5 ms·

Your reply seems focused on size, but this line caught my attention: >trusting them to make the right decisions. I'm wondering if trust isn't the real issue.

by bumby 2y ago

Your reply seems focused on size, but this line caught my attention: >trusting them to make the right decisions. I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?

vegetablepotpie 2y ago
Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.
- ToucanLoucan 2y ago
  I honestly think most orgs would leap forward considerably (with some pain) by doing a severe reduction in middle management, basically making them prove why they are actually providing value, and removing them if they aren't. Tons and tons of middle managers do absolutely FUCK ALL in terms of delivering product, meeting goals, and serving customers.
  - bumby 2y ago
    I generally dislike middle-management as much as the next IC, but I think these types of arguments tend to ignore latent or low-probability risks. You see this all the time in discussions about quality or safety metrics. By definition, if those teams are doing a good job you won't see many quality or safety issues, which leads people to believe they are doing "FUCK ALL" and provide little benefit. Only in hindsight, after a low-probability but high risk event happens, does getting rid of them seem like a bad idea.
  - taneq 2y ago
    You’ve never worked in middle management, have you? Just because they do largely ‘soft stuff’, mediating between different departments, teams and layers of the organisation, and (hopefully) running interference so that their team can focus unimpeded on the actual fun part of the job, doesn’t render their contribution null and void. I’ve dealt with bad upper management, bad project management, bad clients, bad suppliers, but only rarely bad middle management. (And no, I’ve never worked in middle management although at times I’ve been some of the other categories above. :P )
- skybrian 2y ago
  It might be possible to do a better job at improving and discarding metrics? Shared recently: Goodhart’s law isn’t as useful as you think https://news.ycombinator.com/item?id=41956587 https://news.ycombinator.com/item?id=41956587 Though, I’m not sure how well that applies to programming, let alone child care.
bunderbunder 2y ago
Paperwork. I swear, it's paperwork. My mom is a (retired) preschool teacher. By the end of her career, she was working for a school affiliated with a large chain, and maybe 1/3 of her time was spent on filling out all the paperwork required by management. That was time she absolutely was not spending with the kids. My dad is a (retired) doctor. Similar story there. His hospital ultimately ended up associated with a regional health care network, and the paperwork load ultimately got so bad that they ended up having to hire additional staff dedicated to help the actual health care providers fill out all the paperwork so that they could spend more time actually providing health care. I switched primary care providers over this a few years back. I had a great doctor, but her practice got bought up by one organization, which then got bought up by another, and over time working with her office became a huge bureaucratic quagmire. I switched to a different clinic that's still local (although also chain with multiple locations), and everything's easier again. The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work. tl;dr: It's communication that doesn't scale.
- bumby 2y ago
  >The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work. There's some irony here considering software has been promising for decades to help businesses scale information sharing.
  - bunderbunder 2y ago
    Oh, it has. The scale at which we share information has never been greater. Concrete example: 15, 20 years ago when we tracked user stories, the status of the sprint, etc., with sticky notes on a wall. We didn't have to record a lot of information on them because they only needed to track status at a high level. Details were communicated through conversations. That did mean that a lot of that information was tribal knowledge, but that was actually fine, because it was of ephemeral value, anyway. Once the work was done, we'd throw the sticky notes in the trash can and forget the tribal knowledge. Reporting out happened at a much higher level. We'd report status of projects in broad strokes by saying what big-picture features were done and what ones were in progress. We'd fill operations in on the changes by telling them how the behavior of the system was changing, and then let them ask questions. Nowadays, we put it all in Jira. Jira tickets are extremely detailed. Jira tickets live forever. Jira tickets have workflow rules and templates and policies that must be complied with. Jira rules make you think about how to express what you're doing in this cookie cutter template, even when the template doesn't fit what you're actually doing. Jira boards generate reports and dashboards that tell outside stakeholders what's happening in terms of tickets and force them to ask for help understanding what it means, almost like you're giving them a list of parameters for Bézier curves when what they really wanted was a picture. Jira tickets have cross-referencing features, which creates a need to do all the manual data entry to cross-reference things. Jira tickets can be referenced from commits and pull requests, which means that understanding what changed now means clicking through all these piles of forever-information and reading all that extra documentation just to understand what "resolves ISSUE-25374" means when a simple "Fix divide-by-zero when shopping cart is empty" in the commit log would have done nicely. etc. We communicate so much more these days. Because we can, because we have all this communication technology to facilitate all that extra communication. What we forgot is that, while computers can process information at an ever faster pace, the information processing hardware inside our skulls has remained largely unchanged.
