Tag Archives: Sean Safford

Health care reform is an organizational change challenge

Sean Safford gets it right on health care reform and, indeed, reform of just about any kind:

To work, both of those fixes have to be effectively implemented at an organizational level.  They will require changing the way doctors, nurses and other medical care providers do their job.  And that means changing the organizational rules by which hospitals and doctors offices operate.  But what that organizational model will look like has not been specified.  It might look like the Mayo or the Cleveland Clinics which use computerized records, pay doctors salaries and reward them for patient outcomes rather than per service.  Yet as the New York Times points out, only one plan in Congress addresses the organizational model and that one is just a pilot program.  Massachusetts is looking at ways of urging doctors to shift into salary-based provider networks.  But there’s no discussion of a mandate or of anything with teeth that would move the medical industry in that direction.

How many reform movements have succeeded in winning legislation meant to change society, but then fail to actually change anything?  Too many to count.  Why?  Because the devil in achieving real change is in the details of organizational implementation.

Safford goes on to discuss what many consider undiscussable:

Avoiding that fate requires recognizing that organizational change on an industrial scale is a highly contested political process.  But those politics don’t unfold inside the halls of Congress.  They happen inside and among the organizations charged with implementing reforms.  And shaping those politics means recognizing where real organizational power lays.

Politics and power–not the kind on C-SPAN, but the up-close and personal dynamics that enable or doom efforts to change.  One of the elementary concepts one learns in studying the brief history of planned organizational change is that change is more likely to be successful when points of resistance are eliminated rather than increasing pressure for that change.  Put more simply, you have to make it easier to change than not to change.

I share Safford’s concern that history is about to repeat itself, and I would draw attention to three examples from very recent history that could be instructive:  the 9/11 Commission, the Senate Committee on Prewar Intelligence, and the Columbia Accident Investigation Board.

In each case, there were clear, urgent pressures for change.  In each, organizational issues were specifically emphasized.  In each case, the necessary reforms fell short.

As David Hanna notes, “organizations are perfectly designed to get the results they get.”  They tend to stay the way they are for a reason–the current state works well for the people who benefit from it.  Real, meaningful, lasting change requires focus, consistency, clarity, persistence, and strong political support.  Moving boxes on an org chart doesn’t cut it.

For health care reform to succeed in a way that improves what most agree to be a broken system, leaders at the organizational level must demonstrate the courage to address power and politics.  It will likely be the toughest job they’ve ever had.

Parsing the predicted revolution

This post examining the debate on whether Iran is headed for revolution gets my vote for post of the year in both orgtheory and foreign affairs:

It also gets to a central set of questions in orgTheory right now.  This movement, like a few other recent revolutions, seems to have emerged relatively spontaneously.  Networks and identity formation processes are emerging in real time before our eyes (which, remarkably, we can watch in real time through Facebook and Twitter).  If it had sustained itself through the weekend, this might have been enough to force a political confrontation.  At this point, it doesn’t look like that’s happening (though I could easily be reversed by events on that).  But if this lull does persist, then this identity and network revolution will have to give way to a movement built around organizations.  Stay tuned.

Sorry to lead with the final paragraph, but it doesn’t take away at all from the juicy fisking in the many paragraphs that preceded it.  The “assertion, then what the literature says” approach really does it for me.

Week in Public Organizations, 22Jun2009


Health care conundrums, Twitter entrapment, birthdays, the ongoing battle between econ and soc, new regulatory orgs, questioning the tipping point, the limits of collaboration, and torture shrinks.  These were some of the better stories from last week:

Safford on sustainability in health care
Can tweets be used for entrapment?
PublicOrgTheory’s 5th birthday
King revisits econ-soc paper
Department of Financial Security not a stretch after all
Easterly challenges Schelling tipping point model
Haque discusses the limits of collaboration
CIA dumps torture shrinks

Safford on sustainability in health care

The über-reliable Sean Safford has a longish post on orgtheory.net today about the shift in health care debate from fairness and equity to sustainability:

Sustainability is related to the notion of conservation in the sense that it is interested, primarily, in the preservation of the social system. But it shifts the nature of that argument significantly. Rather than focusing on the maintenance of order and stability through systematization, sustainability focuses on interdependence. Its origins are in the environmentalist movement, but I would suggest that statements like Leonhardt’s and even Ken Lewis’s suggest that is has spread to form an ideological basis for government action outside of concerns about the environment.

