When
does the pursuit of 'best practices' make sense, and when do we need to
apply less precise but more effective approaches instead?
 This week's New Yorker has another interesting column by James Surowiecki, entitled Local Knowledge,
which laments the fact that there are huge anomalies in health care in
the US from community to community, a result of a combination of local
customs, patient demographics, and the varying supply and accessibility
of practitioners and facilities. Great variations in treatment have
been noted in many diseases and conditions, including serious and
controversial ones like cesarean sections, spinal fusions,
mastectomies, and coronary-bypass surgeries. Different treatments and
variances in hospital stays mean great variations in medical cost,
Surowiecki says, and this could be costing the US health care system
billions it can't afford. His prescription? Not a new government
standards body, but increasing awareness of people about these
differences, so that the 'inefficiencies' are driven out of the system
by informed patients and caregivers.
What Surowiecki seems to be looking for is what in business is called
'best practices'. What's interesting to me is that business has
recently become disenchanted with 'best practices': In a world where
every job, every situation, every context is different, the
applicability of some documented 'best practice' in any situation other
than the one it was identified in is increasingly dubious. Dave Snowden
articulates these three 'heuristics' about real-world knowledge:
Knowledge can only be volunteered; it can't be conscripted.
People always know more than they can tell and can tell more than they can write.
People only know what they know when they need to know it. Human knowledge is contextual and triggered by circumstance.
So what we have here is a clash of two new and exciting philosophies: Surowiecki's argument that tapping the Wisdom of Crowds
can allow much better answers to emerge than relying on experts, versus
Snowden's argument that such 'wisdom' is possible and useful only in
relatively simple situations where apples can clearly be compared to
apples, and doesn't work in the majority of more complex situations where every case is arguably significantly different.
An identified 'problem' in Surowiecki's article is the large number of
facilities and practitioners providing over-long stays to patients in
Florida, compared to other states. They are drawn there, of course,
because that's where the customers are, and, as in all things, the work
tends to expand to fill the available space, money and time. In public
health services we seem to try to offset these 'market' tendencies by
making sure both facilities and practitioners' time are in constant
short supply, in the presumption that this will yield less waste and
force greater efficiency, rather than posing a serious threat to public
health. And this is exactly the problem with applying mechanistic,
industrial, simple-situation prescriptions to complex-situation
challenges.
So what should we do when doctors in one community perform
appendectomies and tonsillectomies four times as often as they do in
the next community, of the same size, a stone's throw away? Surowiecki
thinks we need to figure out "how to pay doctors for the quality,
rather than the quantity, of the care they provide" and hopes that
"eventually people will start paying attention to the data and
recognize how costly these variations can be". But even he seems
dubious of the possibility of either of these things happening. Of
course patients need to be better informed about preventative health
care, self-treatment and new knowledge about less invasive and
unnecessary procedures. But health care isn't like widgets, where
differences in 'unit' product cost, quality and service are
conspicuous. Every situation is truly different, and we'll never come
up with either a formula for determining the right health care answer,
or an expert system that will tell us precisely where the
'inefficiencies' in health care are and how they can be eliminated.
Surowiecki suggests the problem is geography and parochialism. But
geography is just one way of slicing community, and these days it's not
even the most important one. The issue isn't isolation of community,
it's incomparability of situations with infinitely many different
contexts. When the data is a million cases of one, the significance of
patterns is likely to be illusory.
And health care isn't the exception either -- most of the products and
services that are essential to human well-being, like education,
nutrition, freedom, justice, security, transparency of government and a
healthy environment are also enormously contextual, circumstantial and
relative. Experts and advocates in these fields have torn out their
hair trying to find benchmarks, standards, measures, scorecards and
'best practices' that will allow us to cajole improvements in
performance from those we assess to be falling short. It can't be done.
Complicated solutions don't solve complex problems.
The essence of Snowden's new approach to sense-making
and management 'science' is to first assess whether the situation lends
itself to simple-to-complicated solutions and approaches (like root
cause analysis, systems thinking and The Wisdom of Crowds), or if it
requires more complex approaches (like cultural anthropology,
pattern-seeking, Open Space and emergent understanding techniques like
the AHA! Discovery Framework diagrammed above). It doesn't take much
thought to realize (a) that most of the challenges we face in business
and society today are complex, and (b) attempts to force simple and
complicated-situation solutions in complex situations, like the
deliberate starving of the health and education systems (and like the
ubiquitous imposition of lousy service
in all areas of business today), in the ill-conceived belief these will
somehow mechanically force efficiency and productivity improvements in
them, are doomed to make the situations worse, not better.
It's time we woke up to the realization that industrial-age solutions
are increasingly inapplicable in the information age, and it's time we
got over our discomfort with the imprecision, uncertainty, lack of
causality, and non-amenability to command-and-control hierarchy that
complex approaches entail. Managers, grit your teeth and prepare for
some revolutionary new, difficult and important learning.
So sorry, health care fans desperate for solutions to spiraling costs.
No 'best practices' or 'popular wisdom' answers here. Move along,
please.
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