The Case For A Professional Quality Board In Professional Organizations
Executive
Summary
Large
organizations, both private and public, are necessary to achieve
large scientific and technical goals, but as these large
organizations come to house both scientific/professional personnel
and administrative/business personnel, internal dissonance will
inevitably arise. Keeping these goals in balance is required for
success. If business/administrative goals and mores that come to
predominate, product failures can result. The failure can be
chronic, as when profit or organizational advancement comes to trump
product quality, or acute, as when imminent disaster is overlooked
and crucial knowledge ignored.
To
avert this sort of organizational decline, this paper suggests the
establishment of Professional Quality Boards. This Board would be
composed of highly respected senior scientific and technical
professionals, who would safeguard the scientific quality of the
enterprise. The PQB's would be quasi-independent entities with wide
investigatory powers. They would communicate primarily to the CEO
and Chairman of the Board or governmental unit Director, but would
also be empowered to address the legislature and higher executive
officials in the case of a public entity, or stockholders and
regulatory authorities for non-governmental entities, and even to
make public their point of view. The mission of these PQB's would be
to be the professional
scientific conscience, the professional scientific safety valve, and
professional scientific corrective conduit
for the organization. This idea is explored in the context of NASA,
Boeing, the CDC, and medical organizations, and is contrasted to
other proposed solutions.
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The
Problem
Modern
life and modern technology often demand very large organizations.
Big objectives -- go to the moon, build a modern jet plane, prepare
for and fight a pandemic – require thousands of scientists and
engineers, as well as thousands of administrative personnel and
managers. Organizing all these specialists into a coherent whole has
become, just like the technologies they seek to harness, a modern
innovation in its own right. The successes have often been amazing.
But
along with successes have come failures, some necessary, but some
avoidable. There was NASA's Saturn V rocket, but there was also the
Challenger. There was the Boeing 747, but also the 737 Max. There
was CDC's Smallpox eradication, but there are also the great COVID-19
fumbles in testing, ventilators, truthfulness, and leadership. And
there are the ongoing violations of rationality and humanity in our
medical care enterprises.
The
successes and the failures have a common heritage – the merging
together of technology and administration, and the aging of
organizations. New technical organizations tend to be vibrant,
staffed with innovation believers, intent on achievement, sometimes
messy, places where righteous failures are expected and tolerated as
learning events advancing the mission. These new organizations are
Achievement Organizations. But as victories are won and the
organizations mature, they inevitably tend to lose their initial
fire, less adventurous personnel are attracted to join them, and
eventually errors become sins and achievement becomes less important
than avoiding blame. These are Blame-Avoiding Organizations. As
Eric Hoffer says, "Every great cause begins as a movement,
becomes a business, and eventually degenerates into a racket."
And as Elon Musk observes about
organizational degradation, “So, I think it’s kind of
sad that we were able to go to the moon in ‘69 and here we are 2020
can’t even go back to the moon.”
As
with human bodies, each organization ages with common patterns, but
each in its unique way. In some the scientific innovators are
replaced by those with less vision and more focus on process than end
result. Administrators may come to predominate over the
technical side, profit may come to dominate thinking in a private
organization, or growth of domain and continued funding might
dominate in a governmental organization. Business and bureaucratic
creep can lead the original visionary organizations astray.
The
illnesses of aging organizations can be both chronic and acute.
Chronic misdirection
of the organization can occur, as when the objective of profit trumps
that of product quality, or when the obsession of management bogs
down the professionals with incessant needless paperwork. Acute
misdirection also occurs, as when something dangerous
is about to happen and the technical personnel know it but the
administrators don't, and the message doesn't flow through the
organization properly. Instead of a tight connection of
administration with scientific point of view, it is common to see
conflict of creative people vs. the suits, the administrators vs. the
doctors, the managers vs. the scientists. The imbalance of points of
view can make the organizations less functional, more prone to these
chronic and acute dysfunctions.
