common meritocracy. how a good hospital should be governed
TRANSCRIPT
COMMON MERITOCRACY:
A MULTI-AGENT SYSTEM AS THE MODEL FOR A CO-OPERATIVE COMMUNITY IN HEALTHCARE
Ryszard Stocki Saint Mary’s University MIK - University of Mondragon University of Social Sciences and Humanities, Katowice Andrzej Bielecki University of Mining and Metallurgy !Community, Context and Communication ASB Conference, 26-28 September 2014, Halifax
Erwin Schell of MIT in 1952 in “The Amazing Oversight: Total Participation for Productivity.”
The wish to participate in the direction, guidance, and control – in short, in management―of affairs is one of the deepest desires of man.
BECAUSE WE MIX TWO VIEWS OF PARTICIPATION
Ontological
Our feature - as ability to walk. Inherent in our nature. Element of our dignity as persons.
Something that differentiates us from animals and makes it possible for us to make free choices
according to our will.
A value. An element of our culture. Something to be taught. An important aspect of management strategies, education, etc. Sometimes has to be
limited. An expected element of developed democratic systems.
Ethical
Photo: gthills - cc @ flickr.com Photo: Matthew Anderson - cc @ flickr.com
UNIVERSALITY OF PARTICIPATION
Solon
Buddha
Herodotus
Laozi
SamuelIsaiah
Jesus ChristSpartacus
St BenedictWilberforce
Wielezynski
Kwiatkowski
Mediarrieta
Wojtyła Allport SemlerMaslow Stack Heron
Schell
Owen
Gandhi
King
Vroom
PARTICIPATION IS SO TROUBLESOME AS IT SEEMS TO COMPETE WITH
OWNERSHIP AND BOTH ARE PILLARS OF OUR PERSONAL SECURITY
AND OWNERSHIP IS A COMPLEX CONCEPT
COMPLEXITY OF OWNERSHIP
Legal ownership Kaarsmaker, 2009;
Ben-Ner, 2007; Ellerman, 2006
1
Society and its insitutions recognize
ownership rights, but sometimes the rights have to be shared.
Photo: Tori Rector - cc @ flickr.com
COMPLEXITY OF OWNERSHIP
Psychological ownership: Pierce et al. 2004; O’Driscoll, 2006;
Dwyer and Ganster, 1991 Pierce & Jussila, 2010
2
A person recognizes ownership rights,
but sometimes they have to be shared.
Photo: Matthew Anderson - cc @ flickr.com
COMPLEXITY OF OWNERSHIP
Control related ownership Vroom & Jago, 1988
Mazur, 1966 3
Efficacy related to the object. Requires information and expertise, but sometimes
they have to be shared.
ALL THREE PRODUCE SEVEN STATES OF OWNERSHIP, SOME GENERATING CONFLICTS, BUT ONLY ONE STATE
ALLOWS FOR TOTAL PARTICIPATION.
15 2
4
7
6
3
7. Total participation - never achieved in 100% but is the desired goal as it
conditions real, motivated, responsible actions.
Graham & Titus, 1979 Stocki, Prokopowicz & Żmuda, 2008
Legal
Control
Psychological
TOTAL PARTICIPATIONdefined by Stocki, Prokopowicz & Zmuda, 2008 and 2012
Total participation in management (TPIM) – the method of directing an organization based on the conviction that participation is an inherent characteristic of every human being, and that employee participation has a constant, long-
term, and positive influence on the achievement of organizational and individual goals.
WHAT ABOUT HOSPITALS?
THEY ARE ELITIST INSTITUTIONS BASED ON EXPERTISE OF FEW PERSONS
InterestOne Few Many
Self-interst Tyranny Oligarchy Mobocracy
Society’s interest Monarchy Aristocracy
The bestDemocracy
Number of rulers (Scope of Competence)
Aristotle's division of political systems
Hospital
THEY ARE SEPARATED FROM THEIR STAKEHOLDERS BY FINANCING INSTITUTIONS WHICH ARE IN CONFLICT OF INTEREST WITH BOTH
THE PATIENTS AND THE HOSPITAL
Ministry of Health
Insurance institution Physician
Patient 1
Patient 2
Patient 3
Patient 4 Barriers
THERE IS NOT A SINGLE COUNTRY IN THE WORLD SATISFIED WITH ITS
HEALTH CARE SYSTEM.
The result:
OUR HEALTH CARE IS BASED ON THE “SERVICE MODEL”
Photo: Brian - cc @ flickr.com
AND SERVICE MODELS FIT CAPITAL BASED INSTITUTIONS
AMPLE MEDICAL EVIDENCE PROVES THAT HEALTHCARE CANNOT BE
BASED ON A SINGLE EXPERT SERVICE MODEL.