drivingmenuts 2y ago
Most healthcare organizations in the US are profit-oriented, sometimes to the detriment of the patients. That is why we have large, unwieldy organizations surrounding the very few people that actually do hands-on healthcare. There’s also the issue of liability – it can be pretty litigious in the US, and companies are frequently wanting to limit their liability, which means having the paperwork to back up their decisions. Unfortunately, it also means they have to restrict their decision-making to a very small matrix.
- bumby 2y ago
  >Most healthcare organizations in the US are profit-oriented According to the American Hospital Association, less that 20% are for-profit [1]. I'm sure all are extremely budget-conscious, but that's not the same as being profit-driven. It seems to me that the US optimizes for quality to the detriment of cost and, more recently, access. [1] https://www.aha.org/statistics/fast-facts-us-hospitals https://www.aha.org/statistics/fast-facts-us-hospitals
  - Kevguy 2y ago
    But also be aware that non-profit does not mean non-profit-oriented. Just that any profit goes to executives [1] instead of toward community/charity services [2]. [1] https://paddockpost.com/2021/06/10/executive-compensation-at-trihealth-oh/ https://paddockpost.com/2021/06/10/executive-compensation-at... [2] https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01542 https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01542
    - bumby 2y ago
      I think there’s an error in conflating “not for profit” with “charity”. You could provide all care at cost and have zero charity care. That d doesn’t imply all “profit” goes to executives, but rather to keep reimbursed or charged costs lower.
      - Kevguy 2y ago
davidclark 2y ago
I don’t think it’s that they are incompatible by definition. I think the large organization is a result of low-trust. A trust-breaking event occurs, so a new form gets added, a compliance process is created with a new team monitoring, etc. etc. Have enough of those and you eventually get your typical, modern healthcare bureaucracy today.
vanderZwan 2y ago
Well, Buurtzorg is a large organization, it's just that it does not have a large hierarchy. I suspect you're really asking "high-trust" and "large hierarchy". In that case there's plenty of causes to point at. I'll just give a few of the top of my head First, note any organization that breaks into different departments (hierarchical or not), at least partially does so to let each department "abstract" away the other ones - if you don't have to worry about issues outside of your responsibility, you can focus more on yours. That is actually a form of trust. In the case of a hierarchy however, that means that each layer abstracts away the layers above and below, and since going up multiple levels in the hierarchy happens indirectly, the further away, the more abstract things become. So that often needs some kind of structure to regain the trust that is lost by dealing with abstract departments - leading to bureaucracy. On top of that, usually more power resides higher up the hierarchy. That means that without explicit structures to compensate for this, people lower in the hierarchy lack individual leverage to protect themselves against bad decisions made higher up, that may not even be malicious or intentional but just a consequence of the aforementioned abstraction. Of course, most structures that are created to fix this typically are also abstract procedures, meaning they barely help with our instinctual "I cannot attach a face to this" type of distrust. Bureaucracy can create leverage, but rarely creates trust. Which also explains that quite often, talking to someone in person can make such a difference in being allowed to "go ahead" or not. Because it can provide a more "natural" sense of trust that bureaucracy is supposed to provide but barely does.
typewithrhythm 2y ago
Two reasons I can think of. Legally an organisation is usually exposed in relation to its scale, even if the misconduct was limited to one employee trusted to carry out work independently, the penalty will likely be related to the total size of the company. The second is if you're scale is large enough that you are considering a significant portion of the employees with some skill in a region, you have a harder time selecting for anything other than "holds a qualification" during hiring. This leads to all sorts of policy to prevent someone with qualifications but less integrity causing issues.
RicDan 2y ago
I live in Switzerland and my girlfriend has been working as a doctor (surgery), and it has mostly to do with the politics that come with hierarchy. As in nearly all companies, hierarchy allows politics and favourism to enter the playing field which will attract people that do not act in the primary interest a service should have: ergo, patients. For example you have leading doctors who prefer not to look at patients, even tho they belong to them (from a specialization point of view), as they are "cumbersome" cases. That often leads to them "ignoring" it for some time until someone else takes over, or completely delegating it to non-fit persons. It's a huge pain for me to heard this every day, because it literally sucks out any desire to work as a doctor from my girlfriend. At the same time, it's infuriating: we pay a lot each year, and with every year more, for services like this. If I was to ever win lottery, I'd use that money to make my own hospital without all of this crap.
- bumby 2y ago
  From your perspective, what are some potential avenues to better align the incentives of doctors to see those "cumbersome" patients?

by bumby 2y ago

vegetablepotpie 2y ago

Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.

