COMMON MERITOCRACY:

A MULTI-AGENT SYSTEM AS THE MODEL FOR A CO-OPERATIVE COMMUNITY IN HEALTHCARE

Ryszard Stocki Saint Mary’s University MIK - University of Mondragon University of Social Sciences and Humanities, Katowice Andrzej Bielecki University of Mining and Metallurgy !Community, Context and Communication ASB Conference, 26-28 September 2014, Halifax

Erwin Schell of MIT in 1952 in “The Amazing Oversight: Total Participation for Productivity.”

The wish to participate in the direction, guidance, and control – in short, in management―of affairs is one of the deepest desires of man.

BECAUSE WE MIX TWO VIEWS OF PARTICIPATION

Ontological

Our feature - as ability to walk. Inherent in our nature. Element of our dignity as persons.

Something that differentiates us from animals and makes it possible for us to make free choices

according to our will.

A value. An element of our culture. Something to be taught. An important aspect of management strategies, education, etc. Sometimes has to be

limited. An expected element of developed democratic systems.

Ethical

Photo: gthills - cc @ flickr.com Photo: Matthew Anderson - cc @ flickr.com

UNIVERSALITY OF PARTICIPATION

Solon

Buddha

Herodotus

Laozi

SamuelIsaiah

Jesus ChristSpartacus

St BenedictWilberforce

Wielezynski

Kwiatkowski

Mediarrieta

Wojtyła Allport SemlerMaslow Stack Heron

Schell

Owen

Gandhi

King

Vroom

PARTICIPATION IS SO TROUBLESOME AS IT SEEMS TO COMPETE WITH

OWNERSHIP AND BOTH ARE PILLARS OF OUR PERSONAL SECURITY

AND OWNERSHIP IS A COMPLEX CONCEPT

COMPLEXITY OF OWNERSHIP

Legal ownership Kaarsmaker, 2009;

Ben-Ner, 2007; Ellerman, 2006

1

Society and its insitutions recognize

ownership rights, but sometimes the rights have to be shared.

Photo: Tori Rector - cc @ flickr.com

COMPLEXITY OF OWNERSHIP

Psychological ownership: Pierce et al. 2004; O’Driscoll, 2006;

Dwyer and Ganster, 1991 Pierce & Jussila, 2010

2

A person recognizes ownership rights,

but sometimes they have to be shared.

Photo: Matthew Anderson - cc @ flickr.com

COMPLEXITY OF OWNERSHIP

Control related ownership Vroom & Jago, 1988

Mazur, 1966 3

Efficacy related to the object. Requires information and expertise, but sometimes

they have to be shared.

ALL THREE PRODUCE SEVEN STATES OF OWNERSHIP, SOME GENERATING CONFLICTS, BUT ONLY ONE STATE

ALLOWS FOR TOTAL PARTICIPATION.

15 2

4

7

6

3

7. Total participation - never achieved in 100% but is the desired goal as it

conditions real, motivated, responsible actions.

Graham & Titus, 1979 Stocki, Prokopowicz & Żmuda, 2008

Legal

Control

Psychological

TOTAL PARTICIPATIONdefined by Stocki, Prokopowicz & Zmuda, 2008 and 2012

Total participation in management (TPIM) – the method of directing an organization based on the conviction that participation is an inherent characteristic of every human being, and that employee participation has a constant, long-

term, and positive influence on the achievement of organizational and individual goals.

WHAT ABOUT HOSPITALS?

THEY ARE ELITIST INSTITUTIONS BASED ON EXPERTISE OF FEW PERSONS

InterestOne Few Many

Self-interst Tyranny Oligarchy Mobocracy

Society’s interest Monarchy Aristocracy

The bestDemocracy

Number of rulers (Scope of Competence)

Aristotle's division of political systems

Hospital

THEY ARE SEPARATED FROM THEIR STAKEHOLDERS BY FINANCING INSTITUTIONS WHICH ARE IN CONFLICT OF INTEREST WITH BOTH

THE PATIENTS AND THE HOSPITAL

Ministry of Health

Insurance institution Physician

Patient 1

Patient 2

Patient 3

Patient 4 Barriers

THERE IS NOT A SINGLE COUNTRY IN THE WORLD SATISFIED WITH ITS

HEALTH CARE SYSTEM.

The result:

OUR HEALTH CARE IS BASED ON THE “SERVICE MODEL”

Photo: Brian - cc @ flickr.com

AND SERVICE MODELS FIT CAPITAL BASED INSTITUTIONS

AMPLE MEDICAL EVIDENCE PROVES THAT HEALTHCARE CANNOT BE

BASED ON A SINGLE EXPERT SERVICE MODEL.

