Tuesday, August 21, 2012

The Professional Mandate Pt2: Continuous Improvement, No Regession

Previously, I've defined the central aspect of the Professional Mandate as:
Its "unprofessional" to repeat, or allow, Known Faults, Failures and Errors.
Which is the Deming/Shewart Quality Improvement Cycle: PDCA (Plan-Do-Review-Improve System, also Plan-Do-Change-Act).

All Quality, Safety and Performance Improvement programs share must contain these 4 elements and have a central element in common:
Conscious, deliberate learning and adaption.
Improvement is not accidental: If you don't design it in, why would you expect it to show up?

There is another, personal, factor underlying Quality and Professional Improvement:
Caring comes first.
Which is not quite a restatement of "Professionals owe a Fiduciary Duty to their Clients". Caring is an unforced, voluntary internal state, Duty is an an imposed external obligation. Good Professionals not only have to perform well, they want to.

More specifically, Professionals must both Care about the Client Outcomes they produce and how well they do job they do. Good Professionals aim, every day for every task, to produce their best performance and provide Perfect Client Outcomes.

Perfect Client Outcomes are NOT "Perfectionism" nor unrealistic and unachievable. It's not about a Perfect Performance, execution without flaw, impossible by definition for Real People ("To Err is Human") but about the Client Outcome:

  • Perfect for the Client may be getting any help whatsoever.
  • Perfect for the Client may be getting "Good Enough" service in a timely manner.
  • Perfect for the Client may be resolving an issue within a time-frame.
  • Some some Clients, Perfect is As Cheap as Possible or Really Close and Accessible,
  • whilst the PT Barnum rules also applies: You can please some of the People some of the time, but not all of the People, all of the time.
    • For some Clients, no outcome will ever be deemed by them to be Perfect.
The execution of a Professional Service may contain Errors, in fact you'd expect (small) Errors every time, but the System and Process creating the Client Outcome need to be tailored to noticing them before they can affect the Outcome and in preventing consequential effects.

It's OK to make an error, so long as its corrected before it has an impact or creates damage. Trying too hard to Be Perfect degrades the Performance and Execution - we are not machines... This is the "secret sauce" known by Elite Sports Coaches:
Perfect is the enemy of Great, Perfectionism doesn't lead to Best.
Expanding notions introduced in Part 1:

  • Professionals must refuse directions and work demands that result in unsafe Practice, endangering clients or the public.
  • Doing The Right Thing must never penalised.
  • There are two sides to improvement: 
    • What not to do,
    • What to do.

Extending the rubric to include "and practice What Works (ie. proven)".

But there are two sides to this:

  • Adopting new Practices when proven superior,
  • Extinguishing old Practices when shown inferior.
There are research papers that conclude that for some "high standard" Professions:
  • It takes 15 years for proven new Practices to be adopted by even 50% of Practitioners, and
  • and 40+ years for old, inferior or disproven Practices to be phased out. Universally? not sure.
This work dovetails with the 1961 book, Science Since Babylon by Derek De Solla Price where he estimates the doubling period of Human Knowledge as shown by Journals and publications at 15 years and ties it in to the working lifetime of Scientists to arrive at his famous observation:
80-90% of all Scientists who have ever lived are alive today
The same 3 doubling periods of the average worklife also explains the time to give up old, inferior practices.

more to follow.

Monday, August 20, 2012

Professions/Professionals: Conflicts of Interest

Consistent Altruism is a rare human commodity, probably impossible over a life-time, yet that's the standard implied by: Learned Professions owe a Fiduciary Trust to their clients.
That's All Clients, All the time.

It's simply stated and tested: Are Client Interests always placed before the Practitioner and Organisations? Yet its impossible without sustained, conscious, deliberate and co-ordinated effort by the whole Profession.

As a client or user of Professions, that's a reasonable standard for them to be held to.
As a Practitioner, Professional Organisation or Profession, it's a profound and never-ending challenge.

The overwhelming human behaviour is self-interest: often expressing as greed or avarice, but also in other "temptations", including sex, power and influence.
People may start with good intents, even living up to their ideals for a long time, but as Hollywood amply demonstrates, the road to hell is paved with good intentions.

Most people exhibit Altruism some of the time and often only towards related groups. How can that be leveraged to impeccable Professional Standards? It's not just a hard problem, but a diabolical one.

It's impossible for ordinary people to keep others interests before your own for an entire career, in the face of all direct temptations and, more importantly, preventing gradual, imperceptible declines especially in the face of "but everyone is doing it".

This is exactly what got the USA from a well regulated banking system in 1999 following the repeal of the 1933 Glass–Steagall Act, to a record financial collapse in well under 10 years.

All Professions have to address this central issue: How to monitor and deal with Conflicts of Interests.

The Iron-Cald Law of Quality applies: You cannot check your own work.

Which means ever Profession that needs to meet a Fiduciary Duty has to design, implement, staff and fund third party checking, investigation and monitoring systems (i.e. Governance and Audit), create Licensing, Compliance and Regulatory Bodies with real teeth and constantly train and check its Practitioners and Professional Organisations against those standards of Knowledge, Performance and Practice.

I'd argue that this Governance and Compliance function is more important for "Fiduciary Duty" Professions than Competency Testing and Licensing:
Without an absolute trust of Clients for the Profession's Services, it is fatally compromised and incapable of delivering good, let alone Adequate or Best Practice Services. If the Public won't come to you and don't trust you, it undermines your Mission/Purpose, devalues the Profession and pushes the Public to find substitutes.
In "mid standard" Professions two factors operate that limit the excesses increasingly found in Professions such as Banking, Finance, Financial Advice and Financial Audit which led to the record collapses of 2007/2008 requiring Public Bailouts:
  • By definition, only "high standard" Professions owe a Fiduciary Duty to their clients, the rest only owe "normal commercial and contractual responsibilities.
    • Consumer Protection bodies and legislation (ACCC and TPA/ACC in Australia) offer common law remedies (protections) to consumers against unscrupulous practitioners and organisations.
    • The Consumer Protection bodies actively monitor the business world (practitioners and organisations) for illegal or 'sharp' behaviour.
    • Cartels and price-fixing is illegal and is aggressively pursued by the ACCC.
  • There is seldom, in "mid standard" Professions, a Natural Monopoly of Practitioners, Professional Organisations or Professional groupings/Associations.
    • There are commonly large numbers of "best quality" practitioners and organisations for consumers to choose between:
      • The operation of a large Free Market prevents prices ratcheting up faster than inflation.
      • Market forces (Supply and Demand) act to regulate the number of Practitioners and Organisations offering the Service, including per location.
      • Sometimes there can be a "race to the bottom" caused by new entrants (e.g. Chinese Dental Laboratories) that undermine demand even for high-quality local practitioners.
    • Consumers often can find adequate Service Substitutes, either direct or within the Profession.
    • When the Service is only offered by a sole supplier, often the Public Service or a single Government Licensee, a Natural Monopoly and market competition cannot keep Service, Quality, Safety and Price in check.
      • Often in these situations, Audit and Governance ("Industry Watchdogs") organisations are formed in an attempt to restrain outrageous excesses.
So what's needed of Practitioners, Professional Organisations and Profession Groupings/Associations in "high standard" Professions?

The New Oxford Dictionary defines "Fiduciary" as:
involving trust, esp. with regard to the relationship between a trustee.
I use a more colloquial formulation:
Put the clients interests ahead of your own, every time, and in every way.
In Law, Business and Accounting, this problem is known as Agency Theory: How do you get an 'Agent', such as an employee, trustee or representative, to always put your Best Interests first, even to the detriment of theirs, either directly or through "Opportunity Loss" a.k.a. Insider Trading?

