The Tragedy of the Commons
In an influential 1968 article, Garrett Hardin argued that resources held in common could not be maintained, because each individual, pursuing his own best economic interest, would inevitably exploit the common resource for his own use to the detriment of others. In his view, the only answer was government regulation. While he was talking about resources such as air and water, the implications for us are fairly obvious—physicians use a common resource (the hospital) which is certainly subject to more government regulation than was the case in 1968.
Psychologists and others who have studied this issue have found that there are instances where resources shared in common can be maintained over the long-term and have defined four different strategies used to constrain selfish over-utilization. These four strategies are: information, identity, institutions, and incentives.
I suggest that caring for patient should be our foremost purpose. But what does this mean? The Institute of Medicine has defined the characteristics of a high quality health care system as one that provides care that is safe, timely, effective, efficient, equitable, and patient centered, also known as “STEEEP”. Do you think your patients receive care that has all six of these characteristics? I think we have made a small start, but there is much work yet to be done. Fortunately, we do not have to start from scratch. We have a number of resources, including legal standards, joint commission standards and recommendations, and professional society best practices, all of which are roadmaps outlining methods that have been proven to improve quality of care in one or more of these dimensions. What is lacking, then, is not information on what to do, but a willingness to make changes to get it done.
As we progress down this path toward excellence I want to challenge each of us to examine our practice “habits” to see if they comport with the principles of STEEEP, and resist our natural tendency to stick with “the old ways” when it is clear that changes are needed. Furthermore, I want to ask each of you to work with the medical staff leadership team and the hospital management team to help define “how we do things here” with the goal of making care here as good as anywhere, and getting better over time. I believe doing so is imperative for survival of our patients and for our practices.
1. Hardin, Garrett. The Tragedy of the Commons. http://www.garretthardinsociety.org/articles/art_tragedy_of_the_commons.html.
2. Van Vugt, Mark. Averting the Tragedy of the Commons. http://www.psychologicalscience.org/journals/cd18_3_inpress/vanvugt.pdf.
3. Grohol, John M. The Tragedy of the Commons. http://psychcentral.com/blog/archives/2009/07/29/the-tragedy-of-the-commons/
Written 9 February 2010, revised 1 May 2014.
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