Body like a car to be repaired.

BodyAs a patient

I distance myself to my body and illness. As the owner of my

body I want the doctor to “repair” it, else I can

do whatever I want with it, e.g. destroy it

Patient the ignorant

Doctor the expert

As a medical expert she/he (paternastically)

focusses on treatment and takes responsibility

for it. He/She is interested in a

limited set of information about the

patient.H

ealth care system

Impersonal relationship between the doctor and the patient, based on Cartesian dualism.

HEALTH CARE IS NOT A REPAIR SERVICE

Both doctor and patient are experts in their specific domains and should participate in the treatment process

according to their expertise.

Person becomes the subject of her illness

and as such has to participate in treatment.

Patient - an expert in his family, calling, self-fulfillment, goals

Doctor - a medical expert

As a medical expert (participatively) focusses on the good of the patient and takes

responsibility for her actions and words.

Calling

FamilyThe person transcends to good and is not an owner of his or her body, but

body as well as participation are essential elements of the person. They

make up its dignity.

Sense

Self-fulfillmentBody

As a researcher and provider of service she has

to achieve informed consent.

Expert

Sense

FOR EFFECTIVE HEALTHCARE PATIENT AND DOCTOR’S

RESPONSIBILITY AREAS HAVE TO CHANGE AND MEET IN THE SYSTEM.

Health care system

Health care system allows for defining and responding to common good with

the best expertise available.

Capital based institution is not a good environment for nurturing the personal

relationship.

THIS REQUIRES COMPLETELY NEW HOSPITAL GOVERNANCE MODEL

Interest One Few Many

Self-interst Tyranny Oligarchy Mobocracy

Common good Meritocracy through active participation Different groups and sizes depending on the nature of the problem

Society’s interest Monarchy Aristocracy Democracy

Number of rulers (Competence)

CORRECTED ARISTOTLE’S TYPOLOGY

Hospital

Ministry of Health

Insurance institution Physician

Patient 1

Patient 2

Patient 3

Patient 4

AND LOCAL COMMUNITY BASED MODEL OF HEALTH CARE FINANCING - STEP 1

Hospital

Ministry of Health

Physician

Patient 1

Patient 2

Patient 3

Patient 4

AND LOCAL COMMUNITY BASED MODEL OF HEALTH CARE FINANCING - STEP 2

Helath community

Ministry of Health

Physician Member 5

Member 1

Member 2

Member 3

Member 4

AND LOCAL COMMUNITY BASED MODEL OF HEALTH CARE FINANCING - STEP 3

THE BEST EXISTING LEGAL FORM FOR A HOSPITAL, MEETING ALL THE REQUIREMENTS IS A MULTISTAKEHOLDER CO-OPERATIVE

• Physicians - Producer co-op

• Nurses/midwives - Worker co-op

• Dietitians - Producer co-op

• Patients - Consumer co-op

• Pharmacists - Trade co-op

• Administration - Worker co-op

• Financial service - Credit union

• Social workers - Worker co-opPhoto: U.S. PacificFleet - cc @ flickr.com

BUT IT MAY HAPPEN ONLY THROUGH INFORMATION AND COMMUNICATION

TECHNOLOGY

0

55

110

165

220

Cuba India Canada China USA Poland Gabon

MERITOCRACY REQUIRES EASY ACCESS TO KNOWLEDGE, INFORMATION AND DECISION

MAKING. IT IS POSSIBLE THROUGH MOBILE PHONES.

Number of phones /100 people

The World Bank 2014

M-GOVERNANCE‘a strategy for the implementation of Governance and its implementation involves the utilization of all kinds of wireless and mobile technologies, services, applications, and devices. It improves upon the benefits for those involved in e‐governance, including citizens, businesses, and all government units’ (Pandey & Sekhar, 2013).

Reporting of domestic

violence in South Africa and India

TXT CSC - an SMS service launched by Civil Service

Commission in the Philippines

M-Voting, the

parliament approved mobile

technology for the 2011

elections in Estonia.

M-HEALTHthe practice of medical and public health, supported by mobile devices. The term is most commonly used in reference to using mobile communication devices, such as mobile phones and PDAs, for health services and information.

(Pandey & Sekhar, 2013).

Telemedicine: Patients take a photograph of a wound or illness and allow a remote physician diagnose to help treat the medical problem. Diagnosis and treatment

support projects attempt to mitigate the cost and time of travel for patients located in

remote areas.

Education and awareness: Patients get information about various subjects, including testing and treatment methods, availability of health services, and disease management.

Helpline: T

his involves a dedicated

phone number which an individual

can call to get access to a range of

medical services like availability of

drugs, information on facilities,

availability of mobile health clinics

etc.

