Posts etiquetados ‘MT’

I recently read a wonderful article in the New Yorker which is a very poignant reminder of our values in health care. Many health care professionals start out with high ideals and a deep desire to help every patient. However, unfortunately this often quickly dissolves into disillusionment, cynicism and in an isolated hospital/clinical environment into ignorance of the real underlying problem and needs.

Ask any doctor about their worst or “heart-sink” patients and they will easily identify the frequent flyers, the poorly controlled diabetics that visit the ER every other week, the ones that don’t take control of their physical illness – often those with social issues and little social support.

In the isolated world inside a hospital it is all to easy for management and health care staff to focus on the numbers, the physical illness, the test results, the hospital outcomes and performance in terms of mortality and discharge rates. But without leaving our comfortable safety net of the hospital indicators and biomedical medicine we can not understand nor identify the actual underlying problems and make a difference to those patients that need it the most. And ironically, those patients we are treating inadequately and dismissing as frequent flyers are costing us the most.

Sometimes the more cost-effective solution to a patients poorly controlled diabetes is not frequent readjustments to their medication, frequent admissions due to decompensation but linking them in with social workers and community support to assist with obtaining adequate housing, understanding their medication and autocontrol of their illness and improving social support.

To quote Gawande in the New Yorker – Lower Costs and Better Care for Neediest Patients

… You might decide to increase his insulin dose and change his blood-pressure medicine. But you wouldn’t grasp what the real problem was until you walked up the cracked concrete steps of the two-story brownstone where he lives with his mother…

Gawande further develops his argument by saying that

…“Emergency-room visits and hospital admissions should be considered failures of  the health-care system until proven otherwise,” he told me—failures of  prevention and of timely, effective care….

This last statement is slightly provocative and thought-provoking, but has an element of truth. There is much scope for preventative measures and health promotion. Social and community issues are vital parts of an individuals and community health and should not be forgotten. Although arguably we can shift responsibility for this from the hospital to primary care medicine or public health. We can and should be using the ER admissions and re-admissions as indicators of areas of need in the community and identify social and health needs of a community. In treating each patient we need to remember the importance of the psychosocial factors influencing their health.  And ultimately in economic and managerial terms it may be beneficial for a hospital identify problem areas and to invest in their catchment zone – either directly or indirectly.

We need to get out of our doctors office and reconnect with our community. We should try to identify and understand the underlying issues of our patients remembering that the solution to a health problem may be better solved from a social context,

and ignoring this is costing us more.

— MT —


Leading Women?

Publicado: 12 abril, 2011 en Uncategorized
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A thought provoking talk I wanted to share. It would be interesting to see how the percentages of women in hospital managerial roles stacks up.

Are you a micromanager?

Publicado: 29 marzo, 2011 en Uncategorized

When we talk about micromanagers, we all knowingly nod our head in remembrance and understanding of how frustrating, limiting and disenchanting it is working in a micromanaged environment. We can all easily point out the flaws and criticise how we were micromanaged. But can we turn the mirror and identify these traits in ourselves when we step into a management role, and stop the damage before it’s too late.

How do we identify if we are a micromanager?

MINDTOOLs suggests the following list. Are you guilty of one of these?


Or do you identify with this scenario?

“Micromanagers often affirm the value of their approach with a simple experiment: They give an employee an assignment, and then disappear until the deadline. Is this employee likely to excel when given free rein?

Possibly – if the worker has exceptional confidence in his abilities. Under micromanagement, however, most workers become timid and tentative – possibly even paralyzed. “No matter what I do,” such a worker might think to himself, “It won’t be good enough.” Then one of two things will happen: Either the worker will ask the manager for guidance before the deadline, or he will forge ahead, but come up with an inadequate result.

In either case, the micromanager will interpret the result of his experiment as proof that, without his constant intervention, his people will flounder or fail.”

This then brings up the next question.

How can one avoid micromanagement, or make change?

