Do Professional Societies care about the Public or only their Members?

Yesterday I was horrified when I made a phone call to CPA Australia asking if a) someone had been a member and b) if they'd ever been the subject to Disciplinary action or complaint, especially around 2004.

The answer given I found shocking:

That information is Private, it's part of the "Member Record". You have to get their permission to release that information. [In response to question on 'serial offenders' and 'irregularities' in Association accounts well over $1M.] This is our Policy. If you want to pursue this, you can write to our Legal Department who probably won't respond to you.

Compare that to Aviation, not just Pilots...

Not only do they have the best Quality and Safety systems of any Industry and Profession, they take it as a given that Open and Transparent Governance, including professional discipline matters, is fully public.

Sunshine is the best antiseptic for corruption, negligence and incompetence.

Today I wrote to a TV current-affairs program with:

If you thought Dr Death of Bundaberg and the Butcher of Bega weren't bad enough, what do other Professional Societies do that's different?
Nothing...
Members First, stuff the public!
Unlike Aviation, they are there to keep the Sins of their Members secret.
2 stories: IT Recruiters and Accountants (CPA)

Links

IT Recruiting (ITCRA).
If you complain about a recruiter, whatever they decide about the compliant is a secret. Probably the same with general recruiting [the GM of ITCRA used to work for that Association. Commented they got many, many more complaints.]

My Story:
http://stevej-on-it.blogspot.com/2012/12/recruiting-fail-non-response-of-itcra.html
http://stevej-on-it.blogspot.com/2012/09/recruiting-fail-part-3-itcra-complaint.html
http://stevej-on-it.blogspot.com/2012/09/recruiting-fail-how-to-foul-up-employee.html

CPA Australia:
What happens when you ask if a CPA has ever been disciplined?
 ITS A SECRET...
Even if you think they're part of a 20yr conspiracy, potentially a swindle, worth $1-2MM...

The Association Investigation: NSW Assoc Y0133609.

NOTE: the Association is NOT the subject of this commentary on Professional bad behaviour and are known for being litigious. I will not name them and ask others to maintain this confidentiality although the registered name appears on the official documents and their Journal referenced. [I do have the technology to black-out the information in PDF's.]

RL was the Public Officer Y0133609 from  21 July 1997 to 10 December 2009 according to the official Association Extract.  He was also Treasurer, though the period is uncertain as the historical Committee Register of Y0133609 is not available on-line.

These Association returns, fully public, were procured from the NSW Associations Register and contain the name and address of the Public Officer, RL, at Heysen Close, Pymble:

Y0133609 1996 Return.pdf

Y0133609 1999 Return.pdf

What's NOT in the forms that four years returns (1996-1999) were submitted on the one day, triggering at least two penalty clauses of the 1984 Act:

• s54(1)(f) - Forced winding up on failure to lodge returns for 3 financial years
• s27 - Lodge statements within 1 month of AGM.

The accounts, in my opinion, violate s26(6) in that they don't give a "True and Fair view" of the financial affairs of Y0133609. If I'd been at the AGM those accounts were presented, I and everybody I've known in a Professional Association, would've rejected those accounts.

RL gave a Business Hours number on the Public 1996-1999 returns, identifying his then employer:  "CCS Partners" in the City. CCS used to be Calligeros, Cassim & Simos.
http://www.ccspartners.com.au/Home

CCS confirmed RL once worked there but would provide no other details, not even if he'd been a member of CPA Australia or the Institute of Charted Accountants.

There is a current White Pages listing for RL at 3 Ellendale Rd, Kenthurst NSW 2156.

The gross irregularities in Y0133609 accounts that I wanted to follow-up with CPA Australia is $1.25MM missing from the 1996-1999 Accounts attested to as correct by this upstanding, presumably registered, Accountant.

A large bequest was left to Y0133609 by Stanley Whaley of Queensland, except that it never appears in the Association accounts. The money was transferred to a Trust which under s26(6)(d) they were obliged to report as well, but never did.

Images of relevant Journal pages publicly declaring the Bequest and its movement to a Trust:

Y0133609 Journal 1995 #2 pg3
Y0133609 Journal 1995 #2 pp 5 & 6
Y0133609 Journal 1996 #4 pp 63-64

Full-text PDF on-line:

Y0133609 Journal 1995 #2

Y0133609 Journal 1996 #4

But the matter doesn't end there...