But
that is not to say that the productive life of organizations cannot
be preserved and successfully resuscitated. When dysfunction is
manifest and a company's viability threatened, as happened at Ford,
a great leader can be called in to ream out the arteries and
resuscitate the company. That's a late remedy. Others have tried to
institute continuous renewal – General Electric CEO Jack Welch's
brutal solution was to aim at firing the bottom 10% performing
managers each year. It's not clear that it worked.
The
reform I am suggesting in this paper is a structural change that
would both help to keep companies and agencies on the right track in
balancing the scientific and administrative strands, and to intervene
directly to remedy acute problems.
A
Proposed Solution - The Professional Quality Board
In
brief, I am suggesting the creation of a Professional Quality Board
(PQB), which would be composed of senior scientists, engineers,
physicians and others, maybe even administrators, all widely
respected, and with personal histories that bind them closely to the
success of the institutional mission of the organization.
Administratively, the PQB would lie outside the usual hierarchic
organizational chart, off to the side at the top, attached to the CEO
and the Board or to the head of the governmental unit, with long
terms for members. The PQB would be quasi-autonomous. The mission
of the PQB would be to be the professional
scientific conscience, the professional scientific safety valve, and
professional scientific corrective conduit
for the organization.
Standing
outside the regular organizational chart and privy to extensive
information with the ability to investigate, the PQB would examine
the agency or company for evidence of chronic
misdirection, a
severe deviation from the scientific objectives of the organization –
identifying when the organization was in the process of becoming too
much of a business and not enough of a calling, or worse yet, a
racket. The PQB would also act as a safety valve for acute
misdirection,
when something was all set to go horribly wrong, and when internal
efforts to alert supervisors and leaders of the need to right the
ship have proved unavailing. In that way, the PQB would be
responding to a whistleblower, in effect, but on scientific and
technical matters, not legal ones.
I will
say more about the PQB below. But first, it will be helpful to look
at the organizational disasters I have picked out, and see how a PQB
might have helped avert them.
Disasters
in American Technical Agencies and Companies
The
Challenger Disaster
The
Challenger disaster of 33 years ago displayed a stark contrast
between what the professional engineers at NASA contractor Morton
Thiokol knew was about
to happen,
and the decisions made by the project managers.
On
January 27, 1986, Bob Ebeling, a rocket engineer, drove home from the
office with a dreadful feeling. He told his wife that they should
prepare to watch a terrible tragedy unfold.
“The
night before the launch, Ebeling and four other engineers at NASA
contractor Morton Thiokol had tried to stop the launch. Their
managers and NASA overruled them. ...The data showed that the rubber
seals on the shuttle's booster rockets wouldn't seal properly in cold
temperatures and this would be the coldest launch ever.”
Why did
the NASA hierarchy reject the engineers’ plea of caution about the
rubber seals, known as the O-rings? Space Safety Magazine's account
is telling:
The
disaster could have been avoided. The issues with the O-Rings were
well known by the engineering team working on the SRB, but attempts
to notify the management had been constantly held back. The
phenomenon of abnormal O-Ring erosion had been observed in previous
flights. Instead of requesting an investigation, NASA Management
ignored the problem and chose instead to increase the tolerance.
The
night before the launch, NASA had a conference call with Morton
Thiokol, manufacturer of the SRB. A group of Morton Thiokol
engineers, and in particular Roger
Boisjoly, expressed their deep concern about a possible O-ring
failure in cold weather and recommended postponing the launch.
NASA
staff opposed the delay. “My God, Thiokol, When do you want me to
launch — next April?” said Lawrence Mulloy, one of the shuttle
program manager attending the teleconference.
With
the pressure from NASA, Thiokol management gave their approval to the
launch, and Challenger was on its way to disaster. This failure in
communication, combined with a management structure that allowed NASA
to bypass safety requirements, was the organizational cause of the
Challenger disaster.
(See
also an in-depth exploration in the Teaching Company course on
decision making given by Michael
Roberto.)