"High standard" Professions suffer multiple problems:
  • They are Natural Monopolies without good substitutes (think Law, Medicine and Public Service).
    • Where can the Public go if they don't like the Professions' Services? Nowhere...
    • The rich always have more options like privileged access to other countries and systems, which creates its own special Conflicts of Interest in both countries.
  • If they don't internally regulate, who can or will regulate them?
    • Nobody else can properly assess their performance, errors, omissions and over-servicing.
  • Because they are Natural Monopolies:
    • The Monopoly is usually explicitly granted by the State.
      • meaning there are Registration Boards and Licensing Examinations.
    • They are highly desirable as a choice of Work: well paid, "protected" jobs for life,
    • Numbers are tightly controlled,
    • There is intense competition for admission, often on criteria irrelevant to good Professional Practice, such as Academic prowess.
    • There is usually little effort in identifying desirable High Performer Professional characteristics and less effort or attention in selecting or evaluating against those criteria.
    • All emphasis is placed on The Barrier to Entry, gaining a License, close to none is spent on ensuring All Licences are of Equal Value (a 1910 notion of Flexner's), which implies frequent full competency checking, against all current Knowledge and Best Practices, to retain a license.
  • The traditional Learned Professions are backed by an extensive heritage of Common Law and Statues that create especial problems:
    • They usually embody, explicitly or tacitly, a No Harm or No Fault clause:
      • Medical Doctors, even unqualified frauds, are generally regarded as not ever having criminal intent to harm patients.
      • This unfolded in Australia with the "Dr Death" of Bundaberg case. Whilst strict Academic-quality Evidence indicted him with causing many deaths and huge numbers of injuries, the legal system requires direct causal Evidence, reducing the criminal charges to "harming" a very few patients and a 5- or 7-year sentence. For any "mid standard" professional acting this way, they would've been found guilty of multiple counts of murder and received a probable life sentence.
      • The 2011 sentencing of the "Butcher of Bega" underlines the on-going nature of this problem and jurisdictional inconsistencies.
  • If the Profession in a country systemically fails to regulate itself against Conflicts of Interest, particularly Financial, then you end up with the US Healthcare system:
    • 18% of GDP is spent on US Healthcare, versus 9% of GDP in Australia.
      • In 1960, the US spent 5% of ts GDP on Healthcare, almost a quarter current levels.
      • But Australians have universal Medical care access, out-live and have better health outcomes that US citizens, except for "Rescue Care", where the USA beats everyone.
    • Arnold Relman and Marcia Angell, editors from 1977-2000 of the New England Journal of Medicine, have run a very long campaign against Medical Profession "Conflicts of Interest", starting in 1980 with Relman's, "The New Medical Industrial Complex".
      • Despite unequivocal data and many high-powered, highly influential internal voices/activists, the US steadily increases the proportion of its whole economy spent on Healthcare and the proportion of uninsured people who are uninsured continues to climb.
      • Perhaps in-line with the increasing disparity between the Rich (top 1%) and the bottom 30-50%.
My observations on "high standard" Professions achieving near a uniform, on-going delivery of Fiduciary Duty to Clients are:

  • It's a war without end, every new generation has to discover their own solutions to the constantly evolving challenges. The Internet Changes Everything, including how Professions now experience Conflicts of Interest and the methods to address them.
  • Perfection in managing Conflicts of Interest, like Quality, Security and Safety, is a journey, not a destination.
    • If a Profession's Monitoring and Reporting systems are detecting nothing, they have failed.
    • Human Nature hasn't changed in the 400 years since Shakespeare, it's not changing soon.
    • The US "Medical Industrial Complex" that Relman and Angell have spoken against for 30 years versus the inexorable rise in Healthcare costs is definitive proof that without strong external intervention (from Politicians, pushed by the general public) a whole Profession can be wilfully blind to serious Conflicts of Interest.
      • Without specific Agencies with real teeth, nothing changes.
      • Simple, unequivocal definitions and tests are needed for the Qualitative Tests.
      • Absolute and rarely changed quantitative measures are needed to convert Qualitative goals to measurable, reliable data.
  • The NTSB/FAA example of separate, well-funded Investigation and Compliance, Licensing and Testing organisation staffed by selected dual-experts: they have to be both amongst the most Competent and Knowledgeable Practitioners and expert in Governance, Quality and Safety.
    • These organisations and their staff also take care to constantly monitor, test and train themselves, with periodic "refreshes", or systemic re-examination and redesign.
  • Initial Practitioner Selection and Testing and then through on-going Training, Testing and ReCertification regimes are necessary to even start to achieve high, uniform standards of "Fiduciary Duty" amongst Practitioners and Professional Organisations, along with Competency, Knowledge and Practices.
    • Initial Practitioner Selecting and Training needs to be targeted at selecting for High Performance Practitioner Traits and Characteristics.
    • Which implies they must be first researched, documented then kept current.
    • And explicitly not to default to mere Academic Prowess as the sole entrance test.
  • Fully public, Open and Transparent reporting of all Professional issues, Conflict of Interest and Practice of Individuals and Organisations is a minimum requirement.
    • Without full data, the Profession internally cannot know "how it is travelling" and be able to take corrective actions as necessary.
    • Without full public access, nepotism, cronyism and lax standards are inevitable and unavoidable. "We discipline our own, in private" is the hallmark of a Failed Profession.
      • It also invariably leads to a pernicious and pervasive Inversion of Loyalty and Duty: Professionals swap their perceived Duty to Clients to a Duty to Protect the Profession at the expense of the Public they serve.
      • This attitude of "We look after our own" is an absolute corruption of a Profession.  
    • Professions with strong Duty and Safety Cultures and full disclosure don't need expensive and embarrassing Royal Commissions or Courts of Inquiry: they are doing the job of ensuring Good, Competent Practice and reinforcing the Culture each and every day.
  • Structural elements have to be in place to prevent putting people in the way of temptation or compromise:
    • Laws and Regulations allocating Blame and Liability to individual Practitioners for Ordinary Accidents and Failures must be replaced with Indemnifying Individuals within Organisations, provided they have acted properly and followed all relevant processes and procedures.
      • Practitioners who exhibit unprofessional behaviours, should be stripped of all Professional protections and indemnities and be subject to stiffer Criminal charges and Penalties than the general public.
      • Failing in your Professional and Fiduciary Duty is not an extenuating circumstance, it calls for harsher treatment. Those taking more Responsibility must be held to higher standards.
      • Any Practitioner who self-reports Errors early on should be indemnified from censure for that event, though not for unprofessional action, such as repeating Known Errors, Faults and Failures.
      • Any Practitioner who fails to self-report or report anothers' Error should be metered out harsh penalties. The Professional Mandate requires everyone involved to "own up" to their mistakes - and to make sure everyone else does as well. "No Error goes unreported, ever."
    • Professional Organisations, and their managers, must be Criminally and Civilly liable for malpractice and failures in their Fiduciary Duties.
      • In order to Indemnify individuals within Organisations who act properly and professionally, legal liability and Onus of Responsibility have to transfer somewhere.
      • There also have to be powerful incentives for non-Practitioner Managers and Administrators to uphold the Professions' Fiduciary Duties, Competence, Knowledge and Practice standards and adherence to Quality and Performance Improvement.

Saturday, August 11, 2012

The Professional Mandate: Don't repeat Known Mistakes, yours or anyone else's.

My formulation of the Professional mandate:
It's "unprofessional" to repeat or allow, Known Faults, Failures and Errors.
That sounds complete, perhaps obvious, but let me unpack this some more...

What's "unprofessional"?

If you're a cleaner, mower mechanic or dish-washer, i.e. not someone held to the highest Professional standards, then it's probably "skiving off" or doing a dodgy or substandard job. It might get you reprimanded if detected and if its your normal mode of work, in most places it'll get you fired. But only if detected, and that's only going to happen in better run organisations that routinely check work.

If you're someone who holds other people's lives in their hands, especially in a Profession that owes a profound Duty of Care to them, like Aviation and Medicine, then you should be held to a much higher standard.