The Public Officer is seen under the Act as having special responsibilities, they are the official representative and where notices for the Association will be served by the Registrar. Under s23 of the Act the Committee has just 14 days to advise of a change of Public Officer and the new address to serve notices. It appears RL left Y0133609 5 or 6 years before the Registrar was notified.


RL is in the Journal of Y0133609 at the end of 2003, but never heard from again after that. He is still listed as being on the committee at the end of 2004 and there's no mention of him in mid-2005. After being a major "mover and shaker" within the Association, he's suddenly gone without trace.
Y0133609 Committee Nov 2004
Y0133609 Committee, Jun 2005
Y0133609 Journal 2003 #4

Yet he was still listed as Public Officer until 2009 when the Registrar took the highly unusual step of involuntarily cancelling the registration of Y0133609 for failing to lodge mandatory annual returns for 10 years.

After that little lapse of not filing returns for 4 years in 1996-1999, RL had never filed another one!
The official Association Extract shows Y0133609 didn't file a return in 2000-2003 nor any official documents until 07-May-2010.
After a period of almost a year, when accounts and returns for 2003-2009 were filed together, very strangely the Registrar, under s54A(2), reinstated Y0133609's registration as if nothing had ever happened. No penalties were levied, at least not according to the list of official documents available. Y0133609 were allowed to continue trading while formally deregistered, which makes me wonder "Why bother with the Act and registration at all?". I find this strange...

But this is about RL and his behaviour as a Professional Accountant.

Why were no accounts or returns filed by Y0133609 for the 4 years, 2000-2003?

The reason isn't on public record, but can't be related to a "7 year statute of limitations", nor to 5 years.

What we do know is that RL stopped writing in Y0133609's Journal in 2004.

What we see with the non-lodgement of the accounts is consistent with RL doing a massive Dummy Spit in early 2004 and withdrawing completely from Y0133609 and, we can guess, in a fit of temper deleting all records and files relating to them from his personal and work computers. If he'd felt this way, he also would not have felt a responsibility to inform the Registry of the Public Officer vacancy either. [Under the new Act of 2009, this is now an offence, with a penalty, for the Public Officer, but not then.]

As an Accountant acting as their Treasurer and responsible for filing BAS statements [noted in the Journal], he would've been handling the bookkeeping on a computer. Recreating that work from paper records would've been deemed too hard by both the incoming Treasurer and later by the Registrar.

I've been involved with a number of small Professional Associations and sometimes, in spite of the requirements under the Act, volunteers move on and records, especially 'the books' are lost forever.

It gets better yet, still.

In late 1999, the past-president of the "Victorian Branch", after years of confronting the Committee of Y0133609 and RL (still Treasurer), wrote about the events and misbehaviour in detail.

RL's actions were deliberate and intentional hiding this large bequest entirely from the Regulators and the Committee either went along with it or were involved.

The Victorian tried to publish his detailed account of the goings on at Y0133609 in the Journal of another well known and respected Society, but that editor withdrew the piece after threats of a defamation action.

Y0133609 was known for being litigious and for using Mr Whalley's money to back court cases. In its 1996 Report on Activities (the only one produced publicly), ~$180,000 was given to an individual for a failed lawsuit they'd followed closely, even reporting daily on. (The case was rumoured to have cost north of $500,000). This case, heard and appealed in the Federal Court, produced some much cited Case Law for the Trade Practices Act. The academic who took the action, a Professor, sold up and moved to Adelaide to pay his legal debts.

So, when there is strong Public Interest involved, why don't "Professional" Bodies automatically provide full public disclosure of complaints and disciplinary action?

Why are major and "serial offenders" in Law, Medicine and Accounting not publicly named and shamed to protect hapless victims that these people are known to prey upon but whom the Profession is sworn to serve?? How can these "Professional" Bodies, through deliberate action of suppressing information, not be held accountable for subsequent civil or criminal offences? How can they not have Public Interest as their first Duty of Care?

"Full Disclosure" is proven to work in all aspects of Aviation, so why do these other "professions" insist on still putting the interests of themselves and members ahead of the Public whom they supposedly serve?

My only conclusion, a personal opinion based on the evidence I can find, is:

That like RL, they are rorting the public and they know it...

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.

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.

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.

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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)".

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!

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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.

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?

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.

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.

