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ANNOUNCING my new book

19 April 2017

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

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.”

The 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.

Some other excerpts:

In management no less than medicine, scalpels usually work better than axes.

Narrowness pervades health care, from professionals on the ground who can’t see past their specialities, to managers in the offices who can’t see past their institutions, analysts in governments and insurance companies who can’t see past their numbers, and economists in the air who can’t see past their dogma.

Reorganizing is the expected disjointed intervention for a health care “system” built on disjointed interventions.

While the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This makes the field of health care sick.

There are no management problems in health care, separate from medical problems, nursing problems, or prevention problems. There are only health care problems.

Because economics begins before medicine ends, the technocrats of health care have too often trumped the professionals.

In the name of competition, health care suffers from individualism: every patient, provider, and institution for themselves.

The field of health care may be appropriately supplied by businesses, but in the delivery of its most basic services, it is not a business at all, nor should it be run like one. At its best, it is a calling.

I can think of no field that is more global in its professional practices yet more parochial in its administrative ones than health care.

Certainly we have to measure what we can; we just cannot allow ourselves to be mesmerized by measurement—as we so often are.

Physicians who like to belittle hierarchies of authority are often slaves to their own hierarchies of status.

Who can possibly be against evidence in medicine? Me, for one, when it is used as a club to beat up on experience.

The essential problem in health care may lie in forcing detached administrative solutions on to practices that require informed and nuanced judgments.

It can be taken as almost an axiom of professional work that dysfunctional practices cannot be fixed by tighter administration. The problems have to be addressed within the work itself.

Strategy making in the field of health care tends to be about venturing more than visioning, and personal and collective learning more than institutional planning.

When we promote leadership, we demote everyone else. How about plain old management?

Instead of people pointing the finger at each other, they should be pointing their fingers together at the procedures and structures that set them apart.

Health care doesn’t need more measuring and reorganizing so much as better cultures of collaboration that open up the pathways of communication.

A systems perspective requires a focus on the person in the community, beyond a patient in a population.

There’s a massive amount of health care information out there, some of which I need to know. How much of that part am I actually getting? Is 10 percent a gross exaggeration? And how do I get even that? Haphazardly!

To find the systems perspective in health care, look first in the mirror: we are as close as we are going to get. That is because you and I are significantly responsible for promoting our own health, preventing our potential illnesses, and even treating many of our own diseases.

The invisible hand that is supposed to serve everyone by serving ourselves turns out to be a visible underhand in much of health care when it serves some users at the expense of others.

See full Table of Contents

© Henry Mintzberg 2017

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About this business of government, Mr. President

5 April 2017

[Another version of this was posted on hbr.org last week under the title “The U.S. cannot be run like a business.”]

Dear Mr. President

As a neighbor in Canada who has long worked with businesses and governments around the world, I have some important news for you. America is not suffering from too much government so much as from too much business―all over government. Please understand this to avoid pouring more oil on the fires of America, and this planet.

[Another version of this was posted on hbr.org last week under the title “The U.S. cannot be run like a business.”]

Dear Mr. President

As a neighbor in Canada who has long worked with businesses and governments around the world, I have some important news for you. America is not suffering from too much government so much as from too much business―all over government. Please understand this to avoid pouring more oil on the fires of America, and this planet.

Business in its place is essential, just as is government in its place, which is not all over business. Now, however, thanks to you and your cabinet, business need no longer just lobby government to get its way; it is government. You were elected to challenge the establishment; will the executives who came into your cabinet from ExxonMobile and Goldman Sachs do that? They are the establishment: that other, more powerful business establishment that has now displaced the weaker political establishment.

This is an old problem now being carried to a new extreme. In the early days of the Republic, Thomas Jefferson expressed the hope that “we shall crush in its birth the aristocracy of our monied corporations which dare already to challenge our government to a trial by strength...” Instead, later in that century the U.S. Supreme Court recognised corporations as “persons” in the law. Not long after that, in the new century, President Teddy Roosevelt was railing about the power of corporate trusts in American society, and in the 1960s President Dwight David Eisenhower warned of the “unwarranted influence…by the military-industrial complex.” Nevertheless, in 2010 the Supreme Court gave those corporate persons the right to fund political campaigns to their heart’s content. When “free enterprise” in an economy becomes the freedom of enterprises as persons in a society, to paraphrase Abraham Lincoln, government of the real people, by the real people, for the real people perishes from the earth.