These are the usual types of "unprofessional" behaviour and generally not considered "criminal":
  • malfeasance: deliberate/wilful wrong doing/actions (in the discharge of public obligations)
  • misfeasance: wrong action (esp in the discharge of public obligations)
  • nonfeasance: didn't do what needed to be done (esp in the discharge of public obligations).
  • negligence: didn't pay enough attention or care to the execution of the task, inexpert or incomplete action.
  • incompetence: can't do the job, use the tools or know the process properly or incorrect action(s).
  • indolence: lazy, idle, a "failure to perform".
But we know there are more types of "unprofessional" behaviour:
  • failing to act in a timely manner, i.e. tardiness,
  • "wrong inaction" when action was necessary,
  • rushing to act without sufficient information, or on an incorrect and unquestioned judgement,
  • acting when "inaction" or waiting was necessary,
  • deliberate harm through acts committed or withheld,
  • systematic harm to cohorts of people through deliberate, "wilful blindness" of not reviewing previous outcomes or not implementing known "Best Practice" or continuing with known "Bad Practices".
  • deliberate and systematic "gouging" - resolving "Conflicts of Interest" in favour of monetary outcomes for the Practitioner, against the interests of clients or the public.
  • over servicing, over charging and deliberate price gouging (selecting high priced alternatives over technically equivalent or superior lower priced ones).
  • ignoring or failing to deliver adequate service to individuals and large cohorts of the public for whom they should be responsible.
  • acting whilst intoxicated or drug-affected.
  • deliberately under-performing, not giving or doing your best in all circumstances, including "phoning it in" or "just going through the motions".
Which leads to two questions:
  • In this, the Internet Age, can a Profession even call itself a "Profession" if it doesn't detect all deliberate or unintended errors of commission or omission and impose Professional Penalties on organisations and managers responsible for allowing preventable harm, injury or death to those for whom they were responsible, as they unequivocally fail the "Professional mandate"?
    • Individuals who've are appropriately trained and with current certification, correctly follow organisational guidelines, checklists and processes and attempt to deliver their best Professional performances, or at least self-report Errors, Faults and Failures or omissions, should be protected from legal liability. Professionals need to be explicitly protected from being made "the fall guy" for Organisational or System Errors or managerial malpractice. Doing your job well, to the best of your ability/competence, should never be cause for censure or penalty.
    • Organisations have a Duty of Care to the General Public, Community and the State to ensure the Professionals under their direction are properly selected, adequately trained, including on-going testing/training cycles, are properly informed of the latest/current Organisation Standards, Processes and Procedures and all Professional Performance properly and adequately checked and corrected and if necessary, individuals reassigned, stood aside or removed.
    • If you are a Private Professional Practitioner, you undertake to competently and adequately provide, and perform to, both the Organisational and Individual Professional Standards, being personally liable at both levels. In most current fields, with Knowledge and Skills/Processes/Tools/Equipment doubling every 3-5 years, not within the Professional working lifetime as it once was, this is now beyond even the most competent and able Professionals.
      • I believe Registration and Certification Boards should be acting to prevent Sole Professional Practitioners from getting in over their heads in this way. 
  • What should now constitute Criminal Action or Criminal Negligence by Professionals and their managers/organisations when they deliberately, or with "wilful blindness" or disregard, continue with, or allow harmful Professional behaviour?
    • In Corporations Law, individuals and boards are deemed liable "if they knew or should have know". Ignorance is not a defence, in fact, failing to be informed is in itself an offence.
      • Is there any reason Professionals directly responsible for Human Life should be held to a lesser standard than Corporate managers and boards?
    • What should constitute Evidence of such Criminal Action or Negligence when it can be clearly demonstrated statistically there were adverse outcomes for multiple clients, though individual attribution of harm, injury, death or wrongful act may not possible.
      • Statistics, and their use in the Analysis and Review of Professional Performance of individuals and groups, are well established and universally accepted, with appropriate "Confidence Intervals", as the highest level of Evidence in Research and Scientific investigations.
      • Why should these same tools and results not be acceptable Civil and Criminal Evidence? What counts as indisputable Scientific Evidence should be acceptable in a modern Court of Law.
      • Judges and members of the public empanelled on juries can, and should, be knowledgable in, or able to be tutored in, these concepts, tools and their interpretation and subtleties.
And a bigger question:
Are "high standard" Professionals liable for Errors and Injuries directly attributable to poor management decisions or yielding to "management pressure" to perform unsafely or continually at unsustainably high levels of 'commitment', either excessive hours, excessive supervisory load or "above my pay-grade work", i.e. substantially above their Professional level of competence?
I argue that Dr Brent James' notion of "Professionals owe a Fiduciary Trust to their clients" (and in return are given the right to Professional Self-Determination) applies. Managers, especially if current or once practicing Professionals, should not, either knowingly or not, put those they direct in these invidious position, in effect putting them in a "Conflict of Interest" situation: chose between your employment or career and the safety of those clients or the public for whom you are responsible.

It's not Good Practice, let alone acceptable Professional behaviour, to ever work a continuous 40-hour shift or 100+ hours/week when you may endanger others' lives.
Personally, I consider knowingly working whilst impaired in any way (alcohol, drugs or fatigue/exhaustion), isn't just Professional malpractice, but Criminal, especially if a repeated, even normal, action.

The Nuremberg Defence, "I was just following orders", is as unacceptable and specious, especially for high-standard Professionals, now as it was 6 decades ago. Professionals are solely responsible for their actions and must be held to account for them, in the same way that Managers can't transfer their Responsibility and Accountability to the Professionals that they direct.

Which creates another addendum to The Professional Mandate:
It's unprofessional to accept, or allow, tasks and responsibilities beyond your, or others, competence level or act whilst notionally or practically impaired, incapacitated or impacted by external factors. If you can't competently and adequately do the job before you, you should not be doing it. If others put you in the position where you feel you cannot decline a job/task/role outside you ability/competence, you are obliged to report both your own action and the situation, before, during or as soon as practicable after the event.
Specifically, I reject the widespread notion or "meme" for mangers deliberately demanding unprofessional conduct:
"You're a Professional, you have to 'do whatever it takes'" -  especially to fulfil roles, responsibilities or deadlines/commitments that you yourself did not commit to, but were imposed externally on you.
Any Professional who makes an explicit, not tacit, undertaking to deliver a Professional outcome should reasonably expect to be held to that Promise. Attempting to flip Accountability and Responsibility from Management to Professionals is a variation of this "Blame Assignment" technique and should result in personal liability for those attempting to assign blame.
The resulting Corollary is:
Professionals don't just have an implicit Right, but a Professional Duty, to refuse directions, including work rostering, that may, or will, result in unsafe Practice or a failure in their Professional Duty to clients or the public.
Or more simply: Professionals reserve the right to say "NO!", and make it stick, to unreasonable or unsafe management direction and be protected against reprisals, harassment or recriminations for such action.

Doing The Right Thing must be rewarded, never penalised.

Elsewhere, I've attempted to layout the context of Professional Behaviour within Professions. It isn't just about not doing the wrong thing, but also doing the right thing.

How a "professional" gets to know "What Works and What Doesn't" is another beyond this, "the Professional Mandate".

A relevant extract:

Barry Boehm neatly summaries the importance of the Historical Perspective as:
Santayana's half-truth: “Those who cannot remember the past are condemned to repeat it”

Don’t remember failures?
  • Likely to repeat them
Don’t remember successes?
  • Not likely to repeat them
The critical insight here is that there are two sides to improvement:
  • What not to do,
  • What to do.
So my rubric must be extended to include something like "and practice What Works (ie. proven)".

Thursday, August 9, 2012

Message to ISM/FoSiM: this is what Real contributions to the Healthcare Reform debate look like.

[Post moved to other blog.]

Atul Gawande's piece in the New Yorker on "Big Medicine: Can Hospital Chains Improve the Medical Industry?" is a tour de force on the issues, benchmarks, solutions and challenges facing us in the current Healthcare Reform debate.

At 9,500 words, while it was a riveting read for me, it may be a tad long for many people.

Even if you only read a page or two, you'll be well rewarded.

This is the work of an insightful, competent and engaged (Medical) Professional who is actively looking to mend the US Medical system and has taken considerable time and effort to construct a readable and informed piece to bring the issues, challenges of Real World change to Healthcare to the general public and even posits some solution.

Generally, I was impressed that Gawande didn't invoke Aviation as his Gold Standard, but used people and places the general public know and visit everyday and indeed, many will have worked for, and the majority will personally know someone who works in them.

He quietly and unobtrusively lets us know that he's done a bunch of real journalistic research to write this piece, pounding the pavements, spending hours or days with people in their workplace and asking tough questions.

 This was a carefully planned, researched and executed piece, possibly months in the making. It would've taken a few weeks to edit down and polish into this relaxed, chatty style.

He ends with:
The critical question is how soon that sort of quality and cost control
will be available to patients everywhere across the country.
We’ve let health-care systems provide us with the equivalent of
greasy-spoon fare at four-star prices, and the results have been ruinous.
The Cheesecake Factory model represents our best prospect for change.
Some will see danger in this.
Many will see hope.
And that’s probably the way it should be.
It's not a rant or tirade, it can't be mistaken for "personal attack" nor does it need a naive disclaimer like FoSiM's ("If you misunderstand what we've written, that's your problem, not ours.")

To Dwyer and his little Friends in FoSim, this is what a real contribution to the healthcare Reform debate by a competent Professional/Journalist looks like.

Compare and Contrast to the vapid, vitriolic and self-righeous outpouring of Ms Marron, your unpaid "CEO".

It'd be unkind to say that she remains unpaid because nobody with money would pay for her efforts, though it may be accurate.
Fanaticism and Zealotry in a cause, as demonstrated by FoSiM, don't make for persuasive journalism.

ISM/FoSiM: "Inversion" - Putting the Cart before the Horse in Healthcare Reform

[Post moved to other blog.]

One of the amazing arrogances and Blindspots of the fanatics and zealots of ISM and their "mini-me", FoSiM, is they've got the Healthcare Reform debate turned around completely. Colloquially, they've put the cart before the horse.

It's not hard to spot that the "vision statements" of both ISM and FoSiM aren't backed by any Evidence, any Theory but only Absolutist Assertion: it shows from the start that this is only Ideological based, not based in fact or need, nor indeed arrived at by any valid, credible process.

The "Inversion" of ISM/FoSiM is who they put at the centre of their Healthcare Reform proposal in their call for more "Science in Medicine", ignoring their one-eyed bias where they never examine the Practice or Science of their own, Medical Care.

What's completely missing is The Patient.

This is the Inversion. It's Practitioner- and Profession-centric, not Patient-centric.