Root cause of the GFC: systemic failure in fiduciary trust/duty

Watching a Lateline interview with a British politician last night on the British Leveson Inquiry into the behaviour of the Murdoch media, crystallised my thinking on the root cause of the GFC:

A systemic failure in both fiduciary duty in the global financial community and a concomitant failure in governance and oversight by the regulators, public service and politicians.

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The New Oxford American Dictionary defines "Fiduciary" as:

involving trust, esp. with regard to the relationship between a trustee and a beneficiary

Princeton's Wordnet defines "Fiduciary Duty" as:

the legal duty of a fiduciary to act in the best interests of the beneficiary.

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The critical piece for me in the Lateline interview was that the politicians driving one of the most important Inquiries in recent times let their personal fears override their duties as representatives of the Public:

... Rebekah Brooks [chief executive], who rejected our invitation [to give evidence] on three occasions ... but the committee then decided not to invite Rebekah Brooks, [seen as surprising] ... And I think it is very clear now that the individual fears that committee members felt led to them ... basically losing the will to do that.

The GFC did not arrive unheralded nor without the involvement of many actors through the whole investment "food-chain".

• The front-line sellers of retail "sub-prime" loans that lied, deceived and failed to disclose to victims what they were actually buying, especially A.R.M.'s (Automatically Resetting Mortgages: a low-rate "honeymoon" period (2-3%?) before repayments were increased to the underlying rate (12-15%?).
• The churning of these sub-prime loans as if they were prime-quality loans by Banks through the Mortgage Underwriting houses, Freddie Mac and Fannie May and those underwriters accepting high-risk loans as low-risk.
• The "repackaging" of sub-prime loans from the Mortgage Underwriters as CDO's (Collateralised Debt Obligations) without fully disclosing or properly insuring the embedded risk, instead using CDS's (Credit Default Swaps).
• The complete operational failure and dereliction of duty by all Ratings Agencies in declaring these packaged "toxic loans" in CDO's backed by CDS's to be the lowest risk asset possible, AAA-rating.
• The relentless, high-pressure wie-spread sales of these complex instruments to inappropriate and uninformed consumers, with extraordinary levels of deception, misleading statements and since documented, complete fabrication and wilful dissembling (lying).

But it could only have happened if there was not only widespread failure of agents Fiduciary Duty to investors, but also criminal behaviour.
There were a slew of interlocking system failures that were necessary to translate the "zero-cost" money being thrown around by the US Federal Reserve into systemic rorting (fraudulent gaming of the system) - and none of them was ethical, moral or legal.

The GFC was fuelled by an seemingly infinite pool of zero-cost money being used to "stimulate" the US economy after the "Dot Boom" became the "Dot Bust" circa 2000.

There were many schemes to take this money and convert it into "high return, safe vehicles".
The contradiction inherent, returns are the inverse of safety (higher rates of return compensate for higher risk), went unnoticed, unchallenged and generally uncommented, except towards the inevitable collapse.

Yet, despite, the massive consequences of the GFC, the "socialisation" of the crystallised losses, which for decades will haunt the mug punters, or average taxpayers paying for these bailouts through their governments, nothing has substantially changed. More importantly, almost nobody has gone to jail.

Many banks and financial institutions declared record profits (and hence record internal bonuses), the year after they were bailed-out by the very people they were again relentlessly gouging - the average taxpayer.

There is a fundamental inversion at work in the financial and managerial world that the regulators and legislators have been ignoring for the last 30-40 years:

• CEO's and fund-managers/investment advisors want all the upside of ownership, and none of the downside. They want a large fraction of any gains when the market goes up, and suffer nothing when it goes down. They can bankrupt a company an/or destroy all your investment, and still demand a bonus, let alone compensate the owners for their reckless, irresponsible behaviour.
• Institutional Investors, in the form of Banks, Insurance companies, Retirement Funds/Investment houses give their small, anonymous investors all the downside of ownership and little or none of the upside. Risk is transferred from the Institution to the Individual investors, while they retain all or most of the benefits when the markets improve. The small investor, often forced into compulsory investment, takes all the losses of the gambles and speculation by the Institution, whilst being charged a fixed percentage of their assets and a proportion of "excess gains".

This state of affairs is consistent with the causation of the GFC and stems from a very simple thing:

Politicians, and hence Regulators and Government Bureaucrats, confuse CEO's and Institutional Investors with Owners, when they are merely employees or agents.