TO MEET THE NEEDS OF COMMON MERITOCRACY AND TO MAKE SUCH

GOVERNANCE EFFECTIVE

the elitist and competence based m-health !

has to meet !

the broad, common m-governance

DETERMINANTS OF MERITOCRACY PROCESS (BASED ON VROOM, 2003)

Incumbent characteristics

Decision characteristics

Situation characteristics

Leader’s content competence

Leader’s process competence

Incumbent’s content competence

Incumbent’s process competence

Interaction constraint Goal alignment Role (leader -

member) Content competenceProcess competence

Likelihood of disagreement Likelihood of commitment Value of time

Value of development Decision significance

Importance of commitment

Parti

cipa

tion

leve

l

An individual takes the decision

An individual consults individually

An individual consults a group

A moderated group takes the decision

Not-moderated group takes the decision

AGENTS AND RULES OF THE SYSTEM

Incumbent characteristics

Decision related agents

Rules defined in the system

Matching the incumbents characteristics with the decision characteristics to produce Inferring the incumbent competence Calculating the likelihood of disagreement Calculating the likelihood of commitment after the decision is taken Selecting set of incumbents to propose take the decision Monitoring the response rate to decision proposals Monitoring the engagement in the system, etc etc. Monitoring the input and change in competence of the incumbents

Possible decision domains and their requirements

Charls Darwin: Decision initiation rights Level of general competencies

humane interpersonal business

Level of specialist competencies Organizational position

availability readiness to take decisions age tenure membership in professional groups cooperative membership

Joanna positions: Decision initiation rights Level of general competencies

humane interpersonal business

Level of specialist competencies Organizational position

availability readiness to take decisions age tenure membership in professional groups cooperative membership

Francis positions: Decision initiation rights Level of general competencies

humane interpersonal business

Level of specialist competencies Organizational position

availability readiness to take decisions age tenure membership in professional groups cooperative membership

Margaret Schenk Decision initiation rights Level of general competencies

humane interpersonal business

Level of specialist competencies Organizational position

availability readiness to take decisions age tenure membership in professional groups cooperative membership

John Smith: Decision initiation rights - limited Level of general competencies

humane - 10 interpersonal - 5 business - 4

Level of specialist competencies Organizational position

availability - weekends readiness to take decisions - 10 age 45 tenure 6 membership in professional groups (NAMD, SAPG, etc.) cooperative membership (

Possible decision making methods: Too early Specialist (no consultations) Specialist (after consultations) Incumbent (after consultations) Incumbent (no consultations)

Forms of voting Majority Consensus

Possible decision scope: Individual. local, departmental, etc.

MERITOCRATIC DECISION MAKING PROCESS

Initialization

Input Decision support systemSelection of

incumbents to be involved in the process

Voting Majority

ConsensusDecision

made

Database Incumbents Decision scopes Domains etc.

Rules

OutputDecision Decision initiator Reason to initiate Goals to be met Domain: General Specific Competency/Experience Requirements Urgency Costs Significance Who shall commit in realization Proposed decision owner

Rights and conditions of

initializing decision making process

Training

Decision generator

Selection of actions to be instigated

Debate

Consulting

Research

IS IT A UTOPIA OR JUST A NAIVE DREAM?

Web sites like StackExchange prove

it is neither.

THEY HAVE A MULTITUDE OF DOMAINS OF KNOWLEDGE AND…

… RULES TO START NEW ONES, AND…

… RULES OF DECIDING ON IMPORTANCE, EXPERTISE AND ENGAGEMENT AND…

A CLEAR SYSTEM OF EVALUATING PARTICIPANTS AND THEIR INPUT.

Questions are evaluated

Answers are evaluated

Participants build their reputation

Few have editing rights

PORTALS LIKE:Allow to do effectively and on a large scale what we have always been doing - exchange knowledge and information. !However, Information and Communication Technology allows us to establish systems like…

Common meritocracy

to do things we have never been doing, but should have long time ago to reveal our potential as free persons.

SUMMARY• Participation is us.

• Ownership misleads us in our relationships with others.

• By the nature of their function, hospitals should be communities of persons and not service providers.

• A multistakeholder co-operative is the best legal form for a hospital.

• “Oligarchy” and “aristocracy” of the hospital governance should be replaced by common meritocracy.

• Functional benchmarking of portals like StackExchange may help us build real implementation of this form of governance.

FOR MORE INFORMATION ABOUT COMMON MERITOCRACY AND TOTAL

PARTICIPATION CONTACT ME AT: ryszard@stocki.org

!

THANK YOU.