Body like a car to be repaired.
BodyAs a patient
I distance myself to my body and illness. As the owner of my
body I want the doctor to “repair” it, else I can
do whatever I want with it, e.g. destroy it
Patient the ignorant
Doctor the expert
As a medical expert she/he (paternastically)
focusses on treatment and takes responsibility
for it. He/She is interested in a
limited set of information about the
patient.H
ealth care system
Impersonal relationship between the doctor and the patient, based on Cartesian dualism.
HEALTH CARE IS NOT A REPAIR SERVICE
Both doctor and patient are experts in their specific domains and should participate in the treatment process
according to their expertise.
Person becomes the subject of her illness
and as such has to participate in treatment.
Patient - an expert in his family, calling, self-fulfillment, goals
Doctor - a medical expert
As a medical expert (participatively) focusses on the good of the patient and takes
responsibility for her actions and words.
Calling
FamilyThe person transcends to good and is not an owner of his or her body, but
body as well as participation are essential elements of the person. They
make up its dignity.
Sense
Self-fulfillmentBody
As a researcher and provider of service she has
to achieve informed consent.
Expert
Sense
FOR EFFECTIVE HEALTHCARE PATIENT AND DOCTOR’S
RESPONSIBILITY AREAS HAVE TO CHANGE AND MEET IN THE SYSTEM.
Health care system
Health care system allows for defining and responding to common good with
the best expertise available.
Capital based institution is not a good environment for nurturing the personal
relationship.
THIS REQUIRES COMPLETELY NEW HOSPITAL GOVERNANCE MODEL
Interest One Few Many
Self-interst Tyranny Oligarchy Mobocracy
Common good Meritocracy through active participation Different groups and sizes depending on the nature of the problem
Society’s interest Monarchy Aristocracy Democracy
Number of rulers (Competence)
CORRECTED ARISTOTLE’S TYPOLOGY
Hospital
Ministry of Health
Insurance institution Physician
Patient 1
Patient 2
Patient 3
Patient 4
AND LOCAL COMMUNITY BASED MODEL OF HEALTH CARE FINANCING - STEP 1
Hospital
Ministry of Health
Physician
Patient 1
Patient 2
Patient 3
Patient 4
AND LOCAL COMMUNITY BASED MODEL OF HEALTH CARE FINANCING - STEP 2
Helath community
Ministry of Health
Physician Member 5
Member 1
Member 2
Member 3
Member 4
AND LOCAL COMMUNITY BASED MODEL OF HEALTH CARE FINANCING - STEP 3
THE BEST EXISTING LEGAL FORM FOR A HOSPITAL, MEETING ALL THE REQUIREMENTS IS A MULTISTAKEHOLDER CO-OPERATIVE
• Physicians - Producer co-op
• Nurses/midwives - Worker co-op
• Dietitians - Producer co-op
• Patients - Consumer co-op
• Pharmacists - Trade co-op
• Administration - Worker co-op
• Financial service - Credit union
• Social workers - Worker co-opPhoto: U.S. PacificFleet - cc @ flickr.com
BUT IT MAY HAPPEN ONLY THROUGH INFORMATION AND COMMUNICATION
TECHNOLOGY
0
55
110
165
220
Cuba India Canada China USA Poland Gabon
MERITOCRACY REQUIRES EASY ACCESS TO KNOWLEDGE, INFORMATION AND DECISION
MAKING. IT IS POSSIBLE THROUGH MOBILE PHONES.
Number of phones /100 people
The World Bank 2014
M-GOVERNANCE‘a strategy for the implementation of Governance and its implementation involves the utilization of all kinds of wireless and mobile technologies, services, applications, and devices. It improves upon the benefits for those involved in e‐governance, including citizens, businesses, and all government units’ (Pandey & Sekhar, 2013).
Reporting of domestic
violence in South Africa and India
TXT CSC - an SMS service launched by Civil Service
Commission in the Philippines
M-Voting, the
parliament approved mobile
technology for the 2011
elections in Estonia.
M-HEALTHthe practice of medical and public health, supported by mobile devices. The term is most commonly used in reference to using mobile communication devices, such as mobile phones and PDAs, for health services and information.
(Pandey & Sekhar, 2013).
Telemedicine: Patients take a photograph of a wound or illness and allow a remote physician diagnose to help treat the medical problem. Diagnosis and treatment
support projects attempt to mitigate the cost and time of travel for patients located in
remote areas.
Education and awareness: Patients get information about various subjects, including testing and treatment methods, availability of health services, and disease management.