This is the Big Lie, the massive horn-swoggle that ISM/FoSiM are attempting to pull off:
The Patient, their Outcomes, the Quality of their Care and their Safety under Medical Care is completely absent. And most importantly, Patient Accessibility and Affordability are missing.
The ISM/FoSiM advocacy for more "Science in Medicine", even taken at face value, is a clear call for:
Better Healthcare!
More "Science" won't deliver Better Medical Care, it can only deliver more expensive, less accessible and less effective care, and further stress already over-worked and failing individuals and organisations.

"More Science" does involve more money for research, more expensive devices, drugs, equipment and services and, for the very few that can afford it, much more expensive interventions ("Rescue Care") for extreme conditions. It's a Bonanza for everyone making money out of the process, the Companies, Practitioners and Researchers, and a FAIL for everyone else: the Patients, the Healthcare workers and the Governments funding it.

How can "More Science" equate to "Better Healthcare"?
Not in the Real World and not at all for Ordinary People who'll be paying for it... 
This is a scheme dreamed up by the privileged, for the privileged, of the the privileged:
ISM/FoSiM are Medical-Political Lobby groups aimed directly and solely at attracting More Money to themselves using the ruse of Better Healthcare through More Science.
The ISM/FoSiM pitch:
Better Healthcare is all about us, not the patient, it's More Expensive, More Profitable Business for us, everyone else is irrelevant!

If you'd like to know what Better Healthcare looks like, here's the definitive guide, with actual research references:
"Managing Clinical Processes: Doing Good by Doing Well" by Dr Brent James.

Tuesday, August 7, 2012

FoSiM: Motivations of Founders and Members. It doesn't add up...

[Post moved to other blog.]

The more I've researched the field of Medicine and Healthcare Reform, the more I've come to wonder:
Just why did Dwyer and his Famous Five setup the ISM "mini-me", Friends of Science in Medicine (FoSiM) in the first place?
Why have over 500 practicing and former Medical Practitioners and Researchers publicly identified as supporters of FoSiM?
The usual rubric is "Follow the Money!".

But from what FoSiM tell the world, there's no (real) money involved.

The problem is, I find that either an altruist, hobby/amateur or volunteer organisation just doesn't make sense in one of the largest, most important sectors of the economy, with the most powerful/aggressive vested interests (think Big Pharma) of any Industry including Tobacco, with so many powerful Political and Industry Lobby Groups already extant it makes your head spin and with the decades of research, published material and competing proposals from many sources, each highly funded and staffed with Academic, Practitioner and Maths/Stats experts.

The "Science in Medicine" movement is Ideological not rational, not theory-based, only values based. Insisting that their one model is all that can be and they'll just keep changing the goal-posts so all non-Medical Healthcare is deemed wrong and hence they'd like it to be illegal.

The very process they tout, "Follow the Scientific Method" and "Show me the Evidence", they do not apply to themselves nor their Reform Agenda. There is a huge body of Evidence and prior work out there on what the real problems are with Healthcare and what the implementable solutions to them are: none of that work calls for "More Science".

The fact that FoSiM do not reference the established Field of Healthcare Reform, nor cite the Evidence, screams "This is an Ideological Jihad/Crusade against the Non-Believers, they shall be brought to heel or we will die trying". Anything but "Scientific" or "Evidence Based", which is wonderfully ironic...

The Retired folk - yes, it's a way to spend time and energy, to be involved, to still be relevant, perhaps even to make a difference. I can image Dwyer has a lot of pent-up frustration, regret and resentment resulting from feeling impotent to act against people, well intentioned and not, who attempted to treat his early HIV patients with "non science".

So I 'get' the four Academics: they believe they have are Right and want to change the world in their image.

I 'get' those who practice or research in Medicine: they know their field of practice and can't envision any alternative approaches.

For those still working, it may even be useful in advancing their career, even securing project funding.

But Marron, a non-medical, non-Academic in retirement, what's driving her?

More importantly, what does she get out of this gig, both personally and professionally?
So if she's spending her own time and money, what does she get back in return, especially as she's retired, this 'work' can only only be done For Personal Interest.

This is Psychology 101: Humans need Motivation to continue engaging in an activity.

I can't figure Marron's motivation - it isn't anything Professional nor about helping Individuals, which leaves Internal emotional-defiicit drivers, as far as I can see.

Sunday, August 5, 2012

ISM/FoSiM: The irrelevance of more "Science" in Healthcare Reform

[Post moved to other blog.]

ISM (Institute of Science in Medicine) and their Australian "mini-me", FoSiM (Friends of Science in Medicine), are advocating a rather extreme version of Healthcare reform:
Medicalisation of all Healthcare, under the guise of advancing "Science in Medicine".
These extreme views are published in an ISM Policy paper on the Licensing of non-Medical Healthcare practitioners. They advocate changing world-wide statues/regulation to only allow "science-based" Healthcare (code for Only Medical Care) and finish with:
Unscientific practices in health care should further be targets of aggressive prosecution by regulatory authorities. [italics added]
They don't just want to wind the clock back to The Grand Old Days of the Fifties, but a whole Century. The authority they cite is the 1910 Carnegie Foundation report on Medical Education by Flexner.

Flexner tossed around a bunch of concepts, many more than the State Regulation of Medicine and Medical Schools on which ISM/FoSiM base their calls for increased Healthcare Regulation, a.k.a. "Science in Medicine", as the definitive solution to all the ills of all Healthcare Systems in the world.

In the second half of this piece, Flexner's original thesis and concepts are examined - and not wholly surprisingly they support the opposite position of ISM/FoSiM.

Firstly, What do the world's best experts in Healthcare Reform identify as the local and/or common challenges to Healthcare?

And, How do the proposals of ISM/FoSiM address these Medical Millennium Challenges?
Dr James is also quoted in a forum organised by his University, PANEL ON HEALTH CARE REFORM – FALL 2008, Continuum, Utah University.

This is what he has to say on the Challenges facing Healthcare around the world:
JAMES: Another point is that we’re getting exactly what we pay for. We tend to pay for procedures and rescue care, so we get lots of procedures and lots of rescue care. This is a key factor.
Another thing you need to know is that other countries have exactly the same problems. So don’t look for solutions in Europe. Don’t look for solutions in Canada.
I get a ton of those guys coming through visiting to see how care’s delivered in Utah, believe it or not, because they face exactly the same problems.
There’s a standard working list of the top five problems within health care, and nobody’s solved them.
Travel the world and it’s the same list of five things:
1. The first problem is variation in care on a geographic basis.
It’s so high that it’s impossible that all Americans are getting good care, even with full access.
2. The second biggest problem is high rates of care directly judged to be inappropriate.
This is where the medical risk treatment outweighed any potential benefit to the patient and we did it anyway . . . usually in a rescue setting.
3. The third problem is unacceptable rates of care-associated injury and death.
This is where the care delivered actively killed somebody, whose death was judged to be preventable upon review.
4. The fourth problem is that the system does it right only 55 percent of the time.
There are things that we know for a fact should be done every time but the system does right only 55 percent of the time.
Now, that’s better than zero, but it’s not nearly 95 percent or 98 percent, where it ought to be.
5. And the last one is that there’s at least 50 percent waste in the system.
This is non- value-adding from a patient’s perspective, and that’s where the opportunity exists.


From the hard-data evidence presented by Dr James based on more than 3 decades of successful Healthcare Reform, we know:
  • The ISM/FoSiM proposals address the least important, least useful areas of change. 
  • Addressing Lifestyle Issues and Environment/Public Health would have six times the impact of attempting to improve "Health Care Delivery" through more "Science".  
    • Even then, ISM/FoSiM are either vague or silent on just what benefits their proposals, if adopted, can deliver. If they want to turn Healthcare around the world inside out, with considerable disruption, cost and upheaval, then they need to first inform us of the exact benefits we can expect.
  • The ISM/FoSiM proposals are irrelevant to the common "Top 5" Challenges faced by Healthcare Systems around the world: None benefit from more "Science", they are all about Quality of Care and Effectiveness of Delivery and Implementation.
  • All successful and effective Healthcare Reform, since and including Flexner, has been Patient-centric. The ISM/FoSiM proposals aren't just wrong, but exactly the opposite of what is documented to have worked. Practitioner- and Profession-centric reforms, such as "More Science in Medicine" do not deliver better outcomes for Patients.
ISM/FoSiM consistently demand high-quality Evidence and rigorous Science from those in its sights, yet fail to apply the Scientific Method and their Rules of Evidence to their own proposals and assertions.

To be consistent and credible, ISM/FoSiM must:
  • Meet the same standards of "Evidence", Research and adherence to the Scientific Method as they demand of others.
  • Demonstrate and Quantify how more "Science" will improve Quality of Care, Patient Safety, Equity of Access and Systemic Waste and Cost-Effectiveness issues identified as "Top 5" Healthcare Reform Challenges by the leading experts in the field.
  • First define their own "Top 5" Healthcare Challenges, and
  • provide research backed by verifiable, hard-data on the Efficacy of their own proposals, their own favourite criticism of non-Medical Healthcare.
If ISM/FoSiM criticise the Effectiveness of non-Medical Healthcare, we must in turn ask them to demonstrate the Effectiveness of their own proposals. If they set Rules and Standards for others, they need to follow them themselves, even better, demonstrate by superior example.

