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

[Post moved to other blog.]

ISM (Institute of Science in Medicine) and their Australian "mini-me", FoSiM (Friends of Science in Medicine), are advocating a rather extreme version of Healthcare reform:

Medicalisation of all Healthcare, under the guise of advancing "Science in Medicine".

These extreme views are published in an ISM Policy paper on the Licensing of non-Medical Healthcare practitioners. They advocate changing world-wide statues/regulation to only allow "science-based" Healthcare (code for Only Medical Care) and finish with:

Unscientific practices in health care should further be targets of aggressive prosecution by regulatory authorities. [italics added]

They don't just want to wind the clock back to The Grand Old Days of the Fifties, but a whole Century. The authority they cite is the 1910 Carnegie Foundation report on Medical Education by Flexner.

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

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

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

And, How do the proposals of ISM/FoSiM address these Medical Millennium Challenges?

Dr James is also quoted in a forum organised by his University, PANEL ON HEALTH CARE REFORM – FALL 2008, Continuum, Utah University.

This is what he has to say on the Challenges facing Healthcare around the world:

JAMES: Another point is that we’re getting exactly what we pay for. We tend to pay for procedures and rescue care, so we get lots of procedures and lots of rescue care. This is a key factor.

Another thing you need to know is that other countries have exactly the same problems. So don’t look for solutions in Europe. Don’t look for solutions in Canada.

I get a ton of those guys coming through visiting to see how care’s delivered in Utah, believe it or not, because they face exactly the same problems.

There’s a standard working list of the top five problems within health care, and nobody’s solved them.

Travel the world and it’s the same list of five things:

1. The first problem is variation in care on a geographic basis.
It’s so high that it’s impossible that all Americans are getting good care, even with full access.

2. The second biggest problem is high rates of care directly judged to be inappropriate.
This is where the medical risk treatment outweighed any potential benefit to the patient and we did it anyway . . . usually in a rescue setting.

3. The third problem is unacceptable rates of care-associated injury and death.
This is where the care delivered actively killed somebody, whose death was judged to be preventable upon review.

4. The fourth problem is that the system does it right only 55 percent of the time.
There are things that we know for a fact should be done every time but the system does right only 55 percent of the time.
Now, that’s better than zero, but it’s not nearly 95 percent or 98 percent, where it ought to be.

5. And the last one is that there’s at least 50 percent waste in the system.
This is non- value-adding from a patient’s perspective, and that’s where the opportunity exists.

Conclusion:

From the hard-data evidence presented by Dr James based on more than 3 decades of successful Healthcare Reform, we know:

• The ISM/FoSiM proposals address the least important, least useful areas of change. 

• Addressing Lifestyle Issues and Environment/Public Health would have six times the impact of attempting to improve "Health Care Delivery" through more "Science".  

• Even then, ISM/FoSiM are either vague or silent on just what benefits their proposals, if adopted, can deliver. If they want to turn Healthcare around the world inside out, with considerable disruption, cost and upheaval, then they need to first inform us of the exact benefits we can expect.

• The ISM/FoSiM proposals are irrelevant to the common "Top 5" Challenges faced by Healthcare Systems around the world: None benefit from more "Science", they are all about Quality of Care and Effectiveness of Delivery and Implementation.

• All successful and effective Healthcare Reform, since and including Flexner, has been Patient-centric. The ISM/FoSiM proposals aren't just wrong, but exactly the opposite of what is documented to have worked. Practitioner- and Profession-centric reforms, such as "More Science in Medicine" do not deliver better outcomes for Patients.

ISM/FoSiM consistently demand high-quality Evidence and rigorous Science from those in its sights, yet fail to apply the Scientific Method and their Rules of Evidence to their own proposals and assertions.

