On a very high level, my job in performance excellence is to assist hospital transformation projects that aim to spread Toyota Production System principles. Our overall goal is to create a Lean health care environment at Stanford Hospital. A big part of Lean is empowerment. Lean concepts strive to make whistleblowers of employees, and also make employees the actors and originators of transformation. What this means is that employees identify the problems, they come up with ideas to fix the problems and then they implement their ideas to bring about change. After all this, they must sustain their efforts. This last part is always the hardest. How this part usually plays out is that our team hands-off the management of the project to the unit or the department. After at point, the recipient of the hand-off is expected to run with the project and manage it into the future, making changes and/or seeking advice from our department as needed. Well, as you can imagine this isn’t always easy. At the same time employees want to be empowered to make changes, they often balk at the responsibility that follows close behind. This makes sense, considering that the duties associated with empowerment impose new daily tasks. I mean–no one wants more work, right? But this entire concept of not wanting empowerment conflicts with what we’re taught in school–or, maybe I should say what we aren’t taught. What we are [impliedly] taught is that employees want to be empowered. Yay! What a great thing empowerment is! Well, not really. Don’t get me wrong, empowerment really is great, and to efficiently run hospital empowerment is needed. What school doesn’t teach, though, [or doesn’t expressly convey] is that people are fickle and empowerment is tricky, and working to align fickle with tricky is downright difficult! Needless to say, achieving unequivocal and wanted empowerment (i.e., true empowerment) takes much longer than I originally expected. Knowing that empowerment is necessary is only the half of it. The other half is selling the idea, and that’s where effective management comes into play.
Let’s say that you offer a fee-for-service professional service. A large number of people, not everyone, want this service, so you cater to those who seek it out as they desire. Those who want this service care about its cost, as well as their continued access to it and the cost of that access. You go on providing the service for a number of years. The service works well for some, but for others it doesn’t. For some people your service doesn’t help their underlying situation, but for others it helps them live a longer, fuller life. After several years, the government looks at your service and realizes its benefits. As such, the government enacts regulations to ensure that the private service you make available to your customers will, to a certain extent, always be accessible to your customers–and possibly others–by encouraging you, through indirect incentives, to provide your professional service in situations where your involvement may not be financially beneficial to your bottom line. So, you practice in concert with the regulation for few years and things go well–which we should assume because, technically, things improve when the government involves itself in any situation. After a period of time, though, the government desires to make another adjustment because for some reason or another the regulation it passed several years earlier doesn’t do as much as the government believes it should–not enough people can realize the benefits of your service. At that point, the government identifies a class of people–a class that it feels can’t access your service readily–and decides to pay you for providing your service to that class. This goes on for a few years and things go well–which we should assume because, technically, things improve when the government involves itself any situation. This back-and-forth process continues well into the future. You provide your service; the government tweaks the regulations that affect your service to better serve their incentives. After enough time passes, this back-and-forth activity becomes common practice in your service’s industry, and because change and repeal in governmental law is hard to come by, the way that you practice your service and the manner in which the government desires that you practice your service eventually becomes one in the same. The success of your service is inherently dependent on the government, and vice versa. It’s at this point that the government begins to appreciate the public costs associated with its regulatory ventures. Some officials question whether the costs are too large; none question whether they’re too small. Accordingly, the government looks to you–the only non-altruistic party involved–and reviews your professional service, as well as the professional judgment necessary to provide your service, in attempt recover monies that it feels it wrongfully paid you for your service. The reviews take place using hindsight, and the decisions are, more or less, final. How would you respond to mitigate the losses that you may face resulting from the from this retrospective analysis? Welcome to the world of Medicare and RAC audits.
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