1.
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

2.
The wish to participate in the direction, guidance,
and control – in short, in management―of
affairs is one of the deepest desires of man.
Erwin Schell of MIT in 1952 in “The Amazing Oversight: Total Participation for Productivity.”

3.
BECAUSE WE MIX TWO VIEWS OF PARTICIPATION
Ontological
Photo: gthills - cc @ flickr.com Photo: Matthew Anderson - cc @ flickr.com
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.
Ethical
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.

4.
Solon
Buddha
Herodotus
Laozi
Samuel
Isaiah
Jesus Christ
Spartacus
St Benedict
Wilberforce
Wielezynski
Kwiatkowski
Mediarrieta
Schell
Owen
Gandhi
King
Wojtyła Allport Maslow Vroom
Semler Stack Heron
UNIVERSALITY OF PARTICIPATION

5.
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

6.
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.
COMPLEXITY OF OWNERSHIP
Photo: Tori Rector - cc @ flickr.com

7.
A person recognizes
ownership rights,
but sometimes they have to be
shared.
Psychological ownership:
Pierce et al. 2004;
O’Driscoll, 2006;
Dwyer and Ganster, 1991
Pierce & Jussila, 2010
2
COMPLEXITY OF OWNERSHIP
Photo: Matthew Anderson - cc @ flickr.com

8.
Efficacy related to the object. Requires
information and expertise, but sometimes
they have to be shared.
Control related ownership
Vroom & Jago, 1988
Mazur, 1966 3
COMPLEXITY OF OWNERSHIP

9.
1
5 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
ALL THREE PRODUCE SEVEN STATES OF OWNERSHIP,
SOME GENERATING CONFLICTS, BUT ONLY ONE STATE
ALLOWS FOR TOTAL PARTICIPATION.
Legal
Control
Psychological

10.
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.
TOTAL PARTICIPATION
defined by Stocki, Prokopowicz & Zmuda, 2008 and 2012

11.
WHAT ABOUT HOSPITALS?

12.
Number of rulers (Scope of Competence)
THEY ARE ELITIST INSTITUTIONS BASED ON
EXPERTISE OF FEW PERSONS
Interest
One Few Many
Self-interst Tyranny Oligarchy Mobocracy
Society’s
interest Monarchy Aristocracy
The best Democracy
Aristotle's division of political systems

13.
Insurance
institution Hospital
Physician
Ministry
of Health
Patient 1
THEY ARE SEPARATED FROM THEIR STAKEHOLDERS BY FINANCING
INSTITUTIONS WHICH ARE IN CONFLICT OF INTEREST WITH BOTH
THE PATIENTS AND THE HOSPITAL
Patient 2
Patient 3
Patient 4 Barriers

14.
The result:
THERE IS NOT A SINGLE COUNTRY
IN THE WORLD SATISFIED WITH ITS
HEALTH CARE SYSTEM.

15.
OUR HEALTH CARE IS BASED ON THE
“SERVICE MODEL”
AND SERVICE MODELS FIT CAPITAL BASED INSTITUTIONS
Photo: Brian - cc @ flickr.com

16.
AMPLE MEDICAL EVIDENCE PROVES
THAT HEALTHCARE CANNOT BE
BASED ON A SINGLE EXPERT SERVICE
MODEL.
Body like a car to be repaired.
Patient
the ignorant
Body As 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
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.
Health care system
Impersonal relationship between the doctor and the patient, based on
Cartesian dualism.

17.
HEALTH CARE IS NOT A REPAIR SERVICE

18.
Both doctor and patient are experts
in their specific domains and should
participate in the treatment process
according to their expertise.
Patient - an expert in his family,
calling, self-fulfillment, goals
Person becomes
the subject of her illness
and as such has to
participate in treatment.
FOR EFFECTIVE HEALTHCARE
PATIENT AND DOCTOR’S
RESPONSIBILITY AREAS HAVE TO
CHANGE AND MEET IN THE SYSTEM.
Doctor - a medical expert
Sense
As a medical expert
(participatively) focusses on the
good of the patient and takes
responsibility for her actions and
words.
Calling
Self-fulfillment
Family
The 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
Body
Expert
As a researcher and
provider of service she has
to achieve informed consent.
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.