The
Boeing 737 Max Disaster
Boeing
had long been an expert and profitable engineering organization.
Even in my field of medicine, when we doctors protested how
cumbersome our electronic health records were, we cited Boeing as the
company to emulate, since they spent thousands of hours sitting with
pilots to design their software to fit what pilots naturally do (see
Wachter.)
Yet that
very issue was at the heart of the two scandalous Boeing 737 Max
crashes, where the controls to handle a flawed takeoff pitch problem
were intricate and non-intuitive; where the pilots were poorly
trained for handling the pitch problem; where the software depended
on a single sensor with no back up; and where the procedures for
handling problems when the nose pitched downward were buried deep in
the instruction book. Was this really the fabled Boeing?
The
complicated explanation has become apparent. Internal problems at
the company, pushed to perform quickly to counteract the challenge of
a new efficient Airbus model, led to shortcuts, and actual lies.
Boeing described the new model as simply a revision of its
traditional 737, but this was untrue, since the engines had to be
placed higher on the wings and the software was changed, which led to
many consequences and a substantially different plane. But as a
declared model revision, monitoring was shifted from the FAA to
Boeing itself, long hours of expensive and time-consuming training
could be skipped. The intended result was a must faster time line to
completion to better compete with Airbus.
The
business people within Boeing may have been satisfied with the
results, but the engineers and test pilots weren't. The
most experienced aviators, leery of the revisions, were excluded from
the final decisions that minimized attention paid to the potential
problems, and the engineers and pilots were not even informed of the
final decisions on these design and training elements.
Emails
and interviews discovered by the New
York Times
revealed their disquietude:
“Would
you put your family on a Max simulator trained aircraft? I wouldn’t,”
one said to a colleague in 2018, before the first crash. “This
airplane is designed by clowns, who are in turn supervised by
monkeys.” “I still haven’t been forgiven by God for the
covering up I did last year,” one of the employees said in messages
from 2018, apparently in reference to interactions with the Federal
Aviation Administration. ...Stan Sorscher, a former Boeing engineer
who then worked with a union representing company engineers, said
priorities had shifted over the past two decades, with profits
mattering more than quality.”
Despite
challenges
by line supervisors who blamed the pilots, Congress
issued a report
invoking these severe organizational problems. The report clearly
cites the problem of Boeing's seeking profit
over safety,
and the connivance of the FAA, a captured agency in this case, whose
own leaders neglected the recommendations of their own technical
experts. “It
illustrates how Boeing’s management prioritized the company’s
profitability and stock price over everything else, including
passenger safety. Perhaps even more alarmingly, the report shows how
the F.A.A., which once had a sterling reputation for independence and
integrity, acted as a virtual agent for the company it was supposed
to be overseeing.”
While
the 737 Max problems were clearly acute, chronic company problems
were evident as well.
“Jerry
Useem, a veteran business writer, argued
in The
Atlantic,
last year, that the 737 MAX
calamity can be traced back to Boeing’s move from Seattle, and the
decision to 'divorce itself from the firm’s own culture.'”
Others
have traced the transition from engineering-centric to
business-centric culture to the 2001 Boeing takeover of
McDonnell-Douglas, which paradoxically resulted in McDonnell-Douglas
executives in charge and subsequently the move of headquarters to
Chicago, 1,500 miles away from the company's engineers.
It
is not hard to conclude that over the years Boeing had migrated from
a corporation guided and populated by engineering to a company guided
and populated by business-centricity, and the 737 Max disaster was a
distal result of the prior cultural shift.
The
CDC – Striking out on COVID-19
This
mishandling of COVID-19 by CDC is already legendary, and we have only
understood a small part of it. What ProPublica
summarizes as “the
botched COVID-19 tests, the unprecedented political interference in
public health policy, and the capitulations of some of the world’s
top public health leaders,” came as a shock to the world
at large, which until then regarded the CDC as a world-premier
organization. Although we will soon know much more about the CDC
implosion, we can already discern the outlines of chronic decay that
foretold the acute failures.
