Sunday, 28 August 2011

Management iatrogenisis

This blog entry is now available at

Our new site offers you all of our historic blogs plus a wealth of new insights and resources 
relating to the application of the Vanguard Method in the Health and Care sector.


  1. I've been working in a health system with no systems, no targets, no management speak (Irish healthcare) for 15 of the last 20 years. (I spent the other 5 in the US Heath system one with targets but all in the wrong direction, for the benefit of the few). I can tell you that the cumulative risk of 92% of an error of commission, omission and sheer bloodymindedness, is about correct. Your problem is not with targets it with who sets them and what they mean to the people who are aiming for them. Sure the inputs are variable: so it the weather on a transatlantic flight! We understand that we are not making bottle tops, but don't tell me that we cannot design a system that allows for variation. As Harlan Krumholz says! Variation is bad! Except when it's not! Bad variations are the variations that do reflect the disorganised health system. There are clear disparities in care which need to be eliminated: Patients getting admitted to hospitals for conditions that can be managed as outpatients in one area and not in another is a variation that can be addressed by a pathway approach. This will deal with 80% of that bad variation. There is variation that we must foster which may occur in the remaining 20%! it derives from the values, preferences and needs of the patient. A mark of the systems sophistication is it's ability to distinguish between good and bad variation. Your crusade against 'systems' thinking relates to the imposition of bottle-top making system design for healthcare, it should not include robust patient centred systems that eliminate flawed, unreliable practices, but is flexible to individual needs.

  2. Thanks for taking the time to comment Colin. My view is that first we need to understand people and why they put their hand up for help. With that knowledge then we need to learn how to do perfect from the users perspective. If that knowledge tells us to standardise then that is what should happen. From this perspective standardisation is a possible, not a logical consequence. My worry is that we have too many "go to" solutions, such as standardisation and this can lead us to do the wrong thing and precludes future learning. You only need to read Lord Crisps comments today to get a sense of the scale of problem that can be caused by this sort of thinking. People are hidden from view and the impact on them can be quite dramatic, never mind the cost to the system.

    The application of the Vanguard Method in health is still new to me but what I see when I study heath economies is that they are systemically incapable of being flexible to individual needs. I am still building up my body of evidence but as an example, for one cohort of people who became part of an experiment in finding new ways of working, not one of them went on the prescribed pathway. All of them had a transformed experienced either to live a good life or die a good death.

    My experience is confirming what I have seen in, or what Vanguard knows about, other systems.

    Part of the challenge in what I am doing is that it requires a change in the way we think about the problems we have and the design and management of work. It is also rooted in doing the right thing for people, not organisations. That's not easy to get across in the written word - its something you have to experience. Happy to take the discussion off line if there are any other queries you have.