Learning Activities from Chapter 1
Master in health information management
Healthcare information leadership
Millennia Atlantic University

Mariana Viloria 1. Differences between micro and macro perspective of healthcare.

MACRO-PERSPECTIVE: Macro perspective is a form of analysis which focuses on the structure of society and provides a way of seeing society as a unified whole. In this macro perspective minimal attention is given to the individual or the subjectivity of actors - the structures of society are thought to be primary and responsible for shaping the individual.
MICRO- PERSPECTIVE: A micro perspective focuses on the individual level, while a macro perspective focuses more broadly on society.
Ethics is a major concern in the health care field. Health care professionals must ensure that they are benefitting patients and meeting ethical and moral guidelines in the provision of care. There are two types of ethical issues facing the health care community: micro issues and macro issues. Micro issues cover issues that arise on a daily basis, and they involve such factors as technological change and dealing with a diverse population. Macro issues concern the allocation, use, and management of health care resources. Macro issues are of major importance as the amount of resources being consumed by health care continues to rise.
At the macro level there is a political issue, allegedly somewhere between 25 and 50 million persons who are "uninsured," by which the proponents of the current administration's view of reform mean to say that these persons are barred from health care. Bringing these persons under some insurance plan is the goal. Three major possibilities are a government plan, funded by taxpayers, private plans funded by taxpayers and subsidized by private carriers through lower premiums, and private plans at retail rates, funded by taxpayers. The goals of the proponents of this aspect of reform includes at least gaining the political support of the currently uninsured as well as others of a liberal political bent. The second issue is an economic one, that the cost of providing health care in this country is very high, it has been increasing at a rate much faster than the overall growth of the economy, and it threatens to crowd out most other economic activity and outcomes. This clearly cannot continue, but there is no current dynamic for stopping it, as long as we are spending "other people's money" to pay for it. Reform to address this problem, at the macro level, involves some combination of controls on cost, demand,and utilization, or a reversion to a more "free market" approach to providing health care. At the highest level, we have two extremes: (1) increase government control by providing insurance through the government, and reduce costs through government pricing controls; and (2) eliminate all government intervention other than quality control (FDA regulation, licensing of providers, etc.) and allow the free market to work.
Unless and until policy makers get back to basics, we will continue to hear the terms "health insurance" and "health care" used interchangeably. Of course nothing is further from the truth, but the existence of a health insurance industry gives the Government a convenient way to deal with the otherwise fragmented and unruly world of providing health care, especially with respect to giving away or subsidizing care to those whose votes it is courting. The problem of course is that insurance adds another layer of administration (cost = 15%) and middleman profit (cost = 15%) to the management and total cost of health care.
Four possible outcomes: (1) Insurers lose, essentially go out of business, Government steps in with a single payer system to save the day; (2) Insurers win, and Government finds some new sleight of hand to look good, but the end result is inflation; (3) Insurers and Government find a way to look like we have our cake but are still eating it, mainly by limiting access and benefits to the newly insured, and everyone wins except for the newly insured; (4) Government and insurers find a middle ground, and insurers become much like regulated utilities with a managed return on investment.

2. Solve problems according to the Eight-Step Strategic Problem Solving Method.

Problem solving technique known as the OODA Loop: The OODA Loop consists of four overlapping and interacting processes. Managers must: * Observe the current situation and form theories * Orient the picture by setting improvement targets and determining root causes * Decide by developing solutions * Act by means of implementing and evaluating.

The OODA Loop can be subdivided further into an eight-step problem solving process.

- Observe:

Step 1: Clarify the Problem.
This is a critical step. You need to recognize the correct problem and be sure it is completely understood by all. It helps to state the problem by developing a “problem statement” in terms of what, where, when, and the significance. You also need to “lay eyes” on the situation, ensuring you have first-hand observation. This will then help in drafting a flowchart that diagrams the steps of the process. Lastly, you need to conduct surveys and interviews, talking with the “customer” or end user who determines the value of the process under review.

Step 2: Break Down the Problem and Identify Performance Gaps.
It is tempting to jump to action but you must refrain from doing so just yet. Gather and review the key data. Understand what data is necessary and what role it plays in problem solving. Are there gaps in your analysis? Are there bottlenecks in the process you are reviewing? Under this step, you must also look at waste in your practice as it relates to the problem. There are generally eight types of waste: defects, over production, waiting, over processing, transportation, intellect, motion, and excess inventory. You should always look for waste in your processes.

- Orient:

Step 3: Set Improvement Targets.
Where do you want to be? Determine your desired outcome for the practice. Be sure to look at both strategic and tactical targets. Strategic targets are visions of what your practice strives to become. Tactical targets define the performance level necessary to make your strategic vision a reality. Remember to keep your tactical targets challenging but achievable.

Step 4: Determine Root Causes. This is the most vital step in the problem solving process. All too often practice managers find themselves addressing problems that have been “solved” many times before. This is usually due to directing problem solving efforts at the symptoms of a problem rather than at the root cause of the problem. It often helps to do much brainstorming and when you think you understand the cause of the problem, ask what caused the problem (continue to ask “why?”).

- Decide:

Step 5: Select Solutions.
When selecting solutions, consider both quality and practicality. Be sure to also gain acceptance (or “buy in”) from those that must implement the solutions. Some key factors to consider when analyzing solutions include effectiveness, feasibility, and impact. When developing your action plan, be sure that you have created a clear and detailed plan that everyone can understand. Most importantly, build consensus with others by involving all of your team appropriately to cultivate a sense of ownership in the solution and in its success. Effective communications can be a deciding element as to whether the plan succeeds.

- Act:

Step 6: See the Plan Through.
Collect data according to the action plan. Remember the old adage, “You can’t manage what you can’t measure.” You may need to implement a contingency plan as conditions change and you need to keep the project on focus. Continue to provide required training during this step as well.

Step 7: Confirm Results and Process.
Ensure the plan is producing the intended results. Monitor the project for performance relative to: a) the baseline developed in steps 1 and 2; b) the improvement targets established in step 3; c) where you thought you would be at this stage; and d) meeting targets by the established deadline. You should return to any step as necessary.

Step 8: Standardize Successful Processes.
This is the most commonly skipped and under completed step of the entire problem solving process. You can define this step by asking a series of questions. What is needed to standardize the improvements? Is the appropriate documentation in place? Were other opportunities or problems identified by the problem solving process?
If the answer to this last question is yes, begin the process over ... that is why it is referred to as the OODA Loop.

3. Does theory and research in management offer any guidance for practitioners seeking to improve quality of care?

4. What does each school of thought reviewed in this chapter suggest about what to do?

5. Which of the schools of thoughts seem to offer the most useful advice?