The
now almost forgotten panic over ventilator shortages gives an
indication of possible chronic loss of initiative at CDC. As
detailed by the New
York Times, when the Biomedical Advanced
Research and Development Authority (BARDA) was established under
President George W. Bush's personal enthusiasm for an anti-pandemic
capability, they foresaw a need for ventilators and moved to fill it.
They let a contract to develop cheaper ventilators, were making
progress, but then private business bought the development company
and slow-walked the project, which would have undercut their own
prices. When private business asked that the project be abandoned,
the CDC did not protest, and the foreseen need was not fulfilled.
That is typical bureaucratic passive behavior, not the behavior of a
vibrant, achievement-oriented, admired institution. We can only be
grateful, that ventilators did not prove to be very effective for
COVID treatment, and that the potential need did not become manifest.
Insiders
at the CDC were aware of the shortfall. The New York Times story
alludes to disappointed employees, and to CDC Chief (2008-2017) Tom
Frieden, who said he was excited by the progress in 2013, just before
the sale of the company, but then we hear nothing about his attitude
toward the subsequent failure. There is more to be learned here; the
CDC has proved very adept at organizational self-protection.
The
first pandemic sin of CDC, of course, was failure to connect the dots
early, as Michael
Lewis documents, and as he also documents that non-CDC people
were actually doing in the organizational wilderness. CDC then
acceded to political influence from the Trump Administration to soft
pedal the expectations, hoping that COVID-19 would go away as SARS
and MERS had done – despite indications that the infectivity of
symptomless patients would make a significant difference. The memory
of apparent overreaction to Swine Flu in the 1970's, that had cost
Director David Sencer his job, no doubt remained fresh.
Then
came the test
kits debacle. Test kits were vitally, urgently needed as an
initial step to contain the virus's spread. But the CDC, despite
huge nationwide resources to produce tests, decided to produce its
own and to ban the use of any others, abetted by FDA, which would
need to certify each test. CDC then failed to produce a workable
test. “'We
have the skills and resources as a community but we are collectively
paralyzed by a bloated bureaucratic/administrative process,' Marc
Couturier, medical director at academic laboratory ARUP in Utah,
wrote to other microbiologists on Feb. 27 after weeks of mounting
frustration.”
It
is possible that this simple episode of bureaucratic hubris cost tens
of thousands of lives, or more.
It
is well known how CDC was compromised in allowing wholesale
politicization of their organization and their public communications,
involving specific health directions and specific language and
specific data concerning COVID-19. Books
are already being written about the sharpest decline of reputation of
a public agency in our lifetime. As explanation, making the Director
of CDC a political appointment is cited. Lewis's observation is also
acute: “The
root of the CDC's behavior was simple: fear. They didn't want to
take any action for which they might later be blamed.”
And in fact, despite a change of leadership and administrations, as
of the very finishing of writing this paper – just this week! –
the CDC has once
again committed a sin of ultra-caution by claiming that outdoor
transmission of COVID is “less than 10%,” and recommending
continued wearing of masks outdoors, when the true number is no doubt
less than 1%, and maybe as low as 0.1%.
But
let me stop here. The case is clear enough.
Medical
Care Organizations
No
sector has shown more vividly the parallel growth of science and
administration than health care. Evolving from the past era of
smaller organizations and professional
dominance
when doctors called the shots, the modern era of corporate
rationalization is dominated by large medical organizations with a
strong administrative component, including hospitals and insurance
companies. Instead of one large event, in this section I will cite
small but representative events that my friends in medicine and I
have experienced personally.
A
friend of mine who later became president of the American Academy of
Pediatrics led a program at Cincinnati Children's Hospital that
enhanced connections between community physicians and hospital
physicians. They succeeded in increasing efficiency and reducing
admissions. Seeing reduced occupancy, however, the hospital board
declared themselves not in the business of producing unfilled beds
and promptly axed the program. The board's narrow view of their
mission, even though they are non-profit, differed from the
objectives of hospital doctors and enlightened medicine in general,
but that made no difference. There was no appeal possible.
