Vol 7 #2

Alan Eppel MB, FRCPC

In an era of specialization and subspecialization there is a risk of adopting too narrow a focus with the resulting loss of a wide-ranging perspective. This is as true in healthcare as it is in industry. Repeating conventional practices and uninspired solutions leads to the persistence of the same old problems. Innovation and improvement require looking beyond one particular discipline or domain of knowledge. We cannot rely on the mantra of “innovation” and “excellence” in our strategic plans and mission statements if we want to improve. To arrive at truly new and creative ideas means not just looking outside the box but outside the “building” as well!. Cross disciplinary idea exchange and cross fertilization can lead to quantum changes and paradigm shifts.

At first glance it may seem strange that the United States Marine Corps would have anything to teach healthcare administrators and providers but David Freedman, in his book Corps Business, has shown the translational potential of selective of Marine Corps principles (1).Freedman highlights a number of primary competencies embraced by the Marine Corps including:

  • Impact
  • Speed
  • Versatility
  • Proficiency with complex situations.

Freedman describes complexity as arising from a multiplicity of tasks simultaneously, a lack of information, novelty, situational ambiguity, and rapidly changing conditions.

Effectiveness is postulated as requiring (1):

  • Focus on the small team. The size and makeup of teams should be changed according to the needs of each specific mission
  • Hire by trial by fire
  • Use extreme training. Training should prepare for the situations faced on the job
  • Manage by end state. Tell people what needs to be accomplished and leave the details to them
  • Ceaselessly educate and train at all levels of the organization
  • Recognize the lower levels of the organization. Deflect credit downwards
  • Demand to be questioned
  • Establish a core identity
  • Experiment with new approaches
  • Standardize practices but continually refine and change the practices as needed
  • Build new tactics around new technology but don’t depend on technology. Try to be effective regardless of which technologies are available
  • Get an outside perspective
  • Hiring and training should be undertaken by the most talented managers.


Other principles for provision of healthcare in the field are identified in the Joint Chiefs Report (2)

  • Provide health services as close to combat operations as the tactical situation permits
  • Shift resources to meet changing requirements
  • Provide optimum, uninterrupted care and treatment to the wounded, injured, and sick
  • Ensure that resources in short supply are efficiently employed and used effectively

These tenets can be applied to the civilian context. In the quality improvement paradigm the following are considered as key ingredients for high performance in healthcare.


  • Acceptability/responsiveness: services meet the needs and expectations of patients, family, community, providers and payers
  • Accessibility/timeliness: people can obtain service at the right place and right time
  • Appropriateness: services are relevant to people’s needs and based on accepted standards/evidence
  • Competence/capable: provider knowledge and skills are appropriate to deliver required services
  • Continuity: services are uninterrupted and coordinated across programs, providers, and levels of care, and over time
  • Effectiveness: services achieve desired outcomes

Accessibility is an essential domain of quality care. This includes timeliness of service. There should be minimal waiting time from identification of problems to access to the appropriate service. Speed of response as in the Marine Corps is a critical value.

One maxim to describe quality of care is “the right intervention in the right place, at the right time, and in the right manner” (3).

The original Quality Assurance (QA) paradigm as put forth by Donabedian is based on the parameters of structure, process and outcome (4). He placed a strong emphasis on structure which included both clinical competence and performance.

In the late 1980s there was a major switch from the QA  paradigm to that of Continuous Quality Improvement (CQI). CQI emphasizes that most of the difficulties in a system are caused by processes rather than people. Roughly 80% of hospital or other clinical service inefficiencies and poor outcomes are attributed to failures or inadequacies of the processes of care. There has been less emphasis on identifying “bad apples” and more on the pathways of intervention and healthcare delivery. However, unlike the Marines,  this has led to an underemphasis of recruitment and ongoing training:

The Marines’ intense attention to the hiring process (“trial by fire”)  and “extreme” training should be priorities for all health services. Recruitment and selection are the bedrock for high performing organizations. This is important for staff and faculty appointments and critically for determining who should be admitted to training programs.

In many training and residency programs the assessment of suitability has some blind spots. While academic performance, interpersonal skills, knowledge, and ability to relate in teams can be assessed, it is much more difficult to uncover high stakes flaws such as lack of empathy, lack of ethics and proclivities to break the rules.

In fact in the current training of physicians there is a strong emphasis on empathy. Unfortunately it is possible to learn how to simulate empathy which, regrettably, may parallel the advice given to  new actors in Hollywood- “ sincerity is the most important thing in our business. If you can fake that you’ve got it made!”

Like the marines we need to “hire by fire” and use “extreme training”. We need to have the most qualified personnel lead the recruitment process and training programs. Healthcare systems will no longer tolerate anything less.






       1. David Freedman. Corps Business: The 30 Management Principles Of The US Marines.                 Harper Business 2000

  1. Doctrine for Health Services Support in Joint Operations. Joint Pub 4-02. April 26, 1995 and December 11, 2017. https://www.bits.de/NRANEU/others/jp-doctrine/jp4_02(95).pdf. Accessed 5 Feb, 2020.
  2. Eppel A. Achieving Quality of Care. Canadian Medical Association Journal 1992; 147(9): 1305-1306                                                                                                                                    
  3. Donabedian, A. Evaluating the Quality of Medical Care. The Milbank Quarterly. 2005; 83(4):691-729
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