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Common meritocracy. How a good hospital should be governed.

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Common meritocracy. How a good hospital should be governed.

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There is no country in the world satisfied with its healthcare system. This is why we should look for good systems as the stakes are very high - human life and health. Common Meritocracy, or decision making for everyone is a radical but possible solution. Unlike in democratic decision making, where all, even ignorants, have a say. In common meritocracy voice is given only to those who have some expertise in the decision domain. Such a system is possible thanks to technologies which allow to build a system of control of everyone's expertise and the voting process.

There is no country in the world satisfied with its healthcare system. This is why we should look for good systems as the stakes are very high - human life and health. Common Meritocracy, or decision making for everyone is a radical but possible solution. Unlike in democratic decision making, where all, even ignorants, have a say. In common meritocracy voice is given only to those who have some expertise in the decision domain. Such a system is possible thanks to technologies which allow to build a system of control of everyone's expertise and the voting process.

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Common meritocracy. How a good hospital should be governed.

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 11. WHAT ABOUT HOSPITALS?
  12. 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. 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. 14. The result: THERE IS NOT A SINGLE COUNTRY IN THE WORLD SATISFIED WITH ITS HEALTH CARE SYSTEM.
  15. 15. OUR HEALTH CARE IS BASED ON THE “SERVICE MODEL” AND SERVICE MODELS FIT CAPITAL BASED INSTITUTIONS Photo: Brian - cc @ flickr.com
  16. 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. 17. HEALTH CARE IS NOT A REPAIR SERVICE
  18. 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. 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. 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. 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. 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. 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. 24. BUT IT MAY HAPPEN ONLY THROUGH INFORMATION AND COMMUNICATION TECHNOLOGY
  25. 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. 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. 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. 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. 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. 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. 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. 32. IS IT A UTOPIA OR JUST A NAIVE DREAM? Web sites like StackExchange prove it is neither.
  33. 33. THEY HAVE A MULTITUDE OF DOMAINS OF KNOWLEDGE AND…
  34. 34. … RULES TO START NEW ONES, AND…
  35. 35. … RULES OF DECIDING ON IMPORTANCE, EXPERTISE AND ENGAGEMENT AND…
  36. 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. 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. 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. 39. FOR MORE INFORMATION ABOUT COMMON MERITOCRACY AND TOTAL PARTICIPATION CONTACT ME AT: ryszard@stocki.org ! THANK YOU.

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