread belief, thanks to Bennis (1989), Zaleznik (1977, 2004), and Kotter (1990), that leadership is somehow superior to management. Leaders do the big things; managers do the rest — in medical terms, the "scut work." Or to use the more formal terms, leaders do the right things while managers do things right.
This may sound right, until you try to do the right things without doing them right. In practice, leadership cannot be separated from management; managers who don't lead discourage the people around them, while leaders who don't manage are disconnected from what is going on, and so are incapable of true leadership. True leadership is management practiced well (Mintzberg, 2009a). We don't need more remote control in our organizations.
Excerpted from Managing the Myths of Health Care by HENRY MINTZBERG. Copyright © 2017 Henry Mintzberg. Excerpted by permission of Berrett-Koehler Publishers, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
This Book in Brief 1
Yet Again? 4
MANAGEMENT? or management? 5
A Few Cautions 6
Part I Myths
1 Myth #1: We have a system of health care 11
2 Myth #2: The system of health care is failing 15
Suffering from Success 16
More for Less? 18
3 Myth #3: Health care institutions, not to mention the whole system, can be fixed with more heroic leadership 23
The Position of Heroic Leadership 24
The Person as Heroic Leader 27
The Quest for a Regular Leader 27
4 Myth #4: The health care system can be fixed with more administrative engineering 29
Fads, Fallacies, and Foolishness 30
Re-engineering the Health Care Factory 32
When in Doubt, Reorganize 34
Use Pretend Markets When You Can't Get Away with Real Ones 40
Merge Like Mad 42
The Myth of Scale 43
Keeping the Baby 49
5 Myth #5: The health care system can be fixed with more categorizing and commodifying to facilitate more calculating 51
Categorization for Commodification for Calculation 52
Beyond, Across, and Beneath the Categories 53
Some Myths of Measurement 61
Analyst, Analyze Thyself 72
6 Myth #6: The health care system can be fixed with increased competition 75
Is American Competition the Model? 75
Porter and Teisberg on the "Right Kind" of Competition 78
Does Competition Necessarily Foster Innovation? 80
Is This Really About Competition? 83
The Cost of Competition 84
Cooperation, Not Individualization 85
7 Myth #7: Health care organizations can be fixed by managing them more like businesses 87
Herzlinger on this Business of Health Care 88
When Being a Business Is Bad for our Health Care 90
When Acting Like a Business is hardly Better 92
Health Care as a Calling 94
Summing Up the Fixes 96
8 Myths #8 and #9: Overall, health care is rightly left to the private sector, for the sake of efficiency and choice. Overall, health care is rightly controlled by the public sector, for the sake of equality and economy 99
The Great Divide? 100
Beyond Crude and Crass 102
Welcome to the Plural Sector for the Sake of Quality and Engagement 103
Plural Ownership and the Commons 105
Plural, Public, or Private? 108
Engagement and Communityship in the Plural Sector 110
Disengagement in the Plural Sector 112
Part II Organizing
9 Differentiating 117
The Specialized Players of Health Care 117
The Quadrants of Health Care 119
The Practices of Health Care 122
10 Separating 127
Curtains across the Practices 127
Sheets over the Patients 139
Walls and Floors between the Administrators 142
11 Integrating 145
Mind the Gaps 145
The Mechanisms of Coordination 150
Forms of Organizing 152
Part III Reframing
12 Reframing Management: As distributed beyond the "top" 169
13 Reframing Strategy: As venturing, not planning 173
14 Reframing Organization: As collaboration transcending competition, culture transcending control, communityship transcending leadership 181
Enough of the Separations 181
Enough of the Controls 182
Enough of the Obsession with Leadership 182
Enough of all that Competition 184
Toward Collaboration 184
Toward Communityship 185
Culture for Collaboration and Communityship 188
15 Reframing the Practice of Managing: As caring before curing 189
Leadership Embedded in Management 189
Heroic Leadership or Engaging Management? 192
Choosing the Flawed Manager 195
Who Should Manage Health Care? 198
16 Reframing Scale: As human beyond economic 205
17 Reframing Ownership: As plural and common alongside public and private 207
Roles for the Private Sector 208
Roles for the Public Sector 209
Roles for the Plural Sector 210
18 Reframing Health Care Overall: As a system beyond its parts 213
Promoting a Systems Perspective 214
Downloading the Whole of Health Care into each of its parts 220
Connecting the parts 226
Attaining Cooperative Autonomy 233
The Author and the Others 260
About the Author 260
About the People behind the Author 261