1. Issel, L. Michele PhD, RN

Article Content

A recent personal encounter, albeit very minor, with the health care system opened my eyes to a deep paradox in the delivery of health care services. I call this paradox the Iron Triangle. Let me explain each side of the triangle, why it seems to be more iron than willow branch, and its relevance to health care management research.

FIGURE. No caption a... - Click to enlarge in new windowFIGURE. No caption available

Practice guidelines form one side of the Iron Triangle. Practice guidelines are intended to streamline and standardize processes of care and thereby assure quality of care. In theory, the guideline ought to conform to current knowledge from research findings about best practices to achieve optimal health outcomes. From a process management perspective, guidelines also ought to decrease the burden of decision-making experienced by health professionals, leading to greater efficiencies and higher quality. Many trends and external forces have contributed to the emphasis on using practice guidelines. To the extent that guidelines eliminate or minimize clinical decision-making, they have two adverse effects: deprofessionalizing health professionals and depersonalizing the patient. The expected use of practice guidelines is now entrenched and pervasive, contributing to its ironness. Health care management research has focused on barriers and facilitators to implementing practice guidelines, to the exclusion of studying adverse effects of using practice guidelines.


A second side of the Iron Triangle is professional expertise. Expertise, that deep, almost intuitive understanding, comes with experience mixed with great knowledge. The professional health care provider gains expertise though observation and identification of patterns across situations and time. Most health professionals start their careers expecting to become an expert and thus a "good practitioner." Expertise also contributes to practitioner satisfaction with work and career choices and remains a fundamental safeguard against inappropriate application of practice guidelines. Considerable research in health care management has focused on the relationship of job satisfaction, retention, and burnout of various health professionals. Far less has addressed the value added of expertise, beyond its contribution to market share and what happens when expertise and practice guidelines conflict.


Patient centeredness constitutes the third side of the Iron Triangle. Conceptually, patient centeredness requires that the patient be engaged in the care decisions and that the uniqueness of the person be considered in clinical decisions. As precision medicine advances in its applications, the notion that each patient needs a tailored treatment or service is likely to become more pervasive. These applications of individualized care are fundamentally at odds with the premise of standardization underlying guidelines. The relationship between patient centeredness and professional expertise is complex and interactive, locking those triangle sides together. As with the practice guidelines, most of the patient-centered research focuses on implementation management. The Iron Triangle tensions between patient centeredness, guidelines, and limits of expertise have yet to be explored and understood.


Managing health care organizations and particularly clinical services includes negotiating and balancing policies and persons to create the Iron Triangle that benefit the organization, employees, and patients. Exploring the paradoxes reflected in the Iron Triangle holds promise for advancing the discipline of health care management through theory development (Poole & Van De Ven, 1989).


L. Michele Issel, PhD, RN






Poole M. S., &; Van de Ven A. ( 1989). Using paradox to build management and organization theories. Academy of Management Journal, 14, 562-578. [Context Link]