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A comprehensive account with examples of the types of error that interfere with the abilities of intelligent people to make optimal decisions, together with some advice about ... more
A comprehensive account with examples of the types of error that interfere with the abilities of intelligent people to make optimal decisions, together with some advice about how these problems can be avoided
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Teaching smart people how to learn Argyris C 1991 Harvard Business Review
The healthcare services industry is well supplied with a workforce of highly intelligent and highly educated healthcare professionals and other staff. This paper points out ho... more
The healthcare services industry is well supplied with a workforce of highly intelligent and highly educated healthcare professionals and other staff. This paper points out however that such individuals are not always as adept at learning new information or adapting to new circumstances as might be expected. It is reckoned that this is because they have usually had successful careers with not much opportunity to learn from failure, are therefore more adept at "single loop" learning which may serve them well enough for direct problem solving but less so at the sort of "double loop" learning that is needed when the assumptions that have been used to frame the problem need to be reconsidered.
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Southon G, Perkins R, Galler D. Networks: a key to the future of health services. Australian Health Review. 2005;29(3):317-326
In any organisation reliant on the expertise and experience of a cadre of professional staff whether engineers or medical specialists there will always be a tension between ma... more
In any organisation reliant on the expertise and experience of a cadre of professional staff whether engineers or medical specialists there will always be a tension between managers who exert their influence and control through vertical hierarchies and professional who exert theirs through horizontal networks or communities of practice. This paper describes the increasing role of various forms of clinical networks and their strengths and weaknesses:, and the fundamental differences of the two models of governance and work practices . Quote: " In general, the differences between hierarchical and network relations can be summarised as follows:In hierarchies, people look to their superior for authority; in networks, people look to the most competent colleagues, wherever they may be. Hierarchies are focused on organisational coherence and viability, while networks are focused on expert achievement.Hierarchies are based on formal control, accountability and extrinsic motivation, while networks are based on expertise, collegial values and intrinsic motiation.Hierarchies bring structure, control and accountability, while networks bring knowledge, innovation and capability. Managers, politicians, and policymakers tend to be more comfortable with hierarchies while professionals gain more from networks"
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Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management, and modernisation: a “danse macabre”? Bmj. 2003;326(7390):649.
The tension that often inhibits the relationships and potential cooperation between health service managers and healthcare professionals especially doctors is well known and o... more
The tension that often inhibits the relationships and potential cooperation between health service managers and healthcare professionals especially doctors is well known and often the source of much lamentation but rarely measured in a form that might promote better understanding and remediation. This paper is a notable exception in that it measured and displayed in a convincing graphical form these differences in two key dimension - the priority afforded to budget integrity on one axis and to standardized pathways or processes of care on the other. This clearly demonstrates marked differences between clinicians and general managers with nurse managers and medical administrators falling somewhere in between
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Gaba DM, Singer SJ, Sinaiko AD, Bowen JD, Ciavarelli AP. Differences in safety climate between hospital personnel and naval aviators. Human Factors: The Journal of the Human Factors and Ergonomics Society. 2003;45(2):173
An interesting and disconcerting comparison of the safety climate between naval aviators and hospital staff - mostly consultants and managers but including other staff groups,... more
An interesting and disconcerting comparison of the safety climate between naval aviators and hospital staff - mostly consultants and managers but including other staff groups, and showing that the health care staff worked in environments and / or had attitudes to safety that were significantly more risky than those experienced by or manifest by aviators. This report is now 2 decades old and things may have improved in healthcare, but probably not as much as they should. The greater autonomy granted to healthcare professionals especially to medical consultants compared to those in military hierarchies may account for some of the differences.
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Cameron KS, Quinn RE. Diagnosing and Changing Organizational Culture: Based on the Competing Values Framework. John Wiley & Sons; 2011
There is an extensive descriptive literature on the varieties, functions and dysfunctions of organizational cultures, but a less abundant one on practicable methods of measure... more
There is an extensive descriptive literature on the varieties, functions and dysfunctions of organizational cultures, but a less abundant one on practicable methods of measurement and management. This book is an honorable exception as it contains a wealth of useful information and advice on the classification, diagnosis and the management of four basic types of 'competing values;
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Mant J. Process versus outcome indicators in the assessment of quality of health care. International Journal for Quality in Health Care. 2001;13(6):475.