ToucanLoucan 2y ago
I honestly think most orgs would leap forward considerably (with some pain) by doing a severe reduction in middle management, basically making them prove why they are actually providing value, and removing them if they aren't. Tons and tons of middle managers do absolutely FUCK ALL in terms of delivering product, meeting goals, and serving customers.
- bumby 2y ago
  I generally dislike middle-management as much as the next IC, but I think these types of arguments tend to ignore latent or low-probability risks. You see this all the time in discussions about quality or safety metrics. By definition, if those teams are doing a good job you won't see many quality or safety issues, which leads people to believe they are doing "FUCK ALL" and provide little benefit. Only in hindsight, after a low-probability but high risk event happens, does getting rid of them seem like a bad idea.
- taneq 2y ago
  You’ve never worked in middle management, have you? Just because they do largely ‘soft stuff’, mediating between different departments, teams and layers of the organisation, and (hopefully) running interference so that their team can focus unimpeded on the actual fun part of the job, doesn’t render their contribution null and void. I’ve dealt with bad upper management, bad project management, bad clients, bad suppliers, but only rarely bad middle management. (And no, I’ve never worked in middle management although at times I’ve been some of the other categories above. :P )
skybrian 2y ago
It might be possible to do a better job at improving and discarding metrics? Shared recently: Goodhart’s law isn’t as useful as you think https://news.ycombinator.com/item?id=41956587 https://news.ycombinator.com/item?id=41956587 Though, I’m not sure how well that applies to programming, let alone child care.

bunderbunder 2y ago

Paperwork. I swear, it's paperwork. My mom is a (retired) preschool teacher. By the end of her career, she was working for a school affiliated with a large chain, and maybe 1/3 of her time was spent on filling out all the paperwork required by management. That was time she absolutely was not spending with the kids. My dad is a (retired) doctor. Similar story there. His hospital ultimately ended up associated with a regional health care network, and the paperwork load ultimately got so bad that they ended up having to hire additional staff dedicated to help the actual health care providers fill out all the paperwork so that they could spend more time actually providing health care. I switched primary care providers over this a few years back. I had a great doctor, but her practice got bought up by one organization, which then got bought up by another, and over time working with her office became a huge bureaucratic quagmire. I switched to a different clinic that's still local (although also chain with multiple locations), and everything's easier again. The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work. tl;dr: It's communication that doesn't scale.

bumby 2y ago
>The same thing happens at my own job, software. The bigger a company I'm at, the more of my job consists of filling out paperwork about the work I'm doing, rather than doing the actual work. There's some irony here considering software has been promising for decades to help businesses scale information sharing.
- bunderbunder 2y ago
  Oh, it has. The scale at which we share information has never been greater. Concrete example: 15, 20 years ago when we tracked user stories, the status of the sprint, etc., with sticky notes on a wall. We didn't have to record a lot of information on them because they only needed to track status at a high level. Details were communicated through conversations. That did mean that a lot of that information was tribal knowledge, but that was actually fine, because it was of ephemeral value, anyway. Once the work was done, we'd throw the sticky notes in the trash can and forget the tribal knowledge. Reporting out happened at a much higher level. We'd report status of projects in broad strokes by saying what big-picture features were done and what ones were in progress. We'd fill operations in on the changes by telling them how the behavior of the system was changing, and then let them ask questions. Nowadays, we put it all in Jira. Jira tickets are extremely detailed. Jira tickets live forever. Jira tickets have workflow rules and templates and policies that must be complied with. Jira rules make you think about how to express what you're doing in this cookie cutter template, even when the template doesn't fit what you're actually doing. Jira boards generate reports and dashboards that tell outside stakeholders what's happening in terms of tickets and force them to ask for help understanding what it means, almost like you're giving them a list of parameters for Bézier curves when what they really wanted was a picture. Jira tickets have cross-referencing features, which creates a need to do all the manual data entry to cross-reference things. Jira tickets can be referenced from commits and pull requests, which means that understanding what changed now means clicking through all these piles of forever-information and reading all that extra documentation just to understand what "resolves ISSUE-25374" means when a simple "Fix divide-by-zero when shopping cart is empty" in the commit log would have done nicely. etc. We communicate so much more these days. Because we can, because we have all this communication technology to facilitate all that extra communication. What we forgot is that, while computers can process information at an ever faster pace, the information processing hardware inside our skulls has remained largely unchanged.

