Tuesday, September 23, 2014

The Antifragile VA: Lessons from the NFL

Unacceptable behavior. Tone deaf sanctions. Superficial investigations blaming a few bad apples. Contrite leadership promising change.

Population Health Blog readers might think that this is about the National Football League (NFL), but it's also about the Veterans Administration (VA) whitewash.

But, in reality, this is about something much bigger: the unpredictably predictable dysfunction that happens to large and complex organizations. Mix insular leadership (Commissioner or Secretary), an unaccountable bureaucracy (owners or appointees), huge budgets (as in very huge) with hidebound government oversight, and something very big and very bad is bound to happen. Sooner rather than later.

That something often remote (an elevator or a Phoenix clinic), is only obvious in retrospect (atrocious male violence or gaming outcomes), signals a deeper problem (player recruitment or leadership integrity) and results in a loss of reputation that lasts for years

Think baseball and steroids, NASA and shuttles, GM and starters, Presidents and red lines.

This is classic antifragility.  As we continue to concentrate economic and social power into large organizations, logarithmic jumps in complexity will lead to rare, contagious, catastrophic and unpredictable crack-ups. Naturally, our response will be to layer in more systems complexity.

Assuming large and complex ACOs prove they can really conjure money out of providing fewer health services, the PHB believes their next biggest threat is a black swan event. A huge patient data breach.  Withholding care.  Cutting corners.  Something else. You read it here first.

In the meantime, smart PHB readers will discern that there are some important differences between the NFL and the VA:

                                  VA                                            NFL
Problem:               Waiting lists.                      Switches and fists.

Involving:                   Docs                                     Jocks

Result:          Congressional indignation.       Sponsor consternation

Solution:             Budget Conference                    Press conference.

The Media:     Monday morning quarterbacking   Monday Night Football

So the chief gets:          Replaced                         Breathing space

The real problem:        A monopoly                         A monopoly

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