When
I headed Bayside Medical Group, we were members of a locally-based
Independent Physicians Association (IPA) – an independent payer
group sitting between insurance companies and medical practices. In
an effort to bolster practice quality, the IPA decided to use their
in-house billing statistics to measure each practice's use of inhaled
corticosteroids for chronic asthma, with fines or bonuses to follow.
Our practice had 55 cases judged out of compliance. I investigated
each case individually and demonstrated unequivocably that in 52 of
the 55 cases, their measurement did not reflect reality. The IPA
administrative staff rejected our findings on the basis of
gobbledegook. I appealed to the medical director, a physician in
practice who also worked for the IPA, and he rejected our claim on
the basis that the IPA program had good intentions. As an IPA
employee, he had been captured.
Hospital
forms require attesting that a three year old is a non-smoker. World
class British neurosurgeon Henry
Marsh recounts being illegitimately brought to heel in the
National Health Service by the administrators, who utilized a
physician-administrator whose major qualification was he ability to
agree with administration, and to admonish fellow-physicians in
behalf of administration. A young
American doctor recounts how he could only be properly diagnosed
and treated when he found a primary care practitioner who would buck
the organizations strictures to achieve “productivity.” These
everyday examples reflect a medical enterprise widely polluted by
administrative predominance, which forces doctors to stifle
themselves and soldier on with blinders to ensure their own survival.
The experience of many doctors resembles that of engineers with
O-ring problems, or with airplanes that they fear will crash.
The
Proposed Solution – The Professional Quality Board
As I
alluded to above, the mission of the PQB would be to be
the professional scientific
conscience, the
professional scientific safety valve, and
the
professional
scientific corrective conduit
for the organization. Sitting as a permanent body with
quasi-independence, they would routinely assess the direction and
decisions of the unit (chronic function,) and would be constantly
alert to internal tipoffs about specific situations (acute function.)
The PQB would look for signs of chronic organizational disorder
where professional standards are being compromised, and would be
available for intervention in acutely dysfunctional situations,
especially dangerous ones.
Communication
with members of the organization would be confidential. Access to
information would be guaranteed, although trade secrets would be
protected. The primary communication between the PQB and the unit
would be Chairman of the PQB to CEO and Chairman of the Board in
non-governmental companies, and Chairman to leader of the unit in
question in government. The PQB would have the option of
communication with higher officials or the legislature in the case of
government agencies, or regulatory agencies in the case of a company,
or in both cases, should internal communications fail, with the
media. The PQB would be the ultimate conscience of the organization.
The PQB
would be composed of senior, respected former members of the unit or
recognized experts in the field, all tightly bound to the declared
mission of the agency or company. Being named to the PQB would be
viewed as an honor and a responsibility. Their charge would be to
put the institutional mission first, and they would take a solemn
oath of professional idealism, similar to the still-revered
Hippocratic Oath. Profit of a company or advantage to the
governmental unit would explicitly not be their charge.
Funding
would come from the companies or governmental units themselves. To
cushion the threat of reduced funding which could be used as a
weapon, a specific governmental unit would be assigned to arbitrate
PQB funding disputes of both governmental and non-governmental units.
After the initial establishment of the PQB, further membership
additions and subtractions would be proposed by the PQB itself, with
the agency or company having a veto that could be overridden by a
preponderance of the PQB membership.
To some
extent, the PQB could be viewed as an institutionalization of
preemptive troubleshooting. The PQB would be a constant resource for
leadership course correction. For specific problems they would be
empowered to receive whistle blower complaints, and they could
themselves pursue specific issues with their investigatory power,
including the “L6 approach.” (Lewis, page 231) “L6” refers
to the fact that in bureaucracies, the person who knows the most
important details for specific problems is usually found in the
bowels of the bureaucracy, perhaps at the 6th level down
from leadership. The PQB thus would have some of the qualities of an
Inspector General, but with a specific scientific bent, and more of a
general mandate for policy and acute interventions.
