It’s a common story to anyone who has been around big healthcare: senior management attempts to respond to a business problem by implementing a series of high level mandates that remove front-line management’s ability to think and make operational decisions. The policies and processes do improve consistency for a period of time, but soon the organization begins to strain under the weight of multiple, often conflicting directives and goals. As the directives increase, a new series of corporate metrics are imposed to confirm that the mandates are followed. Front-line managers, hamstrung from above and unable to make flexible decisions, either find ways to circumvent the often unreasonable dictates, or watch as performance suffers and customers leave dissatisfied.
By now, the recent failures of the Veteran’s Affairs system are well known. My colleague Dr. Mike Hein has ample experience at the VA and has written eloquently on its problems. He recently shared a piece from the New England Journal where authors diagnosed the VA’s serious failures. The system’s inability to care for patients, they write, stems from the system’s increasingly centralized system of care delivery.
During the reforms of the 1990s, decentralization of operational decision making was a core principle. Day-to-day responsibility for running the health care system was largely delegated to the local facility and regional-network managers within the context of clear performance goals, while central-office staff focused on setting strategic direction and holding the “field” accountable for improving performance. In recent years, there has been a shift to a more top-down style of management, whereby the central office has oversight of nearly every aspect of care delivery. Concomitantly, the VHA’s central-office staff has grown markedly — from about 800 in the late 1990s to nearly 11,000 in 2012.
A surgeon friend of mine recently laughed at an anecdote: when she was at the VA (as a resident) cases would never start after 1pm because there was a high-level and strict policy about operations needing to be complete by 3pm. Local managers were punished if a case went late (presumably because overtime needed to be paid) so the risk of accommodating a veteran who had travelled for surgery, even for a short case, was too great. Better to have him stay overnight and try again tomorrow than risk pushing the 3pm deadline.
A cascade of things happens with high-level mandates: Senior management becomes obsessive about setting and measuring metrics. The degrees of freedom for people to make patient-focussed care decisions diminishes and every manager along the way starts to feel squeezed on all sides. Some find work-arounds such as the secret set of “waiting lists” kept off the books at the VA and the false reports generated by some. The NEJM authors write:
Though there can be no excuse for falsifying data, we believe that VA leadership created a toxic milieu when they imposed an unrealistic performance standard and placed high priority on meeting it in the face of these difficult challenges. They further compounded the situation by using a severely flawed wait-time–monitoring system and expressing a “no excuses” management attitude.
Considering the VA’s ultimate inability to “flex” to meet the changing needs of its patients, I was recently interested to read of the Massachusetts Nurses Association’s efforts to codify specific nurse to patient ratios into state law. Leaving aside a discussion of which ratio is the right one, since I’m not sure I feel confident enough to take a firm stance, let’s discuss the bigger issue: state laws are the best possible example of high-level, disconnected mandates in healthcare, and one can image the downstream chaos caused by hospitals scrambling to rob Peter to pay Paul, in ways which don’t make much sense. In the case of nurse ratios, one can envision a situation where the policy limits open beds to patients waiting in the ER.
One should instead trust in the intelligence and good intentions of an experienced charge nurse to make this call, which is what hospitals did for decades before the recent legislative bids. The alternative is to agree that frontline managers (and the organizations that employ them) aren’t competent to make effective healthcare decisions and to then pass a variety of state laws mandating a variety of behaviors in healthcare. We could mandate that patient blood pressures be controlled, and that mammograms be performed and that prostates be checked, under threat of law.
And, then, we could sit back and watch as the series of high-level directives stifles initiative and limits the ability of organizations to prioritize and make patient-centered decisions. We have seen this before and the punchline isn’t funny.