19.
THIS REQUIRES COMPLETELY NEW HOSPITAL
GOVERNANCE MODEL
Number of rulers (Competence)
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
CORRECTED ARISTOTLE’S TYPOLOGY

20.
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

21.
Hospital
Ministry
of Health
Physician
Patient 1
Patient 2
Patient 3
Patient 4
AND LOCAL COMMUNITY BASED MODEL OF
HEALTH CARE FINANCING - STEP 2

22.
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

23.
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-op
Photo: U.S. PacificFleet - cc @ flickr.com

24.
BUT IT MAY HAPPEN ONLY THROUGH
INFORMATION AND COMMUNICATION
TECHNOLOGY

25.
MERITOCRACY REQUIRES EASY ACCESS TO
KNOWLEDGE, INFORMATION AND DECISION
MAKING. IT IS POSSIBLE THROUGH MOBILE
220
165
110
55
0
PHONES.
Number of phones /100 people
Cuba India Canada China USA Poland Gabon
The World Bank 2014

26.
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
ser vice launched by
Civil Ser vice
Commission in the
Philippines
M-Voting, the
parliament approved mobile
technology for the 2011
elections in Estonia.

27.
M-HEALTH
the 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
var ious subjects, including testing
and treatment methods, availability
of health ser vices, and disease
management.
Helpline: This involves a dedicated
phone number which an individual
can call to get access to a range of
medical services like availability of
facilities,
information on clinics
mobile health availability drugs, of etc.

28.
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

29.
An individual
consults individually
A moderated group
takes the decision
Incumbent
characteristics
Leader’s content
competence
Leader’s process
competence
Incumbent’s content
competence
Incumbent’s process
competence
DETERMINANTS OF MERITOCRACY PROCESS
(BASED ON VROOM, 2003)
Decision
characteristics
Situation
characteristics
Interaction constraint
Goal alignment
Role (leader -
member)
Content competence
Process competence
Likelihood of
disagreement
Likelihood of
commitment
Value of time
Value of development
Decision significance
Importance of
commitment
Participation level
An individual
takes the
decision
An individual
consults a group
Not-moderated
group takes the
decision

30.
Incumbent
characteristics
Decision
related agents
Rules defined in
the system
Possible decision scope:
Individual. local, departmental,
etc.
Possible decision domains and their
requirements
Charls Darwin:
Decision initiation rights
Level of general competencies
Joanna positions:
Decision initiation rights
Level of general competencies
Francis positions:
Decision initiation rights
Level of general competencies
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
interpersonal
business
Level of specialist competencies
Organizational position
availability
readiness to take decisions
age
tenure
membership in professional
groups
cooperative membership
humane
interpersonal
business
Level of specialist competencies
Organizational position
availability
readiness to take decisions
age
tenure
membership in professional
groups
cooperative membership
humane
interpersonal
business
Level of specialist competencies
Organizational position
availability
readiness to take decisions
age
tenure
membership in professional
groups
cooperative membership
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
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
AGENTS AND RULES OF THE SYSTEM

31.
MERITOCRATIC DECISION MAKING PROCESS
Input Decision support system
Training
Initialization
Selection of
incumbents to be
involved in the process
Consulting
Voting
Majority
Consensus
Decision
made
Database
Incumbents
Decision scopes
Domains
etc.
Rules
Output
Decision
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
Decision
generator
Selection of actions to
be instigated
Debate
Research

32.
IS IT A UTOPIA OR JUST A NAIVE
DREAM?
Web sites like
StackExchange prove
it is neither.

33.
THEY HAVE A MULTITUDE OF DOMAINS OF
KNOWLEDGE AND…

34.
… RULES TO START NEW ONES, AND…

35.
… RULES OF DECIDING ON IMPORTANCE,
EXPERTISE AND ENGAGEMENT AND…

36.
Questions
are evaluated
Participants
build their
reputation
Few have
editing rights
Answers are
evaluated
A CLEAR SYSTEM OF EVALUATING
PARTICIPANTS AND THEIR INPUT.

37.
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.

38.
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.

39.
FOR MORE INFORMATION ABOUT
COMMON MERITOCRACY AND TOTAL
PARTICIPATION CONTACT ME AT:
ryszard@stocki.org
!
THANK YOU.