In comparisons of performance between clinical services it is natural and entirely justified to pay most attention to outcomes such as mortality in heart disease. The problem ... more
In comparisons of performance between clinical services it is natural and entirely justified to pay most attention to outcomes such as mortality in heart disease. The problem with this however is that adverse outcome are relatively rare which means that very large numbers of cases must be collected before valid comparisons can be made. Also final outcomes are sensitive to other variables such as demographic and casemix severity. Comparisons of the processes of care, provided these are of evidence based efficacy, can be made much more quickly as they are or should be used in all cases thus giving larger numbers as denominators. They are also not subject to casemix and other environmental confounding factors.
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Duckett SJ, Breadon P, Weidmann, B, Nicola I. Controlling Costly Care - a Billion Dollar Opportunity. Grattan Institute, Melbourne
A comprehensive and detailed report on the widespread and often very wide variation in usage and costs of hospital services in Australia and the potential national saving at ... more
A comprehensive and detailed report on the widespread and often very wide variation in usage and costs of hospital services in Australia and the potential national saving at that time of around 2 Billion dollars
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McDaniel Jr RR, Driebe DJ. Complexity science and health care management. Advances in health care management. 2001;2:11-36
Many problems can be understood and solved as simple linear cause and effect relationships, but many more in large organisations such as health care services arise from comple... more
Many problems can be understood and solved as simple linear cause and effect relationships, but many more in large organisations such as health care services arise from complex non-linear interactions among multiple factors and often conflicting objectives. Such interactions often manifest unexpected, ill-understood and usually unwanted emergent properties. This paper provides a good overview of these complex adaptive systems in health care services and how they need to be managed.
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Wenger EC, Snyder WM. Communities of practice: The organizational frontier. Harvard business review. 2000;78(1):139-146
How and why some groups form and perform at high levels simply because they are bound together by the pleasures of pursuing and achieving shared goals, and how they are fundam... more
How and why some groups form and perform at high levels simply because they are bound together by the pleasures of pursuing and achieving shared goals, and how they are fundamentally different from teams and other more easily identified and constructed organisational work groups
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Endless Forms Most Beautiful: Evolving Toward Higher-Value Care. NEJM Catalyst. Published online July 26 2018 Accessed Feb 11 2024
A short and instructive but seemingly, if citations are any guide, often overlooked, NEJM Catalyst article. This outlines an interesting analytical and management methodology ... more
A short and instructive but seemingly, if citations are any guide, often overlooked, NEJM Catalyst article. This outlines an interesting analytical and management methodology for implementing and measuring value based healthcare. This involves providing physicians with the outcomes and costs of CABG procedures plotted on a phase map alongside those of their peers for comparison, and accompanied by time trends. A methodology worth replicating
(The relevant figure is shown here)
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Ludeman K, Erlandson E. Coaching the Alpha Male. Harvard Business Review. 2004;(May 2004).
The highly competitive environment of hospital specialist training and recruitment inevitably leads to a disproportionate number of highly driven and competitive 'alpha' males... more
The highly competitive environment of hospital specialist training and recruitment inevitably leads to a disproportionate number of highly driven and competitive 'alpha' males ending up in these positions. This may be advantageous where bold innovation and boundary extending courage are required. Few ground breaking surgical techniques are introduced and nursed through the early learning curves of frequent failures by shrinking violets. We need this type of alpha males (and females, fewer in number tho' no less courageous or turbulent) for progress to be made. The down side ot 'alphadom' is that such individuals may not be easy to work with or be good team leaders or builders. At the extreme they can verge on dangerous narcissism - disruptive to their colleagues and dangerous to their patients because of their unshakable self confidence and over estimates of their own abilities. This paper gives some useful and practical advice for managing these individuals at the milder end of the spectrum.
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Priesmeyer HR. Organizations and Chaos : Defining the Methods of Nonlinear Management. Quorum Books; 1992.
