Management

“You may ask yourself, well, how did I get here?”

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Commenter Lynn Wheeler writes at zenpundit:

“….Boyd would comment in the 80s that the approach was having significant downside on American corporations as former WW2 officers climbed the corporate ladder, creating similar massive, rigid, top-down command&control infrastructures (along with little agility to adapt to changing conditions, US auto industry being one such poster child).”

Wheeler’s comment reminded me of the following post that I had meant to blog earlier:

One occasion in particular in the late 1970s brought this home to me. McNamara had come to one of our staff meetings in the Western Africa Region of the World Bank, where I was a young manager, and he had said he would be ready to answer any questions.
 
I felt fairly secure as an up-and-coming division chief and a risk-taking kind of guy. So I decided to ask McNamara the question that was on everyone’s lips in the corridors at the time, namely, whether he perceived any tension between his hard-driving policy of pushing out an ever-increasing volume of development loans and improving the quality of the projects that were being financed by the loans. In effect, was there a tension between quantity and quality?
 
When the time came for questions, I spoke first at the meeting and posed the question.
 
His reply to me was chilling.
 
He said that people who asked that kind of question didn’t understand our obligation to do both—we had to do more loans and we had to have higher quality—there was no tension. People who didn’t see that didn’t belong in the World Bank.

– Steve Denning

This too from a speech by Robert McNamara, “Security in the Contemporary World”:

The rub comes in this: We do not always grasp the meaning of the word “security” in this context. In a modernizing society, security means development.
 

Security is not military hardware, though it may include it. Security is not military force, though it may involve it. Security is not traditional military activity, though it may encompass it. Security is development. Without development, there can be no security. A developing nation that does not in fact develop simply cannot remain “secure.” It cannot remain secure for the intractable reason that its own citizenry cannot shed its human nature.
 

If security implies anything, it implies a minimal measure of order and stability. Without internal development of at least a minimal degree, order and stability are simply not possible. They are not possible because human nature cannot be frustrated beyond intrinsic limits. It reacts because it must.
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Development means economic, social, and political progress. It means a reasonable standard of living, and the word “reasonable” in this context requires continual redefinition. What is “reasonable” in an earlier stage of development will become “unreasonable” in a later stage.
 

As development progresses, security progresses. And when the people of a nation have organized their own human and natural resources to provide themselves with what they need and expect out of life and have learned to compromise peacefully among competing demands in the larger national interest then their resistance to disorder and violence will be enormously increased.

Think about this in terms of the “armed nation building” of the past decade or so and in terms of successive Clinton, Bush, and Obama administration policies. Really not that much difference if you look at it in terms of securing stability through development – armed or otherwise. Not a novel observation in any way, but bears in mind repeating as the 2012 Presidential campaign continues its “running in place” trajectory….

Update:“Running in place” and “trajectory” don’t really go together, do they? Oh well. You all know what I mean….

Lean practices and starting a trauma center.

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The discussion of the pharmacy reorganization got me thinking of the trauma center that we started in 1979. That was well before I learned about lean practices or the Toyota method but I think we used a number of their principles anyway.

When we started our trauma center, we did something a bit like your pharmacy project. We were a small hospital (120 beds) in a new suburban area with the ocean on one side and national parks and mountains on the other. Orange County narrows down to a triangle which ends at San Clemente where the Marine base begins. We knew the county was going to regionalize trauma. A study had come out suggesting that too many people died because “the golden hour” was lost in trying to get doctors and operating rooms organized, especially at night.

Several large hospitals planned to enter a competition to qualify as centers; one of course, was the UCI medical center. None of them was within 25 miles of our hospital. We didn’t like the idea of seeing the injured patients, some of whom would be neighbors, being taken that far and we looked to see if we could set up a trauma center for our community that would pass muster with the EMS survey team. First we had to see if the hospital and medical staff would support it. My partner and I couldn’t do it alone.

I did a study of the finances of trauma. The stereotype is a drunken insolvent who is stabbed or shot. Our community is located along I-5 where it runs from Los Angeles to San Diego. We are between mountains and the sea. I took the records of all emergency admissions, who went to surgery or who were discharged with a “surgical” diagnosis and who went to ICU. Some of those were general surgery but by using a screen we got down to the trauma cases. I found that 85% of them had some sort of insurance. This was largely because most were auto accidents. Even if people don’t carry health insurance, somebody may have medical benefits with car insurance.

We presented this to the department of surgery and they turned us down flat. The vote was something like 33 to 2. We went to the Board of Trustees. At the time, the hospital was owned by a partnership, one of the dreaded for-profit hospitals. The Board was easily convinced that this was something we needed to do if this hospital was going to grow. Southern California is cursed with many small hospitals and few big ones outside of Los Angeles. I knew a vascular surgery group, of three men, in the San Fernando Valley that went to 12 hospitals. One of the reasons I moved to Mission Viejo was to get out of Los Angeles.

Anyway, we had the hospital on board but not the doctors. The hospital decided to make the trauma center a contract service like the ER. My partner and I would run it. The hospital hired a city planner to draw up a proposal for the county. They gave me a copy when he was finished and it was the size of a Chicago telephone book. I read through it and it sounded like a proposal for a shopping center. I rewrote it. A lot of it was useful, like traffic analysis, but the vast majority didn’t answer the right questions.

Then we had to figure how we could do this and not go broke. There were two of us. We would call other specialists, like orthopedists and neurosurgeons, as needed. That’s how we got around the surgery department. There were grumbles but they faded as the orthopods began to realize that trauma cases paid well, mostly. Then we figured out who is in the hospital at night. The other trauma center candidates all promised to have a surgeon and anesthesiologist in-house 24 hours per day. We could not afford that. We promised that the surgeon and anesthesiologist would arrive within 15 minutes of being called, usually before the victim. The ER doc would be there. That was just as Emergency Medicine was becoming a specialty and our ER docs were GPs.

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