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.