Workforce Issues in the Greater Boston Health Care Industry: Implications for Work and Family

Interviews with more than 40 leaders in the Boston area health care industry have identified a range of broadly-felt critical problems. This document synthesizes these problems and places them in the context of work and family issues implicit in the organization of health care workplaces. It concludes with questions about possible ways to address such issues. The defining circumstance for the health care industry nationally as well as regionally at present is an extraordinary reorganization, not yet fully negotiated, in the provision and financing of health care. Hoped-for controls on increased costs of medical care – specifically the widespread replacement of indemnity insurance by market-based managed care and business models of operation--have fallen far short of their promise. Pressures to limit expenditures have produced dispiriting conditions for the entire healthcare workforce, from technicians and aides to nurses and physicians. Under such strains, relations between managers and workers providing care are uneasy, ranging from determined efforts to maintain respectful cooperation to adversarial negotiation. Taken together, the interviews identify five key issues affecting a broad cross-section of occupational groups, albeit in different ways: Staffing shortages of various kinds throughout the health care workforce create problems for managers and workers and also for the quality of patient care. Long work hours and inflexible schedules place pressure on virtually every part of the healthcare workforce, including physicians. Degraded and unsupportive working conditions, often the result of workplace "deskilling" and "speed up," undercut previous modes of clinical practice. Lack of opportunities for training and advancement exacerbate workforce problems in an industry where occupational categories and terms of work are in a constant state of flux. Professional and employee voices are insufficiently heard in conditions of rapid institutional reorganization and consolidation. Interviewees describe multiple impacts of these issues--on the operation of health care workplaces, on the well being of the health care workforce, and on the quality of patient care. Also apparent in the interviews, but not clearly named and defined, is the impact of these issues on the ability of workers to attend well to the needs of their families--and the reciprocal impact of workers' family tensions on workplace performance. In other words, the same things that affect patient care also affect families, and vice versa. Some workers describe feeling both guilty about raising their own family issues when their patients' needs are at stake, and resentful about the exploitation of these feelings by administrators making workplace policy. The different institutions making up the health care system have responded to their most pressing issues with a variety of specific stratagems but few that address the complexities connecting relations between work and family. The MIT Workplace Center proposes a collaborative exploration of next steps to probe these complications and to identify possible locations within the health care system for workplace experimentation with outcomes benefiting all parties.

Inspection Methods in Programming

The work reported here lies in the area of overlap between artificial intelligence software engineering. As research in artificial intelligence, it is a step towards a model of problem solving in the domain of programming. In particular, this work focuses on the routine aspects of programming which involve the application of previous experience with similar programs. I call this programming by inspection. Programming is viewed here as a kind of engineering activity. Analysis and synthesis by inspection area prominent part of expert problem solving in many other engineering disciplines, such as electrical and mechanical engineering. The notion of inspections methods in programming developed in this work is motivated by similar notions in other areas of engineering. This work is also motivated by current practical concerns in the area of software engineering. The inadequacy of current programming technology is universally recognized. Part of the solution to this problem will be to increase the level of automation in programming. I believe that the next major step in the evolution of more automated programming will be interactive systems which provide a mixture of partially automated program analysis, synthesis and verification. One such system being developed at MIT, called the programmer's apprentice, is the immediate intended application of this work. This report concentrates on the knowledge are of the programmer's apprentice, which is the form of a taxonomy of commonly used algorithms and data structures. To the extent that a programmer is able to construct and manipulate programs in terms of the forms in such a taxonomy, he may relieve himself of many details and generally raise the conceptual level of his interaction with the system, as compared with present day programming environments. Also, since it is practical to expand a great deal of effort pre-analyzing the entries in a library, the difficulty of verifying the correctness of programs constructed this way is correspondingly reduced. The feasibility of this approach is demonstrated by the design of an initial library of common techniques for manipulating symbolic data. This document also reports on the further development of a formalism called the plan calculus for specifying computations in a programming language independent manner. This formalism combines both data and control abstraction in a uniform framework that has facilities for representing multiple points of view and side effects.