The Flexner report doesn't just say "Regulation and Licensing is necessary" as ISM/FoSiM seems to think, it also says many things still relevant today:
  • it asks for common standards and basic clinical education with laboratory practice,
  • suggests the 'Best Practices' as used by the Europeans,
  • says that Medicine is a Performance Discipline [my words] - that Theory and Practice/Experience together are needed by competent Professionals ("Head and Hands"),
  • that Medicine is not primarily a commercial enterprise, but has a very large "Public Service" component, with a Duty of Care not just to individuals treated, but the larger Community,
  • and explicitly recognises "all medical sects", and they be based on good clinical education.
It also contains an implicit commentary that demands:
  • As part of good Professional conduct, the systematic elimination of Known Errors, Faults and Failures, ("To Err is Human", but repeating preventable mistakes is malpractice of the highest order) and
  • From the Flexner principle of "licenses bear a uniform value":
    • Continuing certification retesting of all license holders, not a lifetime grant of license.
    • the adoption of practices that have been demonstrated to have value in assuring Professional competence and skills/knowledge currency at every point in time for all license holders. From Aviation, we know these techniques work:
      • Frequent (2 monthly) "Check Pilot" assessment of the in-situ performance of every Practitioner,
      • Simulator checks of "worst-case" situations. (Quarterly)
Why would we expect Medicine to have lower Quality and Practitioner Certification standards and processes than other fields? Heatlhcare should be the leader in Practice Efficacy, Quality, Safety and Cost-Effectiveness.

In conclusion, Flexner talks of Duties, Ethics and the need of the Medical Profession to guard against the corrupting effects of commerce. Exactly the same "Conflict of Interest" message that Arnold Relman and Marcia Angell started writing about in the New England Journal of Medicine in 1980.
Like the army, the police, or the social worker, the medical profession is supported for a benign, not a selfish, for a protective, not an exploiting, purpose.
The knell of the exploiting doctor has been sounded, just as the day of the freebooter and the soldier of fortune has passed away.
It's fitting to end with a quote from Arnold Relman ("A Drumbeat on Profit Takers"):
“It’s clear that if we go on practicing medicine the way we are now, we’re headed for disaster.”
If the things the best and brightest minds in the world of Medical Science are writing, researching and talking about, and have been doing so for 3 decades, are completely different to what ISM/FoSiM started advocating in 2009, then who should we give credence to?

My vote goes to the existing experts who can provide hard-data to back their stories, not mere puffery, exaggeration and "spin" as offered by ISM/FoSiM.

Sunday, July 29, 2012

FoSiM: The local "mini-me" of Institute of Science in Medicine: Same Bull, different faces.

[Post moved to other blog.]

Dr Harriet Hall and her 26 "Founding Fellows" created the "Institute of Science in Medicine" [ISM] in mid-2009 as a "501(c)(3) organization for US federal tax purposes" registered in Colorado.

It self-describes as:
ISM is a non-profit educational organization dedicated to promoting high standards of science in all areas of medicine and public health.
and in PDF files includes:
Institute for Science in Medicine, Inc. (ISM) is an international, educational and public-policy institute, incorporated in the State of Colorado, and recognized as a 501(c)(3) organization for US federal tax purposes.
The local Australian variant, "Friends of Science in Medicine" [FoSiM] self-describes as:
 Our Association was formed at the end of 2011 out of concern about the increasing number of dubious interventions, not supported by credible scientific evidence, now on offer to Australians.

  • Dr Hall appears in the first list of "Friends", January 2012.
  • The "mini-me" relationship extends further with their DNS names:
  • Dr Hall's group has the obvious website name:
  • Where the local "mini-me" has a website name unrelated to it registered name, "Friends of Science in Medicine", but exactly congruent with being the local arm of ISM.
  • There is a test/development site at:
Why does this matter?
If you read the first policy document of ISM [PDF] as a Declaration of Intent, it finishes with some very worrying 'Recommendations':
The world’s health care systems need to be rooted in a single, science-based standard of care for all practitioners.
Effective, reliable care can only be delivered by qualified professionals who practice within a consistent framework of scientific knowledge and standards.
Practitioners whose diagnoses, diagnostic methods, and therapies have no plausible basis in the scientific model of medicine should not be licensed by any government, nor should they be allowed to practice under any other regulatory scheme.
Any statute permitting such practices should be amended or repealed as necessary to achieve this policy.
Unscientific practices in health care should further be targets of aggressive prosecution by regulatory authorities.
 This unambiguous Declaration of Intent gives the ISM, and it's mini-me, FoSiM, a specific Agenda:
  1. It is an explicit recognition that this is a Political not Academic or Scientific 'debate'. In no way are either of these bodies "Educational" or "about Science". They are only Political Lobby groups, yet aren't registered as such.
  2. ISM/FoSiM want nothing less than making the practice of "Alternative" Medicines illegal ["change of statues"] and practitioners subject to "aggressive prosecution".
  3. Who will judge what has, and has not, a "plausible basis in the scientific model of medicine"?
    • They don't define either "Science" or it antithesis, "Pseudo-Science", i.e. on the formal, strict basis for this rather extreme decision.
    • There seems to be no idea of Professions being able to defend themselves on any other grounds but an undefined "scientific model" and seemingly without means of Appeal or cause for Redress.
  4. What isn't spelled out here, but is noted on the FoSiM site, is the assumed Dawkins Appropriation: anything ISM and their "mini-me"s decide is "Medicine" is automatically included in their Field of Practice. Which, by definition, makes that practice or technique now illegal for any other Profession to practice.
Given the extreme published position of ISM and the close alignment of ISM and its "mini-me", FoSiM, comments like this from Australian apologists strike me as ignorant, uninformed or disingenuous in the extreme:
Having an organisation like FSM to kick-start a public debate about the value of science in healthcare is invaluable. 
So to the extent that FSM can get the media and the general public thinking about how much they might value science as opposed to pseudoscience in their healthcare it can only be a good thing. That’s why I stopped sitting on the sidelines of the debate and signed up when I found out about them.
No, this is not a "debate", this is not something of little concern, an effort of well-intentioned, altruistic experts. It is anything but that.

ISM and their clones want any type of Healthcare they declare "not science" to be illegal, and practitioners "aggressively pursued". Once started, this is a very slippery slope.

Ultimately, internal Politics reliant on funding and 'connections' will determine what treatments are allowed and which will be deemed "unscientific".

The world of Medical Politics is already riven with such extreme dysfunction and violent internecine warfare that few outsiders understand how bad it is.

This campaign by ISM is hard-core Political Lobbying by the dominant Healthcare Profession for exclusive control of the domain.

They seem to not be happy with having captured over 99% of the Healthcare Dollar and now want everything, presumably in anticipation of making a grab for a much larger slice of our income.

After all, you wouldn't want to die from poor Medical care, would you?

Saturday, July 21, 2012

I2P #1: First, Do No Harm.

[Post moved to other blog.]

This is my first post written for "Information to Pharmacists", an interesting Industry Newsletter with a typically idiosyncratic Aussie approach: they welcome authors of any viewpoint and profession, as long as they are respectful to others, not libellous and can write on medical/pharmaceutical issues. And "no dot points, please!" - a challenge for me, leaving behind my favourite organising technique.

"Fist, do no Harm" not only embraces Systemic Quality, but better Economic outcomes and improved Efficiency and Effectiveness with reduced waste and Continuous Improvement. Learning and Process Improvement are common to both efforts as are monitoring outcomes: costs, clinical results and "process deviations", a.k.a. "errors".

Computing/I.T. and Medicine share a Fiduciary Duty to their clients, with the Amplifier effects of I.T. now the most cost-effective means of improving Patient Safety, Quality of Care and Treatment Effectiveness.

The enemy of Quality Improvement isn't only "Change Resistance" but faddism, like a cargo-cult adopting the outward signs whilst ignoring the underlying causes and principles.

This, not technical problems, will be the major obstacle to realising the benefits of e-Health initiatives here and overseas. Successful practice transformations have stemmed from Quality Improvement programs with electronic system assisting, not from the blind adoption of automation.

Friday, July 13, 2012

FoSiM: Damned by their own words??

[Post moved to other blog.]

In February I commented on problems I had with "Friends of Science in Medicine's" Claims, Credibility and Transparency.

Part of my concerns about FoSiM's Credibility was a piece in the SMH 5 days earlier, recounting an amazing tale of illegal hacking of an SMH opinion poll ('gaming', or massive manipulation).

