The “A” Principle in Healthcare Delivery
The “A” Principle refers to a term for a common-sense collection of traditional American ideas about managing people and operations. It’s an idea that NAVAPD believes needs to be expanded at VA.
The “A” Principle has largely disappeared from the VA, and American healthcare in general. Reinforcing and developing and redeploying the “A” Principle belongs at the very top of priorities of the Veterans Affairs operational mission.
What is the “A” Principle and why should the VA fully embrace it?
The “A” Principle is not a business management concept. In fact, it is devoid of many of the bad concepts that dominate American healthcare management. The “A” Principle is a military doctrine that has an history of success. The “A” Principle, which is a shorthand descriptor of Auftragstaktic is a principle developed by the German Army to transform their infantry. Auftragstaktic is Mission specific tactics where the emphasis is placed on the outcome, and not on the specifics needed to achieve the outcome. This principle enabled independent thought and action by troops on the ground, while preventing ill-advised actions by the troops. Field Marshal Helmut von Moltke, Chief of the General Staff of the Prussian Army from 1857 to 1888, is considered the creator of operational-level command and control, and the father of this operational principle. He played a major role in the development and deployment of the Auftragstaktic principles.
For example, the Auftragstaktic Principle in military terms would be to “Stop the attacking forces” rather than “Squad A will march to ‘X’ location, then they will destroy ‘Y’ and this must be completed by ‘Z’ time.”
“The decision-making process can only be expedited decisively and sustainably if we accept the fog of war as a system-inherent facet, even in an environment of total information immersion. Only Auftragstaktic [principles] enables the meaningful exploitation of the most sophisticated technology, and only the Auftragstaktic Principle allows mastery of the increasingly complex challenges of the 21st century. Most important, it takes the encouragement of superiors and the courage of subordinates to make the principle work.”
How would the Auftragstaktic Principle apply to VA and to the delivery of healthcare?
VA already has the principle and structure in place but struggles to effectively apply it because of too much bureaucratic interference. Primary Care already has a Teams based approach. The Teams-based approach is an excellent example of the Auftragstaktic Principle which has the potential to succeed in improving care if it were only fully supported by leadership.
To accomplish Auftragstaktic Principle in healthcare, first, you must assemble a team and effectively train them. The main predictor of success of the team is leadership’s inherent ability to trust in the team’s medical and professional abilities to achieve the stated outcome. The rules of operation would need to change so that the administrators serve the tactical needs of the team in the field, rather than controlling every decision or action that is made. The administration elucidates the objectives and then steps back and allows the teams to use the strategies they consider necessary to achieve the stated objectives without undue interference from the leadership. This includes leadership at the facility, VISN and National levels.
With physician led teams, the physician does not bark out orders and all other members of the team must quietly obey. Any idea that is presented, regardless of who presented it, is inherently valuable. The value of the idea is not weighed based on the source of the idea. Decisions are attained based on what is in the best interest of the Veteran, and their overall healthcare. Every member of the team contributes valuable ideas to achieve the stated objectives for each veteran that they serve.
NAVAPD encourages VA to fully embraces the principle of Auftragstaktic. If it does, then it will have high performing teams and will easily achieve its HRO principles. Too often in VA there is top-down control over healthcare decisions that should be made by front line physicians and dentists. This leads to an environment that is stifling, feels overbearing and has at it’s core the micromanagement of VA healthcare to the point where clinicians do not feel empowered to make the decisions necessary to improve the health and wellbeing of their patients. This then leads to dissatisfaction and burnout, and ultimately the choice to leave VA to seek employment elsewhere.
NAVAPD believes that when the frontline physicians and dentists are truly empowered to make independent decisions regarding the best way to deliver that healthcare, without top- down micromanagement, then there will be better, more sustainable outcomes for the veterans we serve.