Managing the Care of Health and the Cure of Disease—Part I: Differentiation

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Why are the so-called systems of health care so notoriously difficult to manage? No country appears to be satisfied with the current state of its system; almost everywhere reforms are being contemplated, organized, or implemented, some in direct contradiction to others. Each is claimed to make the system more responsive to user needs, yet most are really designed to bring its component parts under control—particularly financial control. Still, nothing fundamental ever seems to change.
The obvious explanation is that this is one of the most complex systems known to contemporary society. Hospitals, in particular, are considered to be extraordinarily complicated organizations. Yet when considered one element at a time, their complexity seems to fall away. Put differently, even the most intricate medical intervention, no matter how difficult to execute, can be easily understood by the intelligent lay person. True, a good deal of the technology of medicine is "high." But most of that is delivered in small, disconnected applications. (Compare all this with the operating processes of a nuclear power plant.) Why, then, does everything become so convoluted when these elements are embedded in an organizational context, and these organizations, in turn, are woven into a social context? Why is overall social control of this system so enormously difficult to effect?
We address these issues by introducing an integrative framework designed to help sort out this complexity. In our view, the "world" of health care has, in fact, long been differentiated into four different worlds—four sets of activities, four ways of organizing, four unreconciled mindsets. So long as these remain disconnected, in our opinion nothing fundamental will change. Our intention here is not to propose definitive solutions to these problems so much as to promote a new mindset whereby they can more easily be solved.
In Part I, we begin by identifying these four worlds, discussing the characteristics of each, especially their differentiation, and considering some of their dynamic relationships. Then in Part II, we address the fundamental management problems in the system, and in so doing, seek to stimulate more creative discussion of possible solutions.
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