In following up a piece in "I2P" (Information to Pharmacists, edited by Neil Johnson) by Peter Sayers, "FSM Strategy has no Middle Ground" where I was mentioned, I saw that the FoSiM CEO, Loretta Marron/Mutton, had penned a piece mentioning the same SMH article where she accuses Blackmore's of being "Blaggards". I find such emotional and judgement-laden words hardly fitting or worthy of a group espousing an "Evidence Based approach" only to all Healthcare.

This was published two weeks after the SMH article and well after mine.

My comment, on that article, submitted today:
Marron is considerably less than honest in her reporting of the gaming of the Poll.
[Rest of post moved to other blog.
I find what she's purposefully omitted from this article to be damning. Or was that just incompetence?

Monday, July 9, 2012

Your money and your life: What the AMA and Friends of Science in Medicine won't tell you.

[Post moved to other blog.]

This piece in Business Spectator has a bunch of 'interesting' facts that both Friends of Science in Medicine and the Medical Industry body, the AMA, ignore.

Why is this??

I'd have thought it was in the Medical Profession's interest to run their operations as efficiently as possible in order to maximise their result and the benefit to individuals and to the community. That is, if that's what their Prime Mission is.

As Don Berwick formulated in 1996 with his Central Law of Improvement:
Every system is perfectly designed to achieve the results it achieves.
So, if Medical Healthcare and Hospitals aren't run efficiently and 'accidentally' kill far too many people, Why is this so?

Just what is the current system designed to achieve, if its not Patient Safety, Quality of Care or Efficient, Effective use of Public Monies?

A superficial, simplistic analysis can't tell us...
But we do know that incumbents must benefit from the system: How?

Monday, July 2, 2012

Failed Professions: Definition, Impact, Consequences

I'd like to assert that (Australian) Medicine, Banking and Finance & Investment Advisors and Information Technology (I.T.) are Failed Professions.

The fields of Management and Politics, whilst notable for their egregious actions and errors and not just failing expectations of good governance, but actively harming or exploiting the general public, are not Professions: they fail the basic tests of "Body of Knowledge" and "Entrance Requirements".

What do I mean by a "Failed Profession"?
How do I support that view?

Monday, June 25, 2012

An answer: Why not an NTSB for Healthcare? II

[Post moved to other blog.]

Continuing this topic: In the seminal Institute of Medicine (IOM) report, "An NTSB for Healthcare", a central question is posed:
Not Why an NTSB for Healthcare ... Why Not?
Medical Healthcare is often compared to Aviation on Quality of Care and Patient Safety, but the comparison is wrong and ineffectual: the story is poor and we're not yet ready to hear the message.

We, as travellers, wouldn't step onto any airplane if Safety and Quality were as variable and haphazard as Medical Healthcare in Hospitals, Primary Care Physicians, Specialists and other facilities.

So why, as individuals and a society, do we accept, seemingly without comment, 1000-fold worse Safety from Medical Healthcare than Aviation?

Medical Error, or "preventable harm", is the leading single cause of death in US Hospitals and seems to be heading in the wrong direction. Which, because Medical Healthcare is a universal, not optional, service, should be causing concern and outrage, instead it goes unremarked and unnoticed in the Media and hence with the General Public.

The more subtle cause is: Preventable Deaths and Serious Injury from Medical Error as not centrally collated and reported.
Even the more complex story, the decline in Medical Quality of Care and Patient Safety, cannot be told because there are no data.

Should then Media report the statistics?
No, as even Stalin knew: A Single Death is a Tragedy; a Million Deaths is a Statistic.

We are our own worst enemies as a society, when we need to address endemic problems:
  • Without "something out of the ordinary", stories have no "news value".
  • We suffer boredom and "compassion fatigue" from long running stories, no matter how terrible.
  • Statistics are not personal, there is no emotional connection, hence little "news value".
  • Nobody is forcing Medical Healthcare to report and categorise 100% of Medical Errors. This removes the possibility of even a larger, investigative story.
What the estimable brothers Heath, authors of "Made to Stick", don't make much of is a zeroth requirement:
There is nothing more powerful than an idea whose time has come, and
there is nothing less interesting than idea before its time.
The efforts being made to report and address the epidemic of Medical Healthcare Error are earnest, "real", well-crafted and creative. In another time they'd succeed, wildly.

The Public, and hence Politicians and legislators/regulators, are not yet ready to hear this message.
Perhaps we'll hit a tipping point when Healthcare either becomes generally unaffordable or 30% of people are directly affected by serious Medical Harm.

Until then, I hope those fighting this Good Fight can keep their spirits up and continue in the face of disinterest.

Sunday, June 24, 2012

An answer: Why not an NTSB for Healthcare?

[Post moved to other blog.]

In the seminal  Institute of Medicine (IOM) report, "An NTSB for Healthcare", a central question is posed:
Not Why an NTSB for Healthcare ... Why Not?
We believe that the question regarding an NTSB for healthcare is not why...but why not!
The Safety Leaders site has more great material than you can believe - its carefully selected, well structured and crafted; and finely targeted to various interest groups. It doesn't rely on assertion and dogma, but forceful and compelling hard-evidence from Healthcare and other high risk fields.

In response to "Why not an NTSB for Healthcare", answers come from Change Management with insight form Human Behaviour and Organisational Dynamics.

The primary answer is:
  • What's in it for me?
    • What's the upside of doing this, of changing how I work?
and the concomitant:
  • Are there consequences for not doing this?
    • What's the downside of ignoring or not doing this, or continuing "Business as Usual"?
Without changing the rewards and penalty structure, there not only won't will be, there can not be any systemic change.
"There is no reason we can't do that in Healthcare"

The first answer to the most of the "Why not" questions, the practitioner, manager and Board answer is simple:
  • Why not? Because we don't have to.
A more insidious, subtle and ultimately deciding, not even pivotal, factor to consider is:
What are the blocks, active and passive, to change?
Reframing this question:
  • Who has the most to win or lose from maintaining the current Status Quo?
  • Who are the gatekeepers, individual, organisational and political, that can either enforce the current Status Quo, or prevent/limit change?
To stop rewarding behaviours and practices that are dysfunctional or not supportive of Societal goals and to start rewarding those things that fix the system, that address known problems. The O'bama administration has attempted to change the Healthcare system, but with extreme opposition from 'conservative' interests. It is unclear that anything will be accomplished from this initiative.

To underline this point, consider the insights in, and impact of, the seminal article by IHI CEO, Don Berwick, over 15 years ago:

Berwick D. A primer on leading the improvement of systems. BMJ 1996;

Good systems are designed deliberately to produce high quality work.
By eliminating waste, delay and the need to redo substandard work, they achieve long-term cost effectiveness." 
The Central Law of Improvement: every system is perfectly designed to achieve the results it achieves
What has changed since 1996? Was there a revolution?

Quality Improvement is still an outlier activity. Medical Healthcare continues to kill and maim more people each year without seemingly garnering attention or comment. The "Doctor as God" Medical Culture continues unabated and new entrants are sill inculcated into it.

But the worst thing of all, the cost of Medical Healthcare, in absolute and relative terms, continues to rise unchecked.

The AMA is the primary gatekeeper to Medical Healthcare in the USA: it has the resources and ability to block any and all changes. At some point, there will be a showdown: the current Status Quo versus Change and Improvement.

There is another important difference between Aviation and Healthcare than must be addressed before there can be any systemic changes in the US Medical Healthcare system:
There are very few personal consequences of "poor performance" or "failures" for Doctors.
As a community, there has to be consensus support and a willingness to hold all Medical Professionals to the basic Professional standard:
  • There is never an reason for a Professional to repeat, or allow, Known Errors, Faults and Failures.
Until the community embraces this as a minimum standard, nothing can change.

While this happens, all the incumbents that profit from maintaing the Status Quo will remain as active, vocal and trenchant Roadblocks to Change.

The path to "an NTSB for Healthcare" lies through Politics and a broad social demand for change, not empty promises and window dressing.

Thursday, June 21, 2012

A Theory of Professions

Here I attempt to lay out a Theory of Professions that can be used to guide and inform practitioners, Professional Bodies, Regulators, Governments and the general Public.

The original contribution here is an attempt to layout a framework to categorise Professions by their Duty to Others and suggest that these duties apply at multiple levels: Practitioners, Organisations, Whole Profession.

Describing Professions in this way makes discourse easier and more focussed, allows reasonable expectations to be set and may inform Policy makers and Regulators when judging if Professions or their parts are succeeding or failing.

Tuesday, June 19, 2012

Good Democracy needs Strong Media: What impact the Fairfax sackings?

Yesterday, Fairfax Media, the publishers of some of the oldest, most respected newspapers in Australia announced it would radically downsize and move its prime business on-line. More video, Lateline and a detailed timeline.