Should government even be run like a business, let alone by businesspeople? No more than that business should be run like a government, by civil servants. As you well know, when an entrepreneur says “Jump”, the response is “How high sir?” You are now finding out what happens when a U.S. president says “Jump”. So far, so bad. Governments are relentlessly subjected to a plethora of pressures that many businesses, especially entrepreneurial ones like your own, cannot easily understand.

Business has a convenient bottom line, called profit, which can easily be measured. What’s the bottom line in government, say for terrorism? (Countries listed? Immigrants deported? Walls built?) What’s the bottom line for climate change? (Do you really believe it is jobs created?)

Running government like a business has been tried again and again, only to fail again and again. You must remember the debacle in New Orleans when Homeland Security was run by a businessman…of sorts. How about when George W. Bush’s Secretary of the Army promised to bring in “sound business practice”? He came from Enron, just before its spectacular collapse.

In the 1960s, Secretary of Defense Robert McNamara introduced PPBS (Planning-Programming-Budgeting System) to run government like a business. The obsessive measuring led to the infamous body counts of the Vietnam War. That bottom line was about as low as it can get. Then in the 1980s came the “New Public Management”, a euphemism for old corporate practices: isolate activities, put a manager in charge of each, and hold him or her responsible for the measurable results. That might work for the state lottery, but how about foreign relations or education, let alone, dare I mention it, health care? And now, at your request, your own son-in-law heads yet another effort to run government like a business. Back he comes with that old buzzword of citizens as “customers.” (Al Gore was using this misguided metaphor when he was vice-president.) You know what? I am not a mere customer of my government, thank you, as if I buy services at arm’s length. I am an engaged citizen of my country.

The place of business is to supply us with goods and services; that of government, aside from protecting us from threats, is to help keep our marketplaces competitive and responsible. Do you really believe that recent American governments have been overdoing this job, let alone even doing it?

I have a little book for you, Mr. President, called Rebalancing Society. It contends that a healthy society balances the power of respected governments in the public sector with responsible businesses in the private sector and robust communities in what I call the plural sector (“civil society”). The most democratic nations in the world today function closest to such balance, including ours in Canada and those in Scandinavia, likewise your own when Alexis de Tocqueville wrote about the community “associations” that helped to maintain democracy in early America. Indeed, during the decades following World War Two, the U.S. was far better balanced, as it experienced striking prosperity and development—economic as well as social―despite high taxes and generous welfare programs. Now, however, the country has lost that balance, and needs the plural sector to offset the fruitless swinging back and forth between left and right—government interventions by the public sector and market forces in the private sector.

Think back to the Berlin Wall, Mr. President. That wall fell on our Western democracies, because we misunderstood what brought it down. The pundits of the West claimed that capitalism had triumphed. Not at all. Balance had triumphed.  While the communist states of Eastern Europe were utterly out of balance, on the side of their public sectors, the successful countries of the West retained a relative balance across the three sectors.

But with this misunderstanding, capitalism has been triumphing since the fall of that wall, and throwing America and many other countries out of balance the other way, in favor of their private sectors. Look around, Mr. President, at income disparities, climate change exacerbated by excessive consumption, and the unregulated forces of globalization running rampant around the globe. That is why we have seen votes like Brexit and your own, by distraught people unsure which way to turn, except against the “establishment”.

When enough people realize what has been going on, if not you, then a subsequent president, will have to restore the balance that made America great in the first place.

Sincerely

Henry Mintzberg
Cleghorn Professor of Management Studies at McGill University in Montreal

© Henry Mintzberg 2017. For elaboration of these arguments, please see Rebalancing Society…radical renewal beyond left, right, and center. Also my Harvard Business Review article “Managing Government, Governing Management”. 

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Some Half-truths of Management

22 March 2017

“There are no whole truths; all truths are half-truths” (Alfred North Whitehead). So here are a few in management.

We live in times of great change.

Have you heard this before—say in the last hour? Did you know that when a laptop detects a CEO about to type a speech, it automatically enters: “We live in times of great change.”  Why bother the CEO to type it again, since just about every management speech in the past few decades has begun with this line. That never changes.

Do we really live in times of great change? Look around and tell me what’s changed fundamentally. Your food, your furniture, your friends, your fixations? Are you wearing a tie, or high heels? How come: because you always have? How about your car? Under the hood is probably a four-cycle, internal combustion engine. That was in the Model T Ford.

