Different doesn’t mean right or wrong. Best practices are sometimes best, and sometimes they’re just a mediocre consensus that a small group agrees to.
Institutions are so often large and stupid because herds of humans are difficult to manage at scale, and the lessons learned by individuals often don’t become institutionalized without significant baggage in the form of procedural debt. So many individual actions and the proliferation of useless bureaucracy can be ascribed to the pursuit of plausible deniability. The fewer things that can be pinned on us, the safer our jobs. No one is fired for being rational, even if the outcome is suboptimal.
It’s not the goals but rather the incentives created by those goals that shape outcomes. It’s the BS that sounds good and reasonable in isolation versus what works in practice. The most important tactic for achieving any strategy is removing the friction, roadblocks, and unintended negative consequences of doing the actual desired behavior.
There is no broadly acceptable present value function to gauge political acts the way we can estimate the effects of economic decisions in terms of monetary value. The time horizon of politics, social media, and fame are all much shorter than the downstream consequences of most decisions, which incentivizes leaders of all stripes to do stupid shit that looks good now—even if it is, on the whole, harmful.
This is a problem because we often conflate “rational” behavior with optimization of easily measurable outcomes.
The creation of red tape is understandable, but the incremental costs are almost never considered and are challenging to undo, as every policy is obviously there for a reason—even if, on balance, that reason does not justify the cost. Nothing is easier than thinking of more things we can do to make something better or safer. What is harder is asking the tough question: at what cost? What are we willing to forgo in order to achieve this addition? Intentions matter, but the consequences matter more.
Bigger often means more inbound data and more layers of management to deal with it. Size isn’t always good, and growth shouldn’t always be the goal. Yes, size can help you fight a bully, and it can also help you be a bully. And there are efficiencies of scale when it comes to both high fixed costs as well as volume-based discounts on costs like IT. But we would be foolish to only look at those measurable costs and lose sight of the downsides: increasing bureaucracy, weak culture, lack of accountability, and a diluted mission.
Step into a large hospital and tell me if you think everybody feels like they’re on the same team. The fragmented care in your average mega-hospital is so often removed from a well-oiled machine. These organizations are essentially too large to have a mission or a really strong, behavior-shaping positive culture. Decision makers and rank-and-file are often separated by helplessness-inducing layers of human flotsam.
The mission of a large healthcare organization is not actully patient care. Healthcare is the industry, and patients are the vehicle for the business model. They are the sine qua non of healthcare profit. But the proliferation of bureaucrats and policies because of the need to “manage people” tells us that it’s not working.
If people were really working together, we wouldn’t need so much bloat.