Helpline: T
his involves a dedicated
phone number which an individual
can call to get access to a range of
medical services like availability of
drugs, information on facilities,
availability of mobile health clinics
etc.
TO MEET THE NEEDS OF COMMON MERITOCRACY AND TO MAKE SUCH
GOVERNANCE EFFECTIVE
the elitist and competence based m-health !
has to meet !
the broad, common m-governance
DETERMINANTS OF MERITOCRACY PROCESS (BASED ON VROOM, 2003)
Incumbent characteristics
Decision characteristics
Situation characteristics
Leader’s content competence
Leader’s process competence
Incumbent’s content competence
Incumbent’s process competence
Interaction constraint Goal alignment Role (leader -
member) Content competenceProcess competence
Likelihood of disagreement Likelihood of commitment Value of time
Value of development Decision significance
Importance of commitment
Parti
cipa
tion
leve
l
An individual takes the decision
An individual consults individually
An individual consults a group
A moderated group takes the decision
Not-moderated group takes the decision
AGENTS AND RULES OF THE SYSTEM
Incumbent characteristics
Decision related agents
Rules defined in the system
Matching the incumbents characteristics with the decision characteristics to produce Inferring the incumbent competence Calculating the likelihood of disagreement Calculating the likelihood of commitment after the decision is taken Selecting set of incumbents to propose take the decision Monitoring the response rate to decision proposals Monitoring the engagement in the system, etc etc. Monitoring the input and change in competence of the incumbents
Possible decision domains and their requirements
Charls Darwin: Decision initiation rights Level of general competencies
humane interpersonal business
Level of specialist competencies Organizational position
availability readiness to take decisions age tenure membership in professional groups cooperative membership
Joanna positions: Decision initiation rights Level of general competencies
humane interpersonal business
Level of specialist competencies Organizational position
availability readiness to take decisions age tenure membership in professional groups cooperative membership
Francis positions: Decision initiation rights Level of general competencies
humane interpersonal business
Level of specialist competencies Organizational position
availability readiness to take decisions age tenure membership in professional groups cooperative membership
Margaret Schenk Decision initiation rights Level of general competencies
humane interpersonal business
Level of specialist competencies Organizational position
availability readiness to take decisions age tenure membership in professional groups cooperative membership
John Smith: Decision initiation rights - limited Level of general competencies
humane - 10 interpersonal - 5 business - 4
Level of specialist competencies Organizational position
availability - weekends readiness to take decisions - 10 age 45 tenure 6 membership in professional groups (NAMD, SAPG, etc.) cooperative membership (
Possible decision making methods: Too early Specialist (no consultations) Specialist (after consultations) Incumbent (after consultations) Incumbent (no consultations)
Forms of voting Majority Consensus
Possible decision scope: Individual. local, departmental, etc.
MERITOCRATIC DECISION MAKING PROCESS
Initialization
Input Decision support systemSelection of
incumbents to be involved in the process
Voting Majority
ConsensusDecision
made
Database Incumbents Decision scopes Domains etc.
Rules
OutputDecision Decision initiator Reason to initiate Goals to be met Domain: General Specific Competency/Experience Requirements Urgency Costs Significance Who shall commit in realization Proposed decision owner
Rights and conditions of
initializing decision making process
Training
Decision generator
Selection of actions to be instigated
Debate
Consulting
Research
IS IT A UTOPIA OR JUST A NAIVE DREAM?
Web sites like StackExchange prove
it is neither.
THEY HAVE A MULTITUDE OF DOMAINS OF KNOWLEDGE AND…
… RULES TO START NEW ONES, AND…
… RULES OF DECIDING ON IMPORTANCE, EXPERTISE AND ENGAGEMENT AND…
A CLEAR SYSTEM OF EVALUATING PARTICIPANTS AND THEIR INPUT.
Questions are evaluated
Answers are evaluated
Participants build their reputation
Few have editing rights
PORTALS LIKE:Allow to do effectively and on a large scale what we have always been doing - exchange knowledge and information. !However, Information and Communication Technology allows us to establish systems like…
Common meritocracy
to do things we have never been doing, but should have long time ago to reveal our potential as free persons.
SUMMARY• Participation is us.
• Ownership misleads us in our relationships with others.
• By the nature of their function, hospitals should be communities of persons and not service providers.
• A multistakeholder co-operative is the best legal form for a hospital.
• “Oligarchy” and “aristocracy” of the hospital governance should be replaced by common meritocracy.
• Functional benchmarking of portals like StackExchange may help us build real implementation of this form of governance.
FOR MORE INFORMATION ABOUT COMMON MERITOCRACY AND TOTAL
PARTICIPATION CONTACT ME AT: [email protected]
!
THANK YOU.