I am writing this blog post while Congress is debating whether and how to change the U.S. healthcare system. This is something that, according to the news, will be determined in three days and will be decided by a simple majority without analysis of consequences by the Congressional Budget Office and without hearings involving the affected parties. This seems like a bad time to talk about long-term planning and a broader view of healthcare.
Let me do it anyway, starting with an important research paper by Mary Dunn and Candace Jones in Administrative Science Quarterly. They looked at a central input to healthcare: medical schools, which educate the doctors who are in charge of providing the type of medical care that requires the MD degree and who direct the medical care done by others, such as nurses and lab technicians. Although medical care is much bigger than doctors, they are at its core, so how they are educated is consequential. The paper found that medical schools have had an enduring division between two logics on how to think about healthcare, and one of these has become more influential over time. This view of education, and healthcare, is very new and needs some explanation.
Much simplified, the logics are as follows. One is that education is the transfer of scientific knowledge, so that this knowledge can be used in practice. So, medical school is about the science of medicine. The other is that education instills values, and the guiding value for medicine is to care for people. So, medical school is about care, which can include care for people who are not yet patients and people who cannot be cured.
Dunn and Jones wrote a fascinating paper on how these two logics were in contention over decades. Advocates of each logic recognized the conflict with the other and fought for resources and attention to be devoted to their own logic. They saw an emphasis of their favored logic as essential for the health of medical education and the health of the nation more broadly. I don’t have room to describe their discussion here, but an important conclusion is that the care logic has grown in importance, and a key element of its growth was greater public discussion on managed care, with its emphasis on preventive medicine and focus on reducing costs.
This conclusion has become even more important in light of recent events. Managed care helped make the care logic more prominent, which facilitated useful initiatives such as thinking of public care more broadly to include prevention of disease and thinking of patients as individuals in need of care instead of just as cases with prognoses. But it also had two other effects that play a role in current politics around healthcare. First, the science part of medicine became less important, which now has become part of a greater movement against science having a role in state decisions overall. Second, cost is now a key consideration in health, which is clear given that estimates of tens of millions of people losing health insurance are acceptable as long as costs go down. Cost savings are even more important than the science behind estimating that tens of millions will lose their insurance, with the health consequences this will have.
Dunn, Mary B., and Candace Jones. 2010."Institutional Logics and Institutional Pluralism: The Contestation of Care and Science Logics in Medical Education, 1967--2005." Administrative Science Quarterly 55(1):114-49.
The news keeps telling us that employment is becoming a more-temporary state, with job changes both the result of footloose employees and of firms treating their workers as easily replaced, downsized, and upsized as needed. Not to mention that many now work as contractors, not employees, like Uber drivers. In these stories, the managers are typically cast as the bad guys treating everyone else as expendables. There is some truth to that, but there is a flip side: managers are also temporary. They are quickly moved around or even fired, and they also try to use job changes to move up faster than they could by staying in place.
How can managers be temps? Not only are managers credible to their subordinates only if they are expected to stick around for a while, but their chances of being promoted depend—ironically—on being able to signal that they are in it for the long run, even in a firm that habitually lets managers go. Well, for every problem that can’t be solved, there is a business school claiming to solve it. Research in Administrative Science Quarterly by Gianpiero Petriglieri, Jennifer Petriglieri, and Jack Denfeld Wood looked at how the participants in an MBA program used their education to make themselves more portable across firms and jobs. They were learning to turn themselves into managerial temps and use it to benefit their careers.
Like any education, business school is a journey, and the path and destination are unique for everyone. But there were clear patterns that tell us a lot about careers, and about management, in the current labor market. One path was to use the education to adapt both skills and identity to how firms now treat their workers, including managers. This is an instrumental pathway, where the idea is to understand the rules of the game and play it well. The other path was to use the pathway to explore one’s own preferred role in this world, and shape an identity that matches this discovery. This is a humanistic pathway, where the idea is to understand the parts available in the play and audition for the one that is the best fit.
These paths cannot easily be taken while working, because the everyday demands of actually managing make the learning process difficult, and changing identity isn’t possible either because everyone looks for and values constancy. So education acts as a valuable hiding place—a bubble, or a deep dive—where changes can happen and it is possible to emerge fully formed, or at least nearly so.
The next question is of course what the manager temps will do when they manage worker temps. Will work get easier when both manager and managed understand that they are not in the firm to stay, and the most stable part of their identity is its portability? To know that we have to wait for more research.
Petriglieri, Gianpiero, Jennifer Louise Petriglieri, and Jack Denfeld Wood. 2017. "Fast Tracks and Inner Journeys: Crafting Portable Selves for Contemporary Careers." Administrative ScienceQuarterly: 0001839217720930.
Management practice has its fair share of cynics, and one story that many cynics will tell is that there are three sources of inefficiency in organizations. The first is that they can’t change into better practices, the second is that they pay for consultants who can’t help them change into better practices, and the third is that they pay for business schools to teach their managers, who end up not being able to change them into better practices. As a faculty member of a school that benefits a lot from the third source, I can at least say I agree with the cynics on the first two. But then, what can be done?
New research by Melissa Valentine in Administrative Science Quarterly has looked closely at consultants and organizational change, and offers some very helpful insights. She studied efforts to improve a cancer treatment center, so the changes were not just simple matters of reducing cost but had significant health outcomes. What did she find? First, it is completely true that significant consultant effort can be invested with no real change as a result. Money wasted, in other words, but perhaps worth trying because it is likely that nothing would have happened without the consultants either.
But consulting changing nothing was just one result – there were also some consultant efforts that did produce better practices. Importantly, the difference in how the consultants and the cancer center interacted in the unsuccessful and successful cases was so systematic that this research gives clear guidance on what needs to be done to improve organizations. The difference can be summed up in one word: commitment. And I will write the rest of the blog without any reference to interpersonal relationships, although I admit to being tempted.
Consultants hear from organizational members what works well and what does not, and they collect ideas on how improvements can be done and who would be in favor of them and under what conditions. This is done every time and has nothing to do with success or failure. The success came from taking one more step. Whenever possible improvements were suggested and had some level of support across the organization, the managers who would be responsible for making changes were asked to renegotiate their obligations to each other and to implement the necessary changes. The renegotiation is needed because changes in complex organizations typically cross boundaries of managers and are most effectively handled by direct negotiation, not by referring up to the shared manager. Immediate implementation is needed because it is easy to give nice-sounding promises without accepting the cost of actually following through. In other words, the success came from making managers decide what to commit to and then making them commit.
This was not just done as a final set of activities after delivering a report. It was a continuous effort, step by step, in which managers made adjustments and re-adjustments, set time tables and expected commitments, set new goals and measures, and followed up. The process also went far beyond managers, because hospitals also have another very powerful group: the doctors. Efforts to integrate their concerns were made in both the successful and unsuccessful project, but again, the successful project pushed all the way to commitment. In the successful case, the key decision makers ended up feeling obliged to fulfill promises they had made to others in the organizations – not to the consultants – and as a result, the organization changed.
The implication is clear. Consulting is often seen as an effective way of making changes because changes require a time investment, and organizations typically don’t have the resources to do their regular work and make time investments all at once. But increasing the capacity to propose change does not relieve the organization of the responsibility to negotiate, decide, and commit. Without those added activities, it is paying for nothing.
Valentine, Melissa A. 2017."Renegotiating Spheres of Obligation: The Role of Hierarchy in Organizational Learning." Administrative Science Quarterly:0001839217718547.
This blog is devoted to discussions of how events in the news illustrate organizational research and can be explained by organizational theory. It is only updated when I have time to spare.