The argument goes something like this: We live in a highly interconnected society which operates within a series of interconnected systems. Resources (physical, material, social, and political) are not only scarce, they are extinguishable. The system is in place, not so much to keep social order, but to ensure the reproduction of the resources needed to reproduce society over time. Undermining any of the systems on which society depends threatens to have ripple effects on others. But importantly, the biggest threat to the system comes not from external threats, but from individuals acting in their own self interest in ways that could undermine the delicate balance on which interdependencies of the system depends. Government action is needed, not to ensure fairness, but in order to save us from ourselves.

His points on org theory and social movements are especially insightful, albeit brief.

As an example of the ripple effect mentioned above, think about the uninsured using hospital emergency rooms as primary care facilities.  The uninsured wait until the situation is dire enough to merit going to the hospital rather than using preventive care or early treatment.  The severity of health problems is likely to be more advanced than those of people who have coverage and regular check-ups.  Treatment in the hospital emergency room–already expensive–becomes more so as advanced illness is treated.  Cost soars.  Unable to pay bills, the uninsured go bankrupt.  Hospitals or insurance companies eat the losses and pass on the cost to consumers in the form of higher premiums.  The now-bankrupt uninsured take advantage of government services, which increases the burden on tax revenues.

It would take more time than I have at the moment to dig out studies supporting the above scenario, but most of it should be fairly intuitive.  If people who are uninsured get health care and cannot pay for it, the costs have to be absorbed somewhere.  To a degree, a somewhat socialized health care system already exists, and it is a truly inefficient one.

If arguments for fundamental fairness in the most powerful country in the world aren’t enough, the economic case–including the current burden to individuals–should be more than clear.

[Note:  chart above from AHIP.]

Week in Public Organizations, 7Jun2009


What a week.  more orgporn, gender and mentorship, playing chess with terrorists, spendthrift car companies, antitrust in high tech, black wires, Scandinavian transparency, Korean intel, tending the automotive garden, debunking Hawthorne, more car stuff, and parsing intel failure.  These were some of the stories that made the cut last week:

Forbes posts corporate orgporn
NBER study links gender gap, mentorship opportunities
Obama strategically undermines Osama
GM sends signals… but perhaps not the right ones
Tech companies under antitrust investigation
Covert agency + construction = secrecy fail
CFP: Finland builds through transparency
Scenarios for increased DPRK surveillance
Safford discusses cars, gardens
Hawthorne debunked?
Are there options for GM beyond cars?
What does “intel failure” actually mean?

Safford discusses cars, gardens

A trifecta of useful suggestions for the embattled auto industry from the ever-perspicacious Sean Safford:

Push more capabilities into the value chain. For years, the auto industry has been restructuring its relationships with suppliers.  But it still retains ultimate power within the value chain.  This is partly due to how complicated a car is.  Someone needs to take ultimate responsibility to ensure all those thousands of pieces fit together seamlessly.  But the current balance of power within the value chain has strategic drawbacks.  The collapse of one car company would bring down the vast supplier network.  Giving suppliers greater autonomy and design responsibility increases the possibility down the line that a new, viable car company could emerge from the morass that is our current auto industry should any of the current giants go down. Specifically, it would by lower barriers to entry so new entrants (or a supplier itself) could forge relationships with suppliers to produce a new kind of car.  It would also free them up to produce parts for non-American auto manufacturers preserving some part of the value chain in the U.S.

The garden metaphors are a thoughtful and presumably intentional departure from the mechanistic metaphors usually employed in discussions of industry.  Incidentally, Safford has turned his guest stint at orgtheory.net into a permanent arrangement, proving that some enterprises continue to evolve and thrive.