How I can prove these assertions:

• The GFC was inevitable from the documents released or surfacing afterwards.
• CEO, 'senior management' and Board salaries have spiralled upwards at a compound rate of 30%pa since ~1975, without any comment, constraint or Inquires by Governments worldwide.
•  while real wages of employees have remained static or declined since ~1985, and
• "big business" especially continues it outrageous calls for "more flexible working arrangements" from those employees to "lower costs" and "increase productivity" when decades of decline in real wages show that none of the savings and improved profits are passed onto those long-sufferring employees.
• Institutional Investors and Governments still pass wide-scale losses onto the general public, who were not responsible for the decisions, had no control and no 'internal information'.
• The unemployment rate is most countries is (very) high, but those people out of work, receiving lower "benefits" and paying higher taxes are exactly not the people who created the GFC.

Then there are the many studies into "Mergers and Acquisitions" of large, publicly owned companies.
They all say the same thing, despite the very expensive and detailed "Due Diligence" processes, the vast majority of Mergers not only fail to create value, they destroy substantial amounts of owner value, which is ultimately the small, anonymous investors funding Institutional Investors.

A case in point from my field (I.T.):

Unisys (UIS): Formed from the 1986 merger of Burroughs and Sperry/Univac (numbers 2 and 3 in turnover and CapEx behind IBM), not only never became #1, but has declined four-fold in share value and declined from $10.5B revenue/year and 120,000 employees to $5Bn/year and 30,000 employees in 2010.

It was never going to be a good idea due to the radically different, and incompatible, corporate cultures and that there were no great synergies in their product lines, rather the reverse, they were direct competitors in most of their markets.

Yet the deal was struck and The Great New Giant Company was formed.
Within two years, the extent and scale of value destruction to both brands was obvious, and in a rational world would've been cause for a rapid demerger and unwinding of the still incomplete "integration".

Yet this didn't happen. The Board, the CEO and all the "management team" kept resolutely destroying the company. Now, decades on, it is a mere shell of its former self, and both brands struggle. Both organisations were successful, growing and sound before the merger. The market or "externalities" didn't change significantly at the time, rather the reverse, IBM grew its business very well for the next 5 years.

At the very least, the CEO and senior management team should've been placed "on notice" by the Board at the end of the first year when they comprehensively missed all their targets, and summarily sacked after the second year when the value destruction and failure to grow was incontrovertible.

Why didn't this happen, and why wasn't the Board sacked for a gross dereliction of duty? Institutional Investors are the majority shareholders and have a general policy of "we don't interfere". It's almost like they don't care about protecting their small, anonymous contributors from the downside...

Those who caused all this carnage at Unisys, the active destruction of shareholder value and the massive opportunity losses from both brands failing to keep growing, have never been held to account or suffered dire economic or civil penalties for their actions and inaction.

The resulting questions are:

• Who pursued and benefited from the Merger? Presumably the two Boards, CEO's and combined "senior management team". Those who stayed got bigger salaries and bonuses, those who left got their "golden parachutes" (outrageously generous severance packages unavailable to the rank-and-file workforce).
• Why was this massive market failure not investigated nor pursued by Regulators and Legislators? I guess because nobody that mattered complained. No Institutional Investor would complain ("we're uninvolved"), nor did they act on behalf of their plethora of small investors, rather handing them back a slightly smaller dividend without explanation.

It seems that Politicians, those we have elected to represent us against the more powerful, have become the captives of Big Business (CEO's and Boards) and servants of Media.

Unsolicited advice for the new Queensland Government

Last night in Queensland, the Liberal National Party (it could only happen in QLD), won in a landslide, led by Campbell "Can Do" Newman, son of Federal Politicians and with 13 years distinguished service as an Engineer in the Army.

One of the candidates I graduated with from school, 40 years ago has a very successful legal practice, I'm an underemployed I.T. consultant.

I sent him this unsolicited advice.
Not very original of me I know, but I hope it gives a useful insight to them.

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First, from my profession of I.T.

 A piece of ~1,000wds on the cost to Govt. of essential infrastructure (IT) not fulfilling its promise (slanted more to CBR than QLD):
"The Triple Whammy - the true cost of I.T. Waste"

And a way out of the hole (600wds):
"Controlling Waste in Government I.T. - An Immodest Proposal"

Summary:

Create two bodies like Aviation has, ATSB/CAA. One to investigate, identify root-causes and write detailed recommendations for remediation, and another to implement and enforce those recommendations...

