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1.6. Principles-Driven Management: Marrying Theory and Practice

The skill and judgment of experienced clinical practitioners is critical to quality outcomes. Yet it would be a mistake to rely on clinical experience alone, unsupported by theory, to advance the field. We could watch a surgeon all day without understanding why she is doing what she’s doing. To understand the “why” behind the “what,” we would need courses in chemistry and anatomy, physiology and neurology. Modern medical practice relies heavily on science.

This was not always the case. For example, doctors used leeches in ancient times for all manner of maladies (even headaches) without any scientific basis. As long as some patients got better, doctors continued to use leeches. But with only experience as a guide, outcomes were unreliable and usage of leeches steadily declined. However, more recently, science demonstrated the anesthetic and anticoagulant features of leech saliva, and modern circulatory theory helped explain when using leeches (or genetically engineered equivalents) might be beneficial and when it would be foolhardy. As a result, leech usage has made something of a comeback. Theory tells us why things work as they do, and by so doing both explains practice and provides us with the tools to improve it.

A theory, according to The American Heritage Dictionary (1985 edition), is “systematically organized knowledge applicable in a wide variety of circumstances, especially a system of assumptions, accepted principles, and rules of procedure devised to analyze, predict or otherwise explain the nature of behavior of a specialized set of phenomena.” Practice without theory is just trial and error, with no guiding principles beyond what “seems to work.” At the same time, theory without practice is ultimately sterile. In academic disciplines, it is a constant temptation to develop theories on theories, moving ever further into the sterile realm of abstraction and away from the real world of actual practice. Yet, it is practice that directly adds value to people’s lives. The best theories are focused on informing real problems that real decision makers face.

Theory development involves separating out phenomena that are idiosyncratic to a certain narrow context from those that are more universal in application. The latter can be expected to stand the test of time, more so than any particular practice. Some theories are more predictably accurate (most laws of physics can be counted on to hold and to predict outcomes) than others (theories of human behavior are less reliable given the open-ended and evolving nature of human understanding and culture). But, in all cases, researchers seek guiding principles that provide fundamental understanding, inform practice, and give us the tools to improve outcomes. As new diseases, risks, and contexts evolve over time, practice can become obsolete. Theory, however, is semipermanent and should apply in circumstances old and new. Theory can therefore provide guidance in new territory, which is why we need it now.

In this book, we strive to marry the worlds of theory and practice by taking a principles-driven approach to hospital management. We identify key hospital management challenges, and for each we base potential responses on general principles that can be relied on to be applicable in a variety of circumstances and help predict or otherwise explain behaviors. Because the same principles apply to a range of specific hospital management challenges, we avoid excessive repetition by accumulating them in Appendix A. Readers who are not yet familiar with one or more of them can consult Appendix A for descriptions, explanations, and examples.

The result is a book that uses general principles of management, derived from many years of research in a variety of business subfields, to inform and improve practical hospital operations. In this way, we allow medically oriented readers to acquire general management knowledge by focusing on specific hospital issues that are familiar to them but that, once mastered, provide an approach that is applicable to new problems in the evolving future.

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