To be consistent and credible, ISM/FoSiM must:

• Meet the same standards of "Evidence", Research and adherence to the Scientific Method as they demand of others.
• Demonstrate and Quantify how more "Science" will improve Quality of Care, Patient Safety, Equity of Access and Systemic Waste and Cost-Effectiveness issues identified as "Top 5" Healthcare Reform Challenges by the leading experts in the field.
• First define their own "Top 5" Healthcare Challenges, and
• provide research backed by verifiable, hard-data on the Efficacy of their own proposals, their own favourite criticism of non-Medical Healthcare.

If ISM/FoSiM criticise the Effectiveness of non-Medical Healthcare, we must in turn ask them to demonstrate the Effectiveness of their own proposals. If they set Rules and Standards for others, they need to follow them themselves, even better, demonstrate by superior example.

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The Flexner report doesn't just say "Regulation and Licensing is necessary" as ISM/FoSiM seems to think, it also says many things still relevant today:

• it asks for common standards and basic clinical education with laboratory practice,
• suggests the 'Best Practices' as used by the Europeans,
• says that Medicine is a Performance Discipline [my words] - that Theory and Practice/Experience together are needed by competent Professionals ("Head and Hands"),
• that Medicine is not primarily a commercial enterprise, but has a very large "Public Service" component, with a Duty of Care not just to individuals treated, but the larger Community,
• and explicitly recognises "all medical sects", and they be based on good clinical education.

It also contains an implicit commentary that demands:

• As part of good Professional conduct, the systematic elimination of Known Errors, Faults and Failures, ("To Err is Human", but repeating preventable mistakes is malpractice of the highest order) and
• From the Flexner principle of "licenses bear a uniform value":
• Continuing certification retesting of all license holders, not a lifetime grant of license.
• the adoption of practices that have been demonstrated to have value in assuring Professional competence and skills/knowledge currency at every point in time for all license holders. From Aviation, we know these techniques work:
• Frequent (2 monthly) "Check Pilot" assessment of the in-situ performance of every Practitioner,
• Simulator checks of "worst-case" situations. (Quarterly)

Why would we expect Medicine to have lower Quality and Practitioner Certification standards and processes than other fields? Heatlhcare should be the leader in Practice Efficacy, Quality, Safety and Cost-Effectiveness.

In conclusion, Flexner talks of Duties, Ethics and the need of the Medical Profession to guard against the corrupting effects of commerce. Exactly the same "Conflict of Interest" message that Arnold Relman and Marcia Angell started writing about in the New England Journal of Medicine in 1980.

Like the army, the police, or the social worker, the medical profession is supported for a benign, not a selfish, for a protective, not an exploiting, purpose.
The knell of the exploiting doctor has been sounded, just as the day of the freebooter and the soldier of fortune has passed away.

It's fitting to end with a quote from Arnold Relman ("A Drumbeat on Profit Takers"):

“It’s clear that if we go on practicing medicine the way we are now, we’re headed for disaster.”

If the things the best and brightest minds in the world of Medical Science are writing, researching and talking about, and have been doing so for 3 decades, are completely different to what ISM/FoSiM started advocating in 2009, then who should we give credence to?

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

I2P #1: First, Do No Harm.

[Post moved to other blog.]

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

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

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

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

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

Management with Measurement: Inputs

"Management by Numbers" is seriously deficient as it focuses on a single dimension of a very complex multi-dimensional task. "numbers" are a necessary but far from complete aspect of the job. Some might say skills in "handling people" are much higher priority.

This stems from the rule of management: we only have managers if there is too much work for a single person.

In 1916 Henri Fayol laid out the dimensions as he saw them:

To manage is to forecast and plan, to organize, to command, to coordinate and to control.

Max Wideman uses "Plan, Organize, Execute, Monitor and Control" for Project Management [uncertain of the source].

"Management with Measurement" seems a much closer fit to what I'm trying to describe.

Why start here?
There are a number of measures that require a common element, Inputs:

• Productivity: Output / Hours Input
• Efficiency: Outputs / Total Inputs
• Effectiveness: Realised Benefit / Total Inputs

I've not seen Management or Cost Accounting methods to determine the input overheads incurred with Management. The total cost to the organisation of all managers.