It means making the Audit Office do more than check for fraud/broken regulations and develop real, on-going expertise in essential disciplines, starting with I.T.

And establishing an Independent Authority with real teeth... One of the first actions has to be "start collecting performance and outcome data", like the 15yr old CHAOS report that reports on I.T. project outcomes in the USA.

If people and firms are assessed as incompetent or worse then, like in Aviation, the Govt has the right to de-licence them, only they aren't licenced. But they can be put on a public "not to be employed by Govt." register , which others will know if it is lawful currently or not.

Most importantly the "Authority" has to focus on Change and Improvement, not disciplining and "handing out consequences" (which is part of its remit) or it becomes counter-productive. (900 wds)
"The Accountability Paradox: Personal Consequences and Blame"

It comes down to a basic proposition:

Is it ever acceptable for a Professional to repeat, or allow, a Known Error, Fault or Failure?

I'd argue that a number of professions owe a Fiduciary Duty to their clients/patients and professional failures in this way should result in the most serious penalties.

In Aviation, not repeating mistakes is taken very seriously, but not in I.T. nor seemingly in the medical world.

In any Engineering profession, a professional who fails in this way, causing fatalities or allowing preventable economic failure, not only loses their license to practice, but is open to criminal, not just civil, charges.

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Secondly, on Public Health and Hospitals.

Urgent reform is needed within Queensland Health, at many levels, but what's been tried over the last 20 years hasn't worked. A radical approach is needed, and one that is known to work.

This is not my area of Professional expertise and I wouldn't know where to start...

But I know who does and how to do it:

Adopt the Aviation model of Systemic Quality and Deliberate Change Implementation.

A recent article in the Journal of Patient Safety proposes exactly this:
"An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate",

What they don't say is that Systemic Quality (my term) isn't just free, but because it embraces active, intentional learning and improvement, it is better than free:

20% cheaper is well documented.

1. Dr Brent James of Intermountain Healthcare. You can read his 2001 ABC interview "Minimising Harm to Patients in Hospital" and his "its 20% cheaper" data.

2. Dr James' work is reflected in a major report by the US Institute of Medicine:
   "To Err is Human: Building A Safer Health System" (1999).

3. Donald Berwick and the "Institute for Healthcare Improvement".
    Here is a landmark article by Berwick from 1996:

"A primer on leading the improvement of systems"
BMJ VOLUME 312 9 MARCH 1996
Institute for Healthcare Improvement, Boston, MA 02215,USA
Donald M Berwick, president and Chief Executive Officer.

I'm sure you've read the 500 page QPHCI report and possibly Margaret Cunneen SC's "The Patel Case – Implications for the Medical Profession" (which as a layperson I found astounding).

The inherent problem with Commissions of Inquiry is that they cannot oversee or enforce the implementations of their recommendations. The responsibility gets handed back to Govt. which delegates the Change and Improvement process to the organisation that has the problems.

This fails a basic sanity test:

If the organisation could've changed itself, it would've.

Continuing systemic problems are not the result of lack of knowledge or insight.
Berwick formulates this problem exactly with:

every system is perfectly designed to achieve the results it achieves.

The Organisational Rules have to be changed to create more than cosmetic change because the incumbents have both an investment in keeping the status quo (its worked for them) and if they could've changed the system within the existing Rules, they would've.

Changing Organisational Rules, and making them stick, can only come from above.
This is exactly why Dr Demings' "Quality Circles" (and his teachings) worked in Japan and failed in their country of origin, the USA. Deming was hired by the heads of Japanese industry and they were able to mandate the changes.

Some things to kick off reform of QLD Health are:

• assess the degree of compliance with the QPHCI recommendations within 2 weeks.
• Any good bureaucratic will attempt to stall efforts like these for months or years. Think of the HSU Inquiry by Fair Work Australia as an outstanding example.

• look to new laws addressing Patel's deliberate action in harming patients.
• There is also a lesser offence of ' professional incompetence', proven by the statistical outcomes of a doctor. Individual victims cannot be identified, but that there are victims is proven by the stats.

The Accountability Paradox: Personal Consequences and Blame

A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate" by experienced, highly-competent Aviators and Medicos prompted me to ask a question about on the subject of Dr Brent James, Chief Quality Officer of Intermountain Healthcare:

The NTSB only recommends, the FAA makes sure those things (and more) are done.
As a regulatory and compliance organisation, the FAA is able to hand out "direct, personal consequences" - and make them stick. [Natural Justice suggests proportionality as well].

