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Public Hospitals and the Tragedy of the Healthcare Commons: Close encounters of the third kind?

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. Recovery. Discharged. home/transfer. Waiting room. Paed ED. another.

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Public Hospitals and the Tragedy of the Healthcare Commons: Close encounters of the third kind?

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  1. 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

  2. Principle 2:Value stream. CASE STUDY

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

  4. Registration & given own p aper work Likely to be Waiting room discharged B - side of ED , B side team Self Triage Desk Amb A side cubicles and team Likely to be admitted Resus ED redesigned See in order of arrival

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

  6. [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…

  7. 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

  8. 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.

  9. 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

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

  11. 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.

  12. 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

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

  14. The governance structure needs to provide: • Timely, useful and useable information about stocks, flows, processes within Common pool resource • Cheap, accessible, timely conflict resolution • 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

  15. The governance structure needs to provide: 4 Preparing for change

  16. Embed Sustain Improve Scope 5 1 Assess Impact 4 Diagnostic Phase 2 3 Intervention Phase P D A S P D P D A S P D P D A S A S A S Problem Authorisations Lean principles Permission for change Real Problem

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