Alternative
Solutions
The
difficulties of integrating professional expertise and values into
large organizations is a well-known problem. Various solutions have
been tried. One is to bring representatives of the expert community
into the management chain as engineer-administrators or
physician-administrators. These bi-skilled personnel can better
understand both intricacies of the problem being attacked and the
thinking process of their personnel. They might also bring the
values of the profession into practice better than
lay-administrators.
Bringing
professionals of the home discipline onto the board is similar. In
all these cases, it is assumed and reinforced that the professional's
primary loyalty is owed to the company and that everyone needs to be
rowing in the same direction. The goals of the company are to be
paramount; the ideals of the profession are more of a constraint than
a goal.
In some
agencies and companies the task of scientific legitimacy is solved
informally. The counsel of “elders,” most often retired and
respected former officials, may be sought. Thus, when the Chairman
of the Joint Chiefs and the current Secretary of Defense joined
President Trump clearing peaceful demonstrators on a march from the
White House through Lafayette Square to St. John's Church, they both
were moved to apologize after they had received substantial pushback
from retired generals and others. The
FDA has a respected advisory committee. Five
former FDA commissioners jointly suggested that President Biden
name a new FDA commissioner promptly. Former CDC director Tom
Frieden wrote an impassioned if fruitless letter to then-current CDC
director Robert Redford to reject the importunities of the Trump
Administration and stand up for science and the independence of the
CDC.
The
obvious scientific and procedural deficiencies and political
influence on the CDC and FDA in the COVID response has provoked a
flurry of suggested reforms to protect science, here in JAMA,
here again in JAMA
, and here in The
New England Journal of Medicine. All look for ways to insulate
science from politics, each considering making the CDC and possibly
the FDA independent on the model of the Federal Reserve. The
NEJM source suggests that: “legislators
could consider a broad reorganization of public health functions and
create a superagency, whose purview would include everything from the
approval of drugs and devices to the maintenance of national
stockpiles of protective equipment. ...These agencies share important
features, including protection of executives, multimember leadership,
established qualifications and confirmation processes for executives,
political balance, and budgetary stability.”
While
all these approaches have made their contributions, I suggest that
they are insufficient. Having personnel with mixed motives will
generally make the primary motive predominant. Older, revered
personnel might carry the scientific and medical ethics strongly, but
the informality of the connection makes quick intervention very
problematic, their information may be deficient, both of which
attenuate the strength of any intervention or influence, and both of
which make the intervention late, and only in major cases. Instead,
the proposed PQC would use the prestige and weathered viewpoint of
august personages, but would ensconce them in positions with some
power, albeit not line authority. The existence of a PQC would give
concerned people a place to go.
The
most recent proposals responding to the CDC shortfall would involve a
huge restructuring of health agencies, which would be attended by the
usual bureaucratic deficiencies, and which would be very difficult to
achieve, given congressional and executive investment in oversight
and turf. Enlarging the circle of responsible agencies and inviting
a diversity of interests to help stir the pot is more likely to lead
to confusion than a sharper focus. Independence of already-troubled
agencies is unlikely to promote reform. Instead, appending a PQB to
each agency and company would be much easier to implement and would
afford more specific expertise and accessibility for each problem as
it arose, and would provide a beneficial filter between concerned
outsiders and the agencies themselves.
Could
PQB Interventions Have Averted the Problems in our Examples?
Challenger.
The engineers who knew the O-rings could lead to disaster had
nowhere to go with their worries when they were dismissed by the
regular line of authority. If NASA had had a PQB, the engineers
could go there on an emergency basis and present their evidence. The
PQB would have an emergency protocol in place. If they found the
evidence convincing or concerning, they would place a call to the
NASA Administrator. If he were concerned enough, he would be able to
supersede the decision of the project manager and disaster would be
avoided. If not, other venues would be available.