“There are no whole truths; all truths are half-truths” (Alfred North Whitehead). So here are a few in management.

We live in times of great change.

Have you heard this before—say in the last hour? Did you know that when a laptop detects a CEO about to type a speech, it automatically enters: “We live in times of great change.”  Why bother the CEO to type it again, since just about every management speech in the past few decades has begun with this line. That never changes.

Do we really live in times of great change? Look around and tell me what’s changed fundamentally. Your food, your furniture, your friends, your fixations? Are you wearing a tie, or high heels? How come: because you always have? How about your car? Under the hood is probably a four-cycle, internal combustion engine. That was in the Model T Ford.

When you got dressed this morning, did you say to yourself: “If we live in times of great change, how come we are still buttoning buttons?” (from Wikipedia: “Functional buttons with buttonholes for fastening or closing clothes appeared first in Germany in the 13th century”.)

What’s my point? That we only notice what is changing, and most things are not. Of course, some things are changing: information technology, most notably. Zap, I hit a few keys and Wikipedia tells me about buttons. I hope you have taken notice of this new technology, because it is rendering great changes.  But I hope that you are also taking notice of all the things that are not changing, because they are no less important. Managing change without managing continuity is anarchy.

The world is becoming more global.

Often, when I work with groups of managers in various parts of the world, I ask them whose businesses have more than half their sales outside the home country. You would be surprised how few do. (If a quintessentially global company like General Electric has about half its sales in the United States, then it is better described as a quintessentially American company.)  Think of how much retailing, banking, food, and so on, is local. On the other hand, more than a century ago, Singer sewing machines were sold as globally as are Apple phones today.

The fact of the matter is that some businesses have long been global, and a great many remain local.

Management sits on top.

Of what? The pay scale, to be sure, and probably the headquarters building too. But mostly on top of that ubiquitous chart. So what? If, as CEO, you see yourself on top of your organization, does that help you keep on top of what is going on in your organization? No. This top is the worst place to manage an organization: looking down on everybody else. Try the ground instead.  Don’t we have enough disconnected managing already?

From this top comes decisions and strategies for everyone else to implement.

IKEA has a terrific strategy: selling unassembled furniture so that we can take it home in our cars, which saves us and the company lots of money. According to IKEA’s own website, this idea came from the ground. A worker tried to put a table in his car, and it didn’t fit, so he took off the legs. Then came the key insight that eventually changed the strategy, and the industry: “If we have to take the legs off, don’t our customers do too?” Who asked that: a CEO on top?

Of course, key to this becoming strategic was a company culture that enabled this idea to get to the CEO, to sprinkle holy water upon it. But I’ll bet this particular CEO, like most successful entrepreneurs, spent lots of time at the bottom finding out what was going on.

Thus: from everywhere, “implementation” included, come little insights that can emerge into big strategies.

Organizations need heroic leaders.

Really? How often have heroic leaders ridden into established organizations on great white horses, only to fall into black holes? New organizations may need aggressive leadership, but most others need engaged management—quiet, humble, thoughtful. Enough narcissism in the executive suites.

People are human resources.

Not me! Feel free to let yourself be called a human resource. I am a human being, thank you. Not even a human asset, let alone human capital. Enough of the demeaning vocabulary of economics—turning us all into things. Resources are things we throw away when we no longer need them. Is that how to build a great enterprise: by throwing away the human beings? (It’s politely called “downsizing”.) Airlines used to refer to passengers as “self-loading cargo.” Are the HR words really any better?

If you can’t measure it, you can’t manage it.

This is just plain silly.  If you can’t measure it, you had better manage it. And if you can measure it, you had better manage it even more carefully. Think of all that matters in management—and in life—that is tough to measure: culture, engagement, leadership, the market for a truly novel product (who ever got that right?), even management itself. And tell me, did anyone who uttered this nonsense ever even try to measure the performance of measurement, instead of assuming it is wonderful? I guess, then, that we shall have to get rid of management and measurement too, not to mention truly new products.

I could go on, since too much management goes on and on with its half-truths. Instead I’ll just quote Winston Churchill, that human being who lived in times of greater change than most of us can possibly imagine:

“[People] occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing happened.”

© Henry Mintzberg 2017. Our International Masters for Managers (impm.org) helps managers face all degrees of truth.

Follow this TWOG on Twitter @mintzberg141, or receive the blogs directly in your inbox by subscribing hereTo help disseminate these blogs, we also have a Facebook page and a LinkedIn page.