As mentioned in MINDTOOLS

Part of being a good manager, one often lost on those of the micro variety, is listening. Managers fail to listen when they forget their employees have important insights – and people who don’t feel listened to become disengaged.


Businessweek Review uses the “Prep-Do-Review” tool

Each task is divided into 3 parts: Preparation, performance of task and subsequent review of the outcome. Depending on expertise of staff, a manager should be more or less in the prep and Do stages or with expert staff not be involved in the performance of the task.

However should maintain involvement of review whether outcome was a success or failure so the team can learn from both. By maintaining communication and involvement and correct stages of the task one maintains communication with staff without intruding on their work. This certainly seems like a valuable tool in management.

However, the first step is self-evaluation in our managerial style and identifying the traits which may be doing more harm than good to the relationship with staff.

We all need to learn to look in the mirror and analyze critically.


Related blog:

— MT —

There has been much debate over how one should pay doctors to increase efficiency.  This debate is based on the motivational effect of financial incentives. The underlying premise that if we don’t have incentive to improve our practice/outcome we won’t, and if we are not “punished” for inefficiency we will not modify our behaviour.

Much has been said in favour of pay for performance for medical staff to make hospitals more efficient and cost-effective. But what about its managers? Can we extend this argument to the CEO and Hospital Management?

Hutton argues that we can and should:

“Hutton wants performance-based pay for public sector managers”

Hutton goes on to argue that every level of an organization should be rewarded in proportion to the value of their contribution. Sounds fair enough. But this raises a few questions. Can a sector used to a lack of transparency and unfamiliar with measuring performance-based pay, implement this?

With medical staff we have more or less come up with formulae to measure performance. What performance-based criteria would we use for managers?

However, the more important question is – do financial incentives actually work?

Dryburgh in Management today argues that it doesn’t. He uses the Candle Problem example.

In the 1930s , cognitive psychologist Karl Duncker devised the “candle problem”. With a candle, a book of matches and a box of drawing pins, you are given the objective of fixing the candle to the wall so that it will burn without dripping wax.

Duncker gave 2 groups the problem. The first group were told the experimenters just wanted to time them to establish norms for the task. The second were given a financial incentives – the fastest 25% got $5 and the fastest person that day got $20.

Results: The incentivised group took, on average, nearly three and a half minutes longer to find the solution.

Reason: Solving the problem involves a tricky cognitive manoeuvre, that of overcoming ‘functional fixedness’. You have to stop seeing the box as a container of drawing pins, and start seeing it as a candle stand. The effect of the incentive was to make people concentrate harder, narrowing their focus and making it harder to see around the edges of the problem.


So, what qualities do you want in a manager in your hospital – raw motivation or creativity, intelligence and lateral thinking?

  • You decide.

Power Hungry?

Publicado: 4 marzo, 2011 en Uncategorized
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As discussed in an earlier post, suggested qualities and abilities of a good hospital manager include professionalism, responsibility, honesty, patience, empathy, assertiveness and leadership. I’m sure we all agree on these.

However, what motivates someone to a management position and is this motivation compatible with these qualities?

A fairly recent “survey of 137 major European employers conducted by the international HR consultancy Cubiks found that most managers take on responsibility for managing people because they want greater involvement in company decision-making and not because they are fundamentally interested in managing and developing teams” “The survey found that only 28 per cent said they were interested in staff development and more than half (53 per cent) said that their chief motivation for managing people was to gain greater involvement in company decision-making. Less commonly stated motivations were the prospect of a higher salary and benefits such as a company car (7 per cent) and considering it a step towards greater seniority (6 per cent).”

This survey suggests that the majority of managers are motivated by self-serving factors and not organizational goals. This is in contrast to the common belief that managers’ goals and organization goals are aligned. However, this is not necessarily a bad thing.

To quote McClellan and Burnham :

“Contrary to popular opinion, the best managers are the ones who like power – and use it.”