First-line staff productivity, without the overheads of the management process and costs, are more indicative of workplace improvements.

As an investor, I'd like to be able to compare across companies their efficiency and effectiveness of management.
In the Public Sector, outputs and realised benefits are more nebulous ("one good policy a year per department"?), but inputs can be accurately measured and reported. Differences can then be explored.
In the Not For Profit sector, all overheads are critical, none more so than paying non-productive free-riders, and of real interest to many stakeholders: financial supporters, volunteers and the Board.

What types of employees are there?

• First-line employees: No reports, directly contribute to goods/services produced. Notionally 100% of time is "direct production".
• Leading Hands, Team Leaders: Have reports, but limited authority to direct them. Directly contribute to goods/services produced. Notionally near 100% of time is "direct production", so are counted as "first-line" employees.
• Supervisors: Reports are First-line employees or Team Leaders. Less than 25% of time is "direct production".
• Managers: Reports are Supervisors or Managers. Less than 5% of time is "direct production".
• Top-line Manager: Those managers who do not report to another manager within the organisation or organisational-unit. This definition includes "co-owners" or "co-CEO's".
• Owners: When the owner works in the business above the first-line, they will be counted as a supervisor, manager, or when the entity is large enough, as the Top-line manager, unless organised otherwise.
• Boards: These are regarded as external to the entity. Directors, owners and managers (like the CEO), who sit on the board and work in the business are counted within the business.
• Double-counting: No individual can be counted more than once. Each must be categorised into exactly one category per report. Internal consistency requires that organisations define a single set of classification rules that can be applied across the whole organisation, and is very infrequently changed.
• Lowest-level Principle: Those who can be classified at multiple-levels, like an owner/manager, should be classified at the lowest level. An owner/manager with one employee might consider themselves Top-line Manager, Manager and Supervisor, but they can only count classify themselves at their lowest authority level: supervisor.

Figures of Merit:

• Definitions:
• W: Size of First-line workforce.
• S: Size of supervisory workforce.
• M: Size of managerial workforce, including supervisors.
• Fan-out: the mean number of reports. Three figures reported:
• F_S: Supervisors (a whole number, not fractional). Sum of all first-line employees / sum of all supervisors.
• F_M: Managers (fractional). Mean of reports per manager, for all managers.
• F_T: Top-line manager (whole number). number of managers irectly reporting to the top manager.
• Hierarchy Depth:
• D: The mean of 'Depth': For each First-line employee, the number of people above them in the management chain to the CEO. Only count one path in "matrix" style organisation.
• Management Burden:
• B: The percentage of salaries and staff benefits paid to management.

These metrics also usefully apply to each Organisational Unit within an Organisation.
ie. Reporting for each Division and every Department, down to work-group level, will be useful for Organisations. Both for comparing the effectiveness/efficiency of the Management Process, but also for highlighting differences in the underlying task difficulty across the Enterprise. For a mining company, digging operations will have a different 'fingerprint' than Commercial and Planning departments.

For Public Service and Not-for-Profit organisations, drilling down, and especially reporting Management Burden, will be very useful to stakeholders, internal and external, to assess the organisation and Management Processes.

The 3-part Fan-out should always be reported/written with Hierarchy Depth: [F_S/F_M/F_T/, D].

Eg: [12/3.5/6, 7.25]

Calculating Workforce size:

For the organisation, [12/3.5/6, 7.25]:

• total supervisory and management staff = management fan-out raised to the power of managerial hierarchy depth. (M = F_M^D-1 + F_T).
• M = 3.5^7.25-1 + 6 = 3.5^6.25 + 6 = 2514 + 6 = 2520.
• approximate supervisory staff = management staff divided by management fan-out. (S = M/F_M).
• S = 2520 / 3.5 = 720
• total first-line staff = supervisory staff times the supervisory fan-out. (W = S * F_S)
• W = 720 * 12 = 8640
• The first-line to management staff ratio ( 8640 to 2520, or 22.6% mgt of 11,160) can be calculated, but the management burden as a proportion of salaries/wages cannot be derived.