Any Aviation Professional who repeats, or allows, a Known Error, Fault or Failure will be discovered and will suffer the consequences. [Hence would a medical version need two bodies?]

Dr James kindly responded to me and I was gently reminded of James Reason's "Blame Cycle" [below] and Dr James own comments on the 2001 ABC's Health Report, "Minimising Harm to Patients in Hospital":

Norman Swan: So remove the culture of blame, sort out the legal liability problems, without ignoring the fact that there will be the odd rogue doctor or rogue nurse who needs to be sorted out. What we should be seeing here, we haven't really emphasised it up till now, is that most of the problems that occur when injuries occur, are system problems, the hospital, the management, the organisation of the hospital, rather than an individual going wrong?

Brent James: Exactly. We know that the individuals will have problems. How do we create an environment in which it's easier to do it right, and hard to fail? That's the real issue. It's an institutional responsibility not an individual responsibility. The next thing that we need is an organisational structure. In the United States we're calling them Patient Safety Officers, and in the Institute of Medicine Report we asked that all care delivery groups appoint Patient Safety Officer, usually from existing personnel, usually a good clinician.

The Military have a "Rule of Three" for all leadership roles [definitions from the Apple dictionary App]. The three have to be aligned for every role or either the task/function won't be done well, or the individual in the role will be falsely held to account for actions they are unable to control:

• Responsibility:
  "a thing that one is required to do as part of a job, role, or legal obligation"
• Accountability
  to be held to account for actions. "(of a person, organization, or institution) required or expected tojustify actions or decisions; responsible"
• Authority:
  "the right to act in a specified way, delegated from one person or organization to another", including "to give orders, make decisions, and enforce obedience".

These are very specific meaning for the words "responsibility" and "accountability".
In normal, conversational English, the words are mostly used interchangeably.

In this more formal sense, there is a difference drawn between "a task or function delegated to an individual" (responsibility) and "an item for which you may be held to account" (accountability), a fine, but important, distinction.

It is in this second, more formal sense that I wish to use "Accountability" here.

My central concern with the NTSB-for-Medicine proposal is the necessity for the organisation to not be a "toothless tiger", to have the power to cause change, but simultaneously engender a "Safety Culture" where Openness and Transparency are the norm and individuals do not feel threatened by the system.

Audit reports and Commissions of Inquiry into major failures (QLD) say what's wrong, but have no powers to cause change. They are equivalent to the NTSB, but lack the ability of the FAA to implement, to cause or require necessary change and to check that it is done.

Reason's "Blame Cycle", and my own more extreme "Blame Spiral", require Dr Demings' exhortation to "Drive out Fear" be scrupulously and systemically be applied.

How can these two conflicting objectives be achieved? I've no experience in this.

This is The Accountability Paradox:

For real change in the system, any person who repeats, or allows, a Known Error, Fault or Failure, must be held personally liable (including criminally if they caused death or severe injury/disability),
BUT if that is perceived as the Primary Role of the compliance and governance organisation, then it will be ineffective, instead it will engender the "Blame Cycle" as a minimum.

We know that in the USA the NTSB/FAA work together, in the UK the AAIB/CAA, in Australia the NTSB/CASA and, from outside, there are well developed and sustainable "Safety Cultures" operating within them all (vs Blaming Cultures).

So how can our Public Healthcare get there from here and avoid perverse outcomes, like the "Blame Cycle"?

How can Hospital and Healthcare systems in Australia copy the Intermountain Healthcare model and move from chaotic, inconsistent "heroics" to a consistent Safety and Quality Culture, embracing Continuous Improvement whilst driving down waste and system inefficiencies?

How can Australia both create a system where the Public Healthcare system improves both its performance and accountability, so the 2004 "Dr Death" scandal in QLD is never repeated but where all Healthcare workers trust they will not be blamed for speaking truth to power,  to know they can raise important issues and be properly heard, unlike Toni Hoffman in Bundaberg?

I'm sure the Medical Error Action Group would love to post a final message saying "the system has been changed to pick up its own problems, we're not needed anymore."

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Some references to Prof. Reasons' "Blame Cycle":
"Diagnosing “vulnerable system syndrome”: an essential prerequisite to efffective risk management" (2001, Qual Health Care 2001;10:ii21-ii25 doi:10.1136/qhc.0100021) and
"Managing the Risks of Organizational Accidents" [1997].