Some Definitions – Rule Sets in Healthcare

I came across the idea of rule sets while reading Tom Barnett’s excellent The Pentagon’s New Map.(1)  Tom is a military strategist who was influential in the 1990’s-2000’s when the collapse of the Soviet Union left the US as the sole hegemonic power (this was before the 2008 Western financial crisis and China’s ascendancy).  I had the pleasure of corresponding with Tom on a few of his ideas which at the time seemed quite radical, but bore out to be accurate.  I’m not going to comment on his military and geopolitical views, as I’m only an armchair foreign analyst.  


Tom promotes the idea of “Rule Sets” – the combined written and unwritten rules that exist in a society or culture.  Entities that have similar rule sets interact and cooperate more effectively, and entities that have very different rule sets have difficulty synergizing well.  Ergo, western cultures (US & European) interface quite well as we have a shared belief system – representative democracy, protection of private property, freedom of religion, rule of law, etc…   However, cultures such as American and Azerbaijan may not interface easily as paternalism, tribal and familial patterns of voting and class, arranged marriages clash between the two cultures (apologies to any Azeris who feel I am unfairly singling them out for the purposes of example).


In healthcare today, we have different rule sets belonging to the various stakeholders involved in healthcare delivery.  The differences between these rule sets create friction in interaction, even when one group asserts dominance over the other.


The physician’s rule set is first and foremost governed by the Hippocratic “primum no nocere” (first do no harm) dictum.  As a result, most physicians are risk-averse, patient-centric, and conscientiously compliance focused, also stemming in part from a fear of malpractice and payment compliance problems.  They are also cognizant of the “captain of the ship” doctrine as it has applied to them (z.b. this may be changing in practice if not as quickly in case law) and are therefore independent and opinionated, not concerned about consensus-building as their decisions tend to be of the “buck stops here” variety.  Consumed by the frequent changes in the medical literature that make up the basis of their practice, they tend to be resistant to other forms of change.  Success is typically measured internally by the satisfaction derived from good patient outcomes, a patient at a time.


The administrator’s rule set is more nuanced with greater attention to soft skills, team and consensus building, and an avoidance of unnecessary risk.  Slow, iterative refinements punctuated by less frequent sweeping change either in response to market conditions or strategic initiatives are the rule.   For all but the highest level administrators, shared decision making is the rule, requiring buy-in from different organizational levels.  Institutional knowledge and know-how are as important as efficient execution and interpersonal skills.  Productivity enhancement is a sure key to success and greater roles in the organization.  Mid-level managers tend to be more narrowly focused, myopically on their own area of supervision and control, while higher level executives are responsible for institutional stewardship.  Success is usually measurable by numbers, either in a P&L basis, volume, time, or outcomes measures.  Responsible for many lives, the administrator focuses on population health measures.  


So, if physician’s rule sets and administrator’s rule sets are so different, how then are we to expect the two to collaborate successfully?


Perhaps a new rule set will need to be developed with commonalities both physicians and administrators?  


They already have one huge thing in common – the patient.


(1) Thomas P.M. Barnett (April 22, 2004). The Pentagon’s New Map. Putnam Publishing Group. ISBN 0-399-15175-3