"The Fourth Estate" is a fundamental to strong Democracy - in Economics terms, it (notionally) provides "full/perfect information" for the Market. It's how the Public become informed of Things That Matter.

I posit that the "Golden Age" of Democracy of the 20th Century co-incided with a strong newspaper, newsreel and later "electronic media" culture:

  • there is strong public demand for "information" coupled with a willingness to pay.
  • "Fresh" news and stories are a competitive advantage: News 'Scoops' made money.
  • Strong competition amongst providers for "fresh news" funded a lot of technology, a lot of research and stimulus to "look under every rock".
  • Under this pressure, the News Cycle shrank from weeks, to days, to hours and minutes. Twitter with its 'news cycle of seconds' may be the end-game.

Media companies had a sound Business Model for around 100 years because they filled a fundamental human need: curiosity and concern.
They had worked out a great way to place a tax on that, far better than just paying for 'a' paper: advertising.

But is this Value Proposition of "Fresh News" dissolving in the New Media?

Newspapers used to be "News", i.e. the facts of {Who, What, Where, When, How and if known, Why}, not "Opinion" - the stuff that I'm writing.

After the Vietnam War, TV took over the immediate delivery of "News", as in "What's New(s)?".

Newspaper couldn't 'break' fresh stories because TV would always beat them with the 6PM or 10Pm bulletins, unless stories were non-obvious and required unusual research.

Newspapers found new niches with Opinion, Analysis and Entertainment and Informing (vs 'News' of delivering new facts).

Woodward and Bernstein's "Watergate" investigation happened precisely because:

  • Post Vietnam, TV had taken over as "where Fresh Stories break" forcing the paper to "dig deeper" for stories,
  • the Washington Post had the resources and editorial judgement and nerve to fund the research and publish the results "without fear or favour",
  • "sources" respected the paper and its journalists enough to speak, with an implied contract that they'd be treated fairly and respectfully and their identity would be protected if needed, and
  • the public trusted the facts were real, correct and checked, and trusted that any fraud, confabulation or misrepresentation would be outed and all those responsible would "suffer consequences".
The Washington Post had an owner that was interested and engaged, and would back their Editors and Journalists. The people on the coal-face trusted they would be defended if they told the truth and acted in Good Faith.

What evolved with News reporting was a delivery pipeline with well-known "rendezvous points", Trust, Respect, and "Reputation" that took decades to build and a moment to destroy, and diversity with competition.

Who kept the Media Honest? Their competitors!
Who prevented complacency, sloppiness and indolence? Their competitors!

And the Media, "the Fourth Estate", with its insatiable appetite for News and Fact, kept those in positions of power and trust, Politicians and Business leaders, accountable.

For a hundred years, the public could (mostly) trust what the papers said and trust them to hold those in power accountable on their behalf.

Without a vibrant, competitive and highly professional News Reporting disciple, this half of the democratic system dissolves...

In a Democracy, the citizenry has a duty to care, to actively maintain their Rights and hold those in positions of power to account. We're not going to see riots in the streets over this, it seems like an inevitable, and minor, business failure or restructure.

But what can and will replace a strong, free Press?
The Internet does Change Everything, but where's the business model that will fund good News Reporting? None has yet to emerge, and after ~15 years of "The InterWebs", if it was going to appear, it should be apparent.

Wednesday, June 13, 2012

On Being a Professional: 3 Axions. Right Reasons, Attitude, Aptitude.

I've stated for a time my rubric of Professional Practice as a rhetorical question:
When it is ever acceptable for a Professional to repeat, or allow, a Known Fault, Failure or Error? [A: Never]
Some larger questions arise but won't be dealt with here, but they imply a meta-level, the "Profession":

  • Define 'Known' (which needs a means of transmission), and
  • What are, or should be, the Consequences of unprofessional conduct or performance?
Healthcare, Medicine and the Learned Professions (eg. Law) have a special (higher) onus of responsibility on them. In the scale of Professional Duty, they are the most stringent and demanding:
  • Fiduciary Duty or Trust:
    •  "involving trust, esp. with regard to the relationship between a trustee and a beneficiary" [Oxford American Writer's Thesaurus]
  • Fair Go, Fair Treatment.
  • No Rules, Buyer Beware.
I argue that the Fiduciary Duty implicit in the Practitioner/Patient contract and relationship is demonstrated in the Hippocratic Oath, "First, Do No Harm,..."

This is a very high standard.
I take it to mean that Practitioner always places the Patients' welfare and health above their own concerns and needs, and those of their employer, supervisors and Professional Bodies.

Internal to this, I assert that the more radical or extreme the effects or possible adverse outcomes of the treatment/procedure are on the patient, they higher the duty of care. A variation of "Your Life in Their Hands".
  • A surgeon or Intensive Care Physician can trivially cause immediate death or terrible permanent injuries. They have the highest level of Fiduciary Duty towards their Patients.
  • Whilst the maker of a prosthetic device needs to avoid transmission of diseases, the use of toxic elements and have the device work safely. There is still a Fiduciary Duty towards the Patient, but it is much closer to the "Fair Go, Fair Treatment" level.
I'm positing three axions of Professional Practitioners, especially those with a Fiduciary Duty to their clients:
  • Clean Motivation of Entry into and Practice in the Discipline: not Money, not Status, not Power/Prestige/Influence.
    • If a Clinician is practicing because of the money, not primarily for providing good Patient Outcomes, they will routinely fail in their Fiduciary Duty.
    • This is counter to the best interests of the Patient.
    • A focus on pecuniary rewards will not sustain a Professional for their full working life. Once immediate goals are satisfied, what then? More of the same, or Just Cruising, not Caring?
    • Caring for others outcomes is the first requirement for Quality and Continuous Improvement.
      • Those who espouse, or act out, "Care Factor Zero", will not and cannot provide good Quality practice. If they have a Fiduciary Duty to others, they should be relived of duty without delay.
  • Continuous Active Learning and Improvement.
    • This isn't the 20-hours/year of mandated CPD (Continuing Professional Development).
    • It's an inherent self-monitoring, self-examination of process, procedures and outcomes leading to Improvement in Quality of Care and Process (efficiency and effectiveness) and Adaptation and Improvement of Practice.
  • A trusting and safe environment, "The fundamental Clinical Requirement", for the patient to "open up" into a full, frank and unstinting clinical communication.
    • As human beings, we have 90 seconds to make a first impression. Recovering from a poor or antagonistic first impression is possible, but lengthy and time-consuming.
    • Within that time, any clinical professional has to establish a basis of communication with the patient where they can be fully open, honest and complete in the clinical dialogue.
      • "Why didn't you tell me before/when I asked" is the calling card of failure in this fundamental clinical requirement.
    • Patients are both fully informed experts and ignorant. They know absolutely the experience of their own bodies, but can not be Clinical experts, even if they are trained in the field. This contradiction requires the clinician to both respect, not discount or ignore, what the patient is telling them and to fully draw out the patient experience. The patient will not be aware of apparently trivial or obvious details that are critical for swift, correct diagnosis by the clinician.
Lastly, there's the matter of Talent.

Some people are gifted in a field and given the same degree of training and practice, outperform us "mere mortals" by many times. Some might say "orders of magnitude".

The proof is Elite Athletes and Professional Sports. Talent counts, not just perseverance, determination and desire. Professional teams pay massive amounts for their stars, not 'the pack'. In professional tennis and golf, it shows up in earnings, both tournaments and sponsorship. The notional performance differences between #1 and #100 are small (<1% or 0.01%), but earnings are different by powers of ten. Talent counts as much in the clinical setting as on the sports field - and the results are similarly different.

Professions don't do themselves favours by allowing those of limited Talent to practice.
It diminishes the field and fails the patients.

Ironically, through the Dunning-Kruger effect (tone-deaf performers self-assess as virtuosos), this can institutionalise perverse selection and assessment regimes:
   when the professors are tone-deaf, they reward those like themselves and remove all others.

Exemplified by the claim: "I'm the Best XXX in the South-West/North/Area/City/State/..."
It's an error of logic of the kind: "compared to what? by whom?"

The Dawkins Appropriation: Not just wrong, dangerous

[Post moved to other blog.]

Richard Dawkins is credited with the observation:
there is no alternative medicine. There is only medicine that works and medicine that doesn't work. [italics added]
Sounds reasonable, sounds obvious, sounds good. But it is wrong.

As Medical practice subsumes other techniques and modalities, how well does it do it?
How well can it do it?

This is the same problem as learning a new language.
Without the Culture and Context, the learning is seriously compromised.

Yes, you might have some fluency, some ability to get yourself understood and able to hold modest conversations.

My thesis:
 the Culture, Theory, Practices and implicit knowledge and models underpinning a technique, therapy, practice or modality cannot be separated from it.

