Public Hospitals and the Tragedy of the Healthcare

Public Hospitals and the Tragedy of the Healthcare Commons: Close encounters of the third kind? Prof. David Ben-Tovim Southern Adelaide Local Health Network & Flinders University

Principle 2: Value stream. CASE STUDY 2

ED map Recovery Triage cubilces Category 3+ to lie down or sit-up waiting Arrival by ambulance Seen by triage nurse at triage desk Arrival by car/bus/ on foot Category 2 st into ed Clerical area for documenting and starting medical record Category 1 or trauma Paramedic provides clerical staff with info for record Paed ED A-side coordinator manages pt flowsmoves pts in according to triage category, waiting time, informal assessment of severity, and dr work flow A side cubicles A side coordinator manages nursing organisation B side cubicles Drs supposed to assess pts in Ed cubicles. Patients seen according to dr seniority, severity of illness, informal assessments and work flow. Drs allocated to pts, nurses allocated to cublcles Resus X-ray waiting room Fast track to existing fasttrack servicechest pain, ICCU, CCMU, labour/deliv B- side coordinator manages nursing organisation EECU ‘Ology and gen med. surg drs and nurses Waiting room PSA helps paramedics put pt onto barouche Discharged home/transfer another hospital Decision to admit after more or less negotiation and assessment, then admit to ward when bed available 3

ED redesigned See in order of arrival Registration & givenown paperwork Likely to be discharged Self Amb Waiting room B-side of ED, B side team Triage Desk A side cubicles and team Likely to be admitted Resus 4

Garrett Hardin- The tragedy of the Commons Science, 1968, : 162; 1243 -1248

[Adam Smith] contributed to a dominant tendency of thought that has ever since interfered with positive action based on rational analysis, namely, the tendency to assume that decisions reached individually will, in fact, be the best decisions for an entire society…

� Picture a pasture open to all � As a rational being, each herdsman seeks to maximize his gain � Each herdsman receives all the benefit of an increment of one animal-but the effects of overgrazing are shared out amongst all the herders

� Ruin is the destination towards which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.

�A commons-Human generated or defined resource, too large to prevent access by many users, but once in, each user is in competition with all other users for the resources within it. � Neither private goods (restricted access, competition creates market) � Not public good- benefits not exhausted by access

� Public Hospitals as Commons. � Tragedy beckons, despite being fully owned by the state.

The Tragedy of the Commons is not inevitable- it is the outcome of the unmanaged Commons Elinor Ostrom-Governing the Commons: the evolution of Institutions for Collective Action- Cambridge Univ Press, 1990 Nobel Prize winner- Economics 2009.

Institutional arrangements for managing common pool resources � Common pool resources generally become degraded when run by top-down national regimes, or by top-down rules not credible to users. � Energy of users goes into gaming, not adapting

Institutional arrangements for managing common pool resources Co-operative governance: users + common pool resource managers

The governance structure needs to provide: 1. Timely, useful and useable information about stocks, flows, processes within Common pool resource 2. Cheap, accessible, timely conflict resolution 3. Rules for resource use that are commonly followed � By developing rules in via informed discussion with users � By ensuring compliance via realistic incentives and graduated sanctions

The governance structure needs to provide: 4 Preparing for change

Problem Embed Sustain Improve Assess Impact 5 4 Scope 1 Lean 2 principles Diagnosti c Phase 3 Interventio n Phase P D A S P D P D A S A S Real Problem