The reason that those motivated by desire for power make effective managers is that they understand the role of influencing people, delegation of responsibility and positive reinforcement/improving staff morale. Managers that are motivated by the need to be “liked”, or personal achievement seem to lack this ability and often become disillusioned by managerial roles. Those motivated by personal achievement often end up doing everything themselves, and tend to be more critical in dealings with staff. This is harmful to staff morale and a team environment. The need to be “liked” results in lack of leadership, direction and authority. 

However, having said this, the motivation for power needs to be disciplined and controlled for the benefit of the institution as a whole. Without discipline and control of this motivation the tendency is toward a more authoritarian leader and dissociates personal objectives and institute objectives. The combination of power with control/discipline has been shown to result in the best outcomes for both the individual and the institution in which they are a manager.

Understanding the three different types of motivations for managers allows for self analysis in what motivates ourselves and what role we may best be suited to in an organization. This leads to the possibility of then utilizing each persons’ motivations in structuring an institute or team to maximise each persons’ talents and team outcomes.

And lastly, also raises the possibility that being motivated by “power” may not be such a bad thing when it comes to management.

— MT —

Doctors as Managers????

Publicado: 18 febrero, 2011 en Uncategorized
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Source: Student BMJ

When referring to doctors as Managers, many make the mistake of assuming that this would mean putting doctors in managerial roles without adequate formation/training. This assumption leads to the immediate discarding of the idea without reviewing the possible advantages.

One often quoted idea is that doctors lack managerial training. Another often used argument, as written by Edwards in the BMJ 2003 is “If doctors decided that their principal concern was to ensure the smooth running of the system and the delivery of policy irrespective of the consequences for the patient in front of them, then both the quality of care and public support would collapse.”

The latter does not go against the argument that doctors can and should be good managers. But cannot and should not take on both roles at once. These are two different concepts and should not be confused. The former argument omits the possibility of a clinician to undertake managerial training and employ experience and expertise in both fields to ensure better hospital outcomes.

I’d like to put forward the argument that clinicians could be very effective in management and their clinical experience and knowledge should be used in management to improve hospital outcomes.

There is no doubt in the argument that both doctors and managers have different backgrounds, training and skills. Differences also exist in terms of their job roles, their approaches to health care and their primary objectives. However they also have a lot in common, both medical and managerial roles require analytical skills, problem solving skills and the ability to make decisions. From this perspective both parties have a lot to learn and benefit from each other for the effective running of a hospital.

A manager/administrator needs to know his organization and product. This means that a manager with no clinical background this requires extra education/learning to fill this gap. The same goes for a doctor filling a managerial role – they need to fill the education gap of administration/finance.

In both the NHS and Australasian Medical College a Residents training programme has been developed to train clinicians in hospital administration after having benefited and gained clinical experience after a number of years “at the coal face”. In the USA it’s being increasing common for a combined MD/MBA  programme. These programmes aim to fill the managerial education gap and increase clinician involvement in management.

The premise being that  combining the knowledge, skills and experience of a clinician, who understands the coal face of a hospital, the day to day challenges of clinical care and more importantly has a strong foundation in evidence based medicine and health care, and combining that with managerial formation/training can give a great advantage in the effective management of a hospital or health organization.

Where is the evidence for this? One article worth mentioning on this is a recent article in the Economist. This article discussed an analysis of hospitals internationally for “best management practices” and on “standardised measure of medical success”. Out of the five characteristics associated with the management of successful hospitals, employing clinically qualified staff in management scored better than those that do not.

Does this mean that a hospital manager must be a clinician? No. But that there are many potential advantages and benefits to be gained from employing clinicians in management.

Links of interest:

Stephenson, Doctors in Management, BMJ 2009; 339:b4595                   

What can doctors and managers learn from each other? – a lot, BMJ vol 326 22 MARCH 2003

Edwards, Doctors and Managers: a problem without a solution? BMJ vol 326 22 MARCH 2003

How to save lives: Five simple rules for running a first-class hospital, The Economist, Oct 21, 2010

 Wai-Ching ,Career focus: studying for an MBA, studentBMJ 2000;08:131-174 May