 Secondly, it's called "practice" for a reason. Like playing a musical instrument, to become accomplished in the art, you need a lot of practice to build the skill. But then you have to maintain the level of practice to maintain the skill. Mere performances won't maintain concert-level skill, and worse, infrequent performing result in lessening of skills. At some point you are back to "amateur" status.

"Cherry Picking" can only lead to sub-optimal results, or worse, real harm to patients through ignorance and poor techniques.

Can Doctors perform Acupuncture or Spinal Manipulations as well as native trained, specialist practitioners? Those who practice their craft daily.

I argue, not nearly.

So why does Dawkins make his statement, if it works, it ours? It's so trivially wrong and dangerous as to be absurd.

At best it is an ignorant and unwise sentiment, at worst disingenuous and mendacious.

It's a great sound-bite and simplistic rationalisation - and has been endlessly repeated by the proponents of the Medical Healthcare Treatment Only (all other banned/illegal) school of thought.

If Dawkins had said:
Medical Healthcare will embrace and accept as whole specialities what are now regarded as Alternative Modalities or Treatment when they are shown "Safe and Effective",
then I'd agree with him.

Dawkins thinking on this seems to be mechanistic, based on the Classical Science/Physic notions of absolute knowledge and predictability.

Sunday, June 3, 2012

Only for the brave? Doom and Gloom analysis of "USA Inc" + solutions.

This report, co-authored in early 2011 by Mary Meeker of KPCB (Kleiner, Perkins, Caulfied, Byers) the legendary Silicon Valley Venture Capital firm, is deeply challenging.
Long PDF and Short PDF available as well.

It's not your average "Doom & Gloom" report or "The Sky if Falling, all is lost, get to the Bunkers" shrill fear-mongering.

This is solid analysis backed by good research and unrelenting numbers.

These folks know their way around a balance sheet, their record speaks for itself. If you can't refute it, you have to believe and act on it.

The headlines for me are dual:
  • If nothing changes, within 15 years the USA won't be able to pay its bills [like Greece and Spain], and
  • these folks are very positive. They layout the strengths of the US Economy and its people and a game-plan for getting back into the black.
So, look at the video [43mins] and pull down one or more of the PDF's if you like, I'm not only suggesting that this is not something that everyone should read, but that people should carefully consider beforehand if they even want to read this. It's not said, but the GFC was just the beginning...

Be prepared to read some deeply disturbing and challenging data/analysis, I found it quite sobering.
The authors pointedly don't dwell on the negative outcomes or consequences inside the USA and for the rest of the world. There will be many commentators only too glad to bang that drum and instil "Fear, Uncertainty and Doubt" into a wider audience.

BUT, the whole reason Mary and her team spent a small fortune constructing this report, is they, the acknowledged experts in analysing the operations of any business, not only think there is hope, but think solutions are possible and achievable. This comes from a fundamentally positive 'frame'.

That they did the research, produced the analysis and published it, is a massive vote of confidence by some of the world's best financial minds in the resilience and capability of "USA Inc" and that solutions are within the grasp of Americans. The solutions may not be easy or palatable, but they are achievable.

This report is about Hope and Inspiration, don't lose sight of that when you read it.

Vote [1] Independent: Gillard vs Abbott - why we hate them both.

The last newspoll in May-2012 had Gillard and Abbott both with  disapproval ratings of ~60%.

Who cares about the approval ratings jiggling up and down a little with one or the other sneaking 'ahead' by a single point? It's all noise.

The BIG message here for these leaders and their parties is: the electorate hates you both, equally and with a passion. Almost the only folk still supporting either leader and party are the rusted-on faithful. The rest of us want "None of the Above".

This is why we have the hung Parliament, with the balance of power being held by Independents.

The Greens may be a safe bet "to keep the Bastards Honest" in the Senate, to borrow Don Chip's line, but intense disapproval of major parties will not translate into lower-house support for the Greens. They have yet to earn that support from the majority of voters.

There are around 500-days until Gillard has to go to the polls.

Is that enough time for strong independent candidates to declare themselves in all the lower house seats? I've no idea.

It would be so wonderful if Abbott or Gillard lost their seat to an Independent, in much the same way that the electorate of Bennelong "sent a message" when they replaced PM John Howard in 2007 with Maxine McKew. But only for a single term: The ALP got sent another message when she wasn't reelected.

We are in this "Tweedledee, Tweedledum" situation exactly because of all the "sophisticated" tools that political parties have used and refined over the years.

When Dr Gallup invented sampling theory for his PhD thesis and showed it comprehensively worked in the 1948 election of Truman, we embarked on this course towards "identical candidates and parties".

Simple survey techniques have been supplemented with frequent, targeted polls, "focus groups" and enhance with technology.

But the Political Party's analysis and use of this data to create "Perfect Candidates" and "Perfect Policies" has a monumental flaw: it can only tell you what to leave out, or not do, it cannot tell you what to do, what is missing.

A perfect example from my Industry, I.T., is Microsoft versus Apple:
Microsoft has products and a persona perfectly constructed from Opinion Polls and Focus Groups. Apple builds stuff it is passionate about, that springs from a clear well-expressed vision and worldview and is intentionally, not for everyone
Until 5 years ago, you would've said Microsoft had won hands down. Now Apple is so far ahead on all measures and Microsoft results so poor in absolute and relative terms, that there is simply no contest. The business press has called for the firing of the long-term Microsoft CEO and a set of commentators are now waiting for them to fail.
The lesson from MSFT v AAPL?

Pandering to the whims and desires of the masses and attempting to "never offend anyone" yields short-run benefits, but in the long-run guarantees all but the most faithful hate you with a passion. The majority of people will only buy and use your product if they have no other choice. Look at the share price and revenues since the 2007 launch of the iPhone... It had stopped being a contest before then, now the iPhone and iPad have "nailed shut the coffin" on Microsoft's business model.

Apple and Steve Jobs have, since the 1984 launch of the Macintosh, shown that they put Great Design ahead of everything else. Without Jobs in the company to solidly maintain this stance with upper management and the board, the company floundered, almost to the point of extinction.

When Jobs returned with the same core philosophy but now with the skills to profitably implement it, the turn-around of the company has been nothing short of amazing to those who don't understand the rule, and more than comforting to those who do understand this philosophy.

This is the "secret sauce" of Apple and Steve Jobs: Stay true to your deeply-held Beliefs.
Jobs' 2005 Commencement Address for Stanford says more.

You cannot "cut your way to success" in business, nor elsewise achieve greatness through appeasement, placating and being "politically correct" - newspeak for "never offend anyone". Being a reed that blows in the winds of opinion does not buy you friends, influence or respect.

This is why Australian voters don't just dislike, but actively hate, the major parties, their leaders and their policies:
 they don't have the guts and gumption to strongly state their message and stick with it.
If you have real, strongly-held beliefs, you will have a whole raft of people disagree with you, but they will admire and respect you for it and given the choice, grudgingly allow you to get on with it.

Voters know too well that the party hacks they vote for locally will, when given the choice between the interests of their own electorate and "the party", consistently not put the interests of their constituents first.
So why vote for someone that won't stand up for you and your interests when it counts???

This is exactly why strong, capable Independents are being increasingly elected.

Voters know that Bob "mad hatter" Katter will fight to the death for them. He might hold a bunch of crazy and unimplementable views, but he is passionate about his electorate and volubly so. Love him or hate him, you have to respect his passion, his work ethic and commitment to his constituents: this is real Public Service, putting others interests ahead of your own.

So this is why my recommendation for the 2013 Federal election is:
Vote [1] Independent.
Because if you don't vote the bastards out, nobody else can.

If you don't have a strong, capable Independent standing in your Electorate?

You still have many avenues to make your views known, though there are few I can write about.

Just be sure when you do share your views and attempt to influence others, that you don't fall foul of the Electoral Act.

You cannot advocate that people don't vote nor that they vote 'informal', especially not that they avoid being on the electoral rolls. We are a Democracy and this entails a duty to care, it relies on your active engagement, not passive acceptance of the Status Quo and wishy-washy 'statements' that waste your vote.

Voting is compulsory in Australia (we're such an apathetic lot and seemingly love to obey authority!) and failing to vote for a good reason attracts a $25 fine. The penalties for advocating others not vote are considerably harsher and more onerous (court appearance, not a fine, possibly criminal offence) than an individual failing to vote.
To be clear: I support everyone casting a vote, this is fundamental to maintaining our Democracy.

IIRC, Somewhere around 4-6% of registered voters don't cast ballots on the day. I've no idea, nor any interest in finding out, if or where the reasons for not participating in the cornerstone of our Democratic process are tabulated.

Update 10-Jun-2012: The Financial Review has estimates that 20% [~3MM] eligible voters "choose not to vote". 2.88MM of 14.09MM people:

  • 1.20MM not on the roll,
  • 0.95MM don't turn up to vote (and face the fine)
  • 0.73MM don't cast a formal vote

 To create change, you have to vote.

Think about it and make your vote count in 2013.