In
addition, if NASA were becoming overly bureaucratic and chronically
making bad scientific decisions, a PQB would be a perfect vehicle to
report this belief to Congress, the Inspector General, or the
President.
737
Max. The engineers who were emailing each other, telling each
other that they wouldn’t risk their family being on a 737 Max
flight, could go to the Boeing PQB with their concerns. The PQB
could then call a meeting with the CEO and make a presentation to the
Boeing board. If they made no progress, they could demand a
presentation to shareholders, or they could go to Congress or the
FAA. As consummate professionals, they should have the ability to
make a top quality determination.
In
addition, Boeing is alleged
to have tilted strongly toward the business-orientation for profits
rather than the professional-orientation traditional at Boeing. The
PQB staff should be sensitive to this as they make their continuous
assessments looking specifically for this. Interviews and access to
internal documents should be revelatory. The PQB would take their
concerns to the CEO and the board, and they would be empowered to
present their findings to shareholders in their annual report to the
board that would be shared. Their governmental contractees would
then be informed and be able to act appropriately. The engineers
within the company would have no other formal way of working for that
rebalancing, and failure in the marketplace works too slowly, and too
dangerously.
CDC.
The long running problem with ventilators would be exquisitely
amenable to an PQB intervention. The COVID lab test issue happened
so quickly that it might not have been avoidable – bad decisions
under pressure are hard to avoid. But one can picture an alert PQB,
activated for the acute problem of an impending pandemic, playing a
very active role where the organization was clearly failing. A PQB
would have been a strong protection against the political pressures
of the Trump Administration, although it would have involved going to
Congress and the press, and it may not have worked.
The
chronic decline of the CDC is a different story. As detailed by
Lewis, like many once-proud organizations, the
CDC had migrated from an agency guided and populated by audacious
disease fighters, to scientists who were excellent in their quality,
but who looked more toward academic achievement in their writings and
support of other actors in giving data of what had already happened,
rather than an agency geared to active combat with the current
problems of people and death. The CDC had been bureaucratized and
encrusted in righteous isolation from battle. At the very least,
however, the tradition of the CDC could speak through the PQB and
wage a fight to be activist.
Actually,
given the history of the CDC and the history of the rise and fall of
the Bush pandemic alert efforts, it seems obvious that a major review
of our structures and objectives has to be pending.
Various
Medical Issues. A PQB would give medical professionals somewhere
to go to with their concerns. The PQB could go to the Board and CEO,
to higher governmental officials, to Congress. They could issue
periodic reports. Transparency rather than obscurity would give
professionals a chance to regain some traction in their concerns. As
health care institutions continue to consolidate, major changes are
needed at the highest governmental levels, and PQBs would be
excellent sources for innovation ideas and continuous monitoring, and
a prescient blogpost
has indicated.
In
running companies and government, nothing is assured. In the end,
one can arrange administration into many different configurations,
but in the end it is high character and skill that is telling.
Nonetheless, properly arranging units and explicitly seeking high
character and skill can increase the chances for justice to be done;
transparency likewise.
Counter-arguments
It is
worthwhile to consider possible objections to the PQB proposal. They
would be generally that one is not necessary, or that they would
probably fail.
Not
necessary
Some
might say that senior ex-officials already serve some of the PQB
goals informally. But such interventions are sporadic, disorganized,
and ad hoc. The possibility
that ex-leaders will intervene as a deus ex machina
solution to a dangerous situation or chronic displacement of goals
seems quite unreliable. Informal influence worked to get Esper and
Milley to recant their participation in the Assault on Lafayette
Square – ex post facto
– but it was ineffective
with Redfield at the CDC.
Others
say that having a professional voice all through the organization by
having the professionals in administrative positions should serve to
inform organizational actions with professional ethics.
Unfortunately, that is rarely true. Most often, the professionals
are seduced by the business mission of the organization and by the
lure of their own advancement from conforming to organizational
norms. They are told that their role is to bring along the
professionals and pacify them. In short, it is common experience
that professionals in administrative positions to be most often
representing the organization to the professionals rather than
vice-versa.