drivingmenuts 2y ago

Most healthcare organizations in the US are profit-oriented, sometimes to the detriment of the patients. That is why we have large, unwieldy organizations surrounding the very few people that actually do hands-on healthcare. There’s also the issue of liability – it can be pretty litigious in the US, and companies are frequently wanting to limit their liability, which means having the paperwork to back up their decisions. Unfortunately, it also means they have to restrict their decision-making to a very small matrix.

bumby 2y ago
>Most healthcare organizations in the US are profit-oriented According to the American Hospital Association, less that 20% are for-profit [1]. I'm sure all are extremely budget-conscious, but that's not the same as being profit-driven. It seems to me that the US optimizes for quality to the detriment of cost and, more recently, access. [1] https://www.aha.org/statistics/fast-facts-us-hospitals https://www.aha.org/statistics/fast-facts-us-hospitals
- Kevguy 2y ago
  But also be aware that non-profit does not mean non-profit-oriented. Just that any profit goes to executives [1] instead of toward community/charity services [2]. [1] https://paddockpost.com/2021/06/10/executive-compensation-at-trihealth-oh/ https://paddockpost.com/2021/06/10/executive-compensation-at... [2] https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01542 https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.01542
  - bumby 2y ago
    I think there’s an error in conflating “not for profit” with “charity”. You could provide all care at cost and have zero charity care. That d doesn’t imply all “profit” goes to executives, but rather to keep reimbursed or charged costs lower.
    - Kevguy 2y ago

davidclark 2y ago

I don’t think it’s that they are incompatible by definition. I think the large organization is a result of low-trust. A trust-breaking event occurs, so a new form gets added, a compliance process is created with a new team monitoring, etc. etc. Have enough of those and you eventually get your typical, modern healthcare bureaucracy today.

vanderZwan 2y ago

Well, Buurtzorg is a large organization, it's just that it does not have a large hierarchy. I suspect you're really asking "high-trust" and "large hierarchy". In that case there's plenty of causes to point at. I'll just give a few of the top of my head First, note any organization that breaks into different departments (hierarchical or not), at least partially does so to let each department "abstract" away the other ones - if you don't have to worry about issues outside of your responsibility, you can focus more on yours. That is actually a form of trust. In the case of a hierarchy however, that means that each layer abstracts away the layers above and below, and since going up multiple levels in the hierarchy happens indirectly, the further away, the more abstract things become. So that often needs some kind of structure to regain the trust that is lost by dealing with abstract departments - leading to bureaucracy. On top of that, usually more power resides higher up the hierarchy. That means that without explicit structures to compensate for this, people lower in the hierarchy lack individual leverage to protect themselves against bad decisions made higher up, that may not even be malicious or intentional but just a consequence of the aforementioned abstraction. Of course, most structures that are created to fix this typically are also abstract procedures, meaning they barely help with our instinctual "I cannot attach a face to this" type of distrust. Bureaucracy can create leverage, but rarely creates trust. Which also explains that quite often, talking to someone in person can make such a difference in being allowed to "go ahead" or not. Because it can provide a more "natural" sense of trust that bureaucracy is supposed to provide but barely does.

typewithrhythm 2y ago

Two reasons I can think of. Legally an organisation is usually exposed in relation to its scale, even if the misconduct was limited to one employee trusted to carry out work independently, the penalty will likely be related to the total size of the company. The second is if you're scale is large enough that you are considering a significant portion of the employees with some skill in a region, you have a harder time selecting for anything other than "holds a qualification" during hiring. This leads to all sorts of policy to prevent someone with qualifications but less integrity causing issues.

RicDan 2y ago

I live in Switzerland and my girlfriend has been working as a doctor (surgery), and it has mostly to do with the politics that come with hierarchy. As in nearly all companies, hierarchy allows politics and favourism to enter the playing field which will attract people that do not act in the primary interest a service should have: ergo, patients. For example you have leading doctors who prefer not to look at patients, even tho they belong to them (from a specialization point of view), as they are "cumbersome" cases. That often leads to them "ignoring" it for some time until someone else takes over, or completely delegating it to non-fit persons. It's a huge pain for me to heard this every day, because it literally sucks out any desire to work as a doctor from my girlfriend. At the same time, it's infuriating: we pay a lot each year, and with every year more, for services like this. If I was to ever win lottery, I'd use that money to make my own hospital without all of this crap.

bumby 2y ago
From your perspective, what are some potential avenues to better align the incentives of doctors to see those "cumbersome" patients?