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In constructing a house, that role is played by

diagnosed at the age of 88 with esophageal

a general contractor.

cancer. A month later, he fell and broke his

For complex patients, there should be one

hip, and then found himself in eight differ-

person who is aware of all aspects of the

ent hospital units over the course of three

patient's needs and who acts as a project man-

weeks. As he was moved from floor to floor,

ager. Except in cases of dire emergency, the

each unit seemed to pick up on a problem

first person a complex patient sees upon diag-

that the previous unit had missed--or per-

nosis should be the project manager, who

haps had caused. His greatest suffering was

would formulate a plan to get the patient well.

caused by infected bed sores that developed

The project manager would anticipate prob-

while he was in the hospital. He remained

lems and balance risks, adjusting the plan as

under hospital care for two more months,

needed.

until he died.

It should be a project manager's job to

Professor Kling likely received hundreds

anticipate risks such as bed sores, which

of thousands of dollars in health care ser-

afflicted Arnold's father. Under the existing

vices, almost all paid for by Medicare or addi-

approach, no one took responsibility for antic-

tional insurance. During his father's illness,

ipating or dealing with that risk until it was

Arnold observed firsthand the lack of conti-

Medical

too late.

nuity and coordination of care, which squan-

care lacks

The project manager should be responsible

dered the sincere efforts of many individual

for ensuring adequate communication among

doctors and nurses.

coordination,

all parties. That means ensuring that everyone

Complex patients require more than inde-

in part because

involved in the patient's care, including the

pendent craftsmen. An independent crafts-

Medicare has not

patient, is involved in making the plan and is

man can fix your sidewalk, but he cannot

kept informed of changes and other issues

build a highway interchange. An indepen-

kept pace with

that require attention. The project manager

dent craftsman can create a website for your

technology and

should coordinate the work of medical spe-

soccer team, but he cannot build a computer

patients'

cialists by bringing them together, if necessary,

system to support the operations of a finan-

in order to go over the trade-offs and resolve

cial services firm.

changing needs.

issues.

A homebuyer typically does not oversee

Organizational Competence

the day-to-day construction work. Instead,

buyers may be involved in the initial plan-

ning process, and they may be consulted as

To serve the needs of complex patients,

different problems present themselves along

medical care delivery needs to include more

the way. Likewise, medical care today is too

than just the skills of doctors and nurses.

Complex patients require coordination, plan-

sophisticated for complex patients to be their

ning, better communication, more attention to

own project managers--though they should

process, and accountability. The importance of

remain the project manager's boss.

The project manager may or may not be

planning, communication, accountability,

and so forth suggests a need for organization-

an M.D., but doctors would have to treat this

al competence in addition to pure technical

person as the boss--just as in home building,

where an electrician acknowledges that the

skills.

general contractor is the boss.

A Project Manager

Medical care typically lacks coordination,

in part because payment systems such as

Treating a complex patient is comparable

to building a house. The work of a number of

Medicare have not kept pace with technology

skilled craftsmen needs to be planned and

and patients' changing needs, and because

managed. When unexpected problems occur,

many doctors are unwilling to cede authority

someone needs to revise and adapt the plan.

to a boss. Medicare and other payers continue

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