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When faced with organizational bureaucracy, physicians can either give in, get out or learn how to orbit.

Fam Pract Manag. 2007;14(4):58

Jack Valancy is the principal of Jack Valancy Consulting, based in Cleveland Heights, Ohio, and is a clinical assistant professor in the Department of Family Medicine at Case Western Reserve University's School of Medicine. Author disclosure: nothing to disclose.

Physicians increasingly complain to me about the time, effort and expense that go into getting paid for their services and complying with regulations. The tens of thousands of pages of laws, policies, guidelines, systems, procedures, methodologies and techniques are health care's giant hairball.

The Health Insurance Portability and Accountability Act (HIPAA) epitomizes this. Just a few years ago, swarms of consultants spread over the land like locusts to help health care organizations comply with the confusing regulations, yet HIPAA myths still persist. Many organizations have erred on the side of overcompliance, adding unnecessary red tape, confusing their patients and needlessly impeding the flow of information. One group uses six different HIPAA authorization forms for different circumstances. Some have even purchased restaurant-style beepers to notify waiting patients, instead of calling out their names.

The late Gordon MacKenzie described the accretion of bureaucracy in his book, Orbiting the Giant Hairball: “Every new policy [or regulation, system, procedure or form] is another hair for the Hairball. Hairs are never taken away, only added.” The intricate patterns of adaptive behavior that grow around hairballs are “a Gordian knot of Corporate Normalcy.”

In health care, we call it “compliance,” and we have “compliance officers” to train us in compliant behaviors. We also measure ourselves against other organizations' “benchmarks” and adopt their “best practices.” The trouble with compliance, benchmarks and best practices is that they solve past problems and leave no room for original thinking or creativity. It's paint-by-numbers management.

Many well-meaning physicians and other health care professionals succumb to the pull of the hairball's gravity, immersing themselves in the minutiae of policies, procedures, processes, surveys, statistics and methodologies that consume 33 cents of each dollar Americans spend on health care and obscure their organization's higher purpose.

A few people actively engage the opportunities in health care by “orbiting,” which MacKenzie defines as “responsible creativity: vigorously exploring and operating beyond the Hairball of the corporate mind-set… all the while remaining connected to the spirit of the corporate mission. To find Orbit around a corporate Hairball is to find a place of balance where you benefit from the physical, intellectual and philosophical resources of the organization without becoming entombed in the bureaucracy of the institution.”

Organizations provide more than resources, they also provide comfort and safety. It's easy to become mesmerized by the organization's history, philosophy, policies and politics. MacKenzie cautions that it's a delicate balance resisting the hypnotic spell of an organization's culture yet remaining committed to its personally relevant goals.

This is not to say that you don't have to code your services properly, follow insurance plan rules, adhere to medical staff bylaws or comply with HIPAA and myriad other regulations. Just don't let health care's giant hairball suck you into a bureaucratic black hole.

Within these boundaries, if you try, you can find new, invigorating and satisfying ways to pursue your calling in medicine: You may try open-access scheduling or group visits. You may use e-mail to communicate with your patients. You may charge an access fee for services not covered by your patients' insurance plans. You may implement electronic health records. You may reorganize your practice as a multidisciplinary group. You may insist on communicating across your organization's departmental lines and levels rather than communicating indirectly. You may start an incentive plan that rewards group success, rather than individual achievement. You may even start your own independent practice.

The idea, of course, is to do the right things for your patients and yourself by finding the courage to be who you truly are, instead of who you think the organizational culture expects you to be, by orbiting health care's giant hairball.


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