Some
might say that the market should be the proper disciplinary force for
a company. If we are dealing with television companies or computer
companies or toaster companies, yes, true. But if we are dealing
with large companies and institutions, or local monopolies like the
ones that hospitals often enjoy, then no, the market will be
inapplicable. Something else is necessary.
Some
might go further and say a PQB would unnecessarily burden and
distract a management team that needs support in its mission rather
than further encumbrances. After all, the natural tendency of
organizations is to become “blame organizations,” where the main
motivational incentive for personnel is to stay free of blame and
thus keep their jobs safe, while the best leaderships seek to make
their organizations into “achievement organizations,” where
failure in pursuit of aggressive goals is acceptable. A conservative
PQB could be a hindrance rather than a professional quality
corrective; the old guard can be anti-progress. The answer to this
objection lies in the selection of excellent and experienced
personnel for the PQB, but it has to be admitted, mistakes will be
made. The PQB would not be a universal cure-all.
Could
fail
While we
hope for the wise views of seasoned veterans with high ideals and
professional values, a PQB could easily find itself composed of
overzealous, oppositional, regressive types seeking to promote their
own pet projects, favoring personnel within the agency for personal
reasons, and pursuing narrow idiosyncratic objectives. The PQB might
be more trouble than it is worth, and seek to insinuate itself in
areas where it should be intrude, and thus become more of a pest than
a salutary corrective force. The PQB might become a haven for those
who were passed over and have grudges to pursue. It would not be
unusual for an administrative leader to be more invested in
professional excellence than ensconced professionals, as in a
hospital. The administrators could be the ones who know how to mount
successful operations to instigate change (here).
The PQB
might come to see its task not as upholding technical standards and
being sensitive to the concerns of technical staff, but as supporting
the company and reinforcing their business objectives. The
backgrounds of the members of the PQB might actually be more
pro-business than pro-professional standards.
The PQB
could be captured, just as industry captures regulatory agencies. A
difference here might be that regulatory agencies are often staffed
by personnel weaker than the leadership of the company. The PQB
leadership would be senior, and besides having the knowledge that
comes with long experience, it would have no further aspirations for
advancement or fears of losing a source of personal security.
Likewise,
the company or agency might actively oppose the findings and attitude
of the PQB, and be inured to its calls for change, and simply
sideline them. From the initial appointment through many other
points of vulnerability, the PQB can be disrespected and neutralized.
The PQB could be subject to bad-will by the leadership of the unit.
Having a PQB foisted upon an unreceptive agency or company leadership
could be a recipe for conflict and failure, and should not be tried.
In all
these instances, the key to the PQB effectiveness would be its
membership, how they are selected, how they view themselves, and how
active they are willing to be. Organizational structure can convey
possibilities, but it cannot ensure personal actions. Any PQB would
require the strictest attention to membership, and a common
understanding of the role of the PQB.
In the
end, perhaps the key point of leverage of the PQB would be
transparency. Internal struggles could become more visible.
Arguments could be widened to include more participants. Management
would be forced to make tougher choices with the knowledge that their
decisions could well be publicly reviewed. Even if the PQB members
missed the mark on occasion, public knowledge of points of contention
would be salutary. With transparency, if the administration were
virtuous and the PQB in error, the truth would out, and the PQB
reformed.
Conclusion
The
science-based technical large enterprise is a distinctly modern
creation. Their achievements have been immense; there is no escaping
their necessity in the future. Thus, we should look at their
failures and deficits with a mind to supporting them and enabling
them to do better.
It
is obvious that organizations change with time, although individual
paths of growth and decay will vary. A very common pattern, however,
is for the bureaucratic and administrative functions to overtake the
influence of the basic scientific mission of the entity. I submit
that a Profession Quality Board would be one solution to the problem.
The
objections are not without merit. But, in the right organization and
with the right people, the PQB could be just what the doctor ordered.
Budd
Shenkin