A lucid account with descriptions of several interesting and practicable analytical methods for investigating and managing non-linear phenomena in commercial environments. Exp... more
A lucid account with descriptions of several interesting and practicable analytical methods for investigating and managing non-linear phenomena in commercial environments. Expands on the paper on the use of phase maps by Priesmeyer and Sharp (Ref no 608)
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Priesmeyer HR, Sharp LF, Wammack L, Mabrey JD. Chaos theory and clinical pathways: a practical application. Quality Management in Healthcare. 1996;4(4):63.
Although much has been written about the nature of many healthcare services as complex adaptive systems and the consequent 'wicked' problems and unexpected emergent properties... more
Although much has been written about the nature of many healthcare services as complex adaptive systems and the consequent 'wicked' problems and unexpected emergent properties, not a great deal of this literature gives much practical guidance in the development and use of useful analytical tools. This paper is an exception in that it explores the possible application of a very simple form of analysis and data display - the phase map.
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Simon HA. Bounded rationality and organizational learning. Organization science. 1991;2(1):125-134.
A very readable essay by a polymath and Nobel prize winner on how organisations do or don't learn what they need to know. One of the most interesting and intriguing sections r... more
A very readable essay by a polymath and Nobel prize winner on how organisations do or don't learn what they need to know. One of the most interesting and intriguing sections refers to Bavelas networks - studies of how groups communicate when configured in different ways and how one study purportedly shows that once particular patterns of using centralized or peripheral communications routines are established they persist despite complete changes of all staff involved. This is probably why some organizational cultures can be so hard to change.
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Australian Atlas of Healthcare Variation Series | Australian Commission on Safety and Quality in Health Care. Accessed July 9 2023.
A gold mine of national information about the startlingly high levels of variation in various conditions and processes of care - with ranges from the highest to lowest of diff... more
A gold mine of national information about the startlingly high levels of variation in various conditions and processes of care - with ranges from the highest to lowest of differing many fold indicating areas of both under use and overuse of care. In its published from it is given at state and SA3 statistical (regional) area but finer grain detail down to a hospital level is apparently available and that should the known and if necessary acted upon by senior clinicians and managers
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Thor J, Lundberg J, Ask J, et al. Application of statistical process control in healthcare improvement: systematic review. Quality and Safety in Health Care. 2007;16(5):387
A review based on a meta-analysis of the use of statistical process control in healthcare - or perhaps more precisely of the under use of this valuable form of analysis,
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Coory M, Scott I. Analysing low-risk patient populations allows better discrimination between high-performing and low-performing hospitals: a case study using inhospital mortality from acute myocardial infarction. Quality and Safety in Health Care. 2007;16(5):324
For assessing clinical performance in hospital mortality from acute myocardial infarction, comparing low risk groups of patients provides better discrimination than those at h... more
For assessing clinical performance in hospital mortality from acute myocardial infarction, comparing low risk groups of patients provides better discrimination than those at higher risk. This seems worth exploring in hospital mortality of other causes, a possibility that thus far this does not seem to have attracted much attention
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Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review. 2002;18(4):501-531
As diagnostic and therapeutic options continue to multiply, and health care services become more and more specialized, they begin to manifest the properties of complex adaptiv... more
As diagnostic and therapeutic options continue to multiply, and health care services become more and more specialized, they begin to manifest the properties of complex adaptive systems including unforeseen interactions and emergent properties.The consequent risks are often not understood by clinicians and managers, and as this review of Sterman's contributions nicely illustrates, high intelligence and educational achievements are no guarantee of effective problem solving, especially in standard stock and flow problems of a type encountered in bed management on a regular basis in large acute hospitals. The need for specific education in this domain is very clear.
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Wennberg JE. Tracking Medicine: A Researcher’s Quest to Understand Health Care. Oxford University Press; 2010.
Should be required reading for any clinician or manager wanting to increase the value of the services they provide either by improving quality or reducing costs or both. The a... more
Should be required reading for any clinician or manager wanting to increase the value of the services they provide either by improving quality or reducing costs or both. The author has been a pioneer and leading researcher of unjustified variation in these variables for several decades, His major contributions include the development of the USA Dartmouth Atlas of geographic variation, and a tripartite classification of health care services into Effective, Supply-sensitive and Preference-sensitive categories as aid to aid to improvement.