Note: Because summary statistics are reported and are all that is necessary for good comparisons, exact headcount/FTE's cannot be derived from the metric. In special circumstances, discussed below, exact numbers might be added to the metric.


FTE vs Headcount?

The Hierarchy Depth must be reported in Headcount, not FTE.
But both numbers are meaningful for Fan-out and I don't have a preference,

Presumably, nearly all managers and most supervisors will be permanent employees, so in the pyramid above the first-line, FTE and Headcount are identical.

In workforces with a high proportion of casual labour, like large retail operations, headcount must be reported not FTE, to get a true picture.

An 'F' could be added to the supervisory fan-out for clarification. eg: [5F/3.5/6, 7.25], For enterprises which feel both numbers are needed for a true picture, the supervisory fan-out in terms of Headcount should be written first. viz: [(12, 5F)/3.5/6, 7.25]

Smaller Enterprises, Depth less than 3

Why is a Depth of 3 interesting?
It is the first level at which managers report to managers and the top-line manager only has managers reporting to them.

• For an owner/operator enterprise, the depth, 'those above first-line', is zero. viz: [0/0/0, 0].
• When a business gets its first employee and the owner becomes a supervisor, the depth is 1. viz: [1/0/0, 1]
• As the business expands, leading hands or team leaders are hired. The owner is still a supervisor and the depth is 1. An owner with a staff of 15, including leading hands is: [15/0/0, 1]
• The next breakpoint, is the hiring of the first supervisor (as distinct from team leaders). The owner is now a manager. The depth is 2. At this point, good businesses will have appointed, even if not listed companies, a board to advise them and to provide some external review, feedback and accountability to the owners. Avoiding double-counting, a single-owner business with 4 supervisors and 32 staff would be: [8/4/0, 2]
• After the next step, managers reporting to managers, all business are equal under this model. viz [8/3.5/6, 4] and [(12, 5F)/3.5/6, 7.25] tell an investor, stakeholder or manager that both organisations have similar management processes and overheads but one has a much higher part-time casual workforce.

When a business has co-owners and no supervisors (and hence no managers), the fan-out for supervisors, managers and top-line manager should be written as 0.

Eg: [0/0/0, 0]

When a business has an owner(s), no employed supervisors and no managers, the fan-out for managers and top-line manager should be written as 0 due to the lowest-level principle. As discussed below, the first-line workforce size cannot be uniquely calculated, because the effective supervisory staff, the owners, isn't specified. The metric is ambiguous in these cases:

Eg: [(12, 5F)/0/0, 1] could describe an organisation with one owner and head-count 12, or two owners and head-count of 24.

Metric Deficiency: Workforce size for small organisations and exact Supervisor Count.

The proposed metric does not inform interested parties of the total headcount or FTE of first-line staff an organisation, only summary statistics of management. First-line staff numbers could be added as a preceding term when the organisation is small. For larger organisations, management and first-line staff numbers can be computed from the metric.

Eg: [(12, 5F), (12, 5F)/0/0, 1] or [(24, 10F), (12, 5F)/0/0, 1] to disambiguate the one or two owner example.

And for a large organisation with a large casual workforce:

[(12,500, 6150F), (12, 5F)/3.5/6, 7.25]

Application

The Fan-out and Depth figures can be used to accurately define "Small", "Medium" and "Large" enterprises. The ATO defines a small business as having an aggregate turnover of under $2million a year, and everything else by default, is "large". There is another break-point at $20million/year, where taxes must be paid monthly, suggesting that "medium" sized entities have turnover between $2- and $20-million/year.

At the average weekly wage and with 25% on-costs and staff costs of 50%, $2-million/year is currently 10-15 FTE's.

The US SBA (Small Business Administration) defines 'small' as under 500 (local) employees. Any entity larger is a "large" business.

Company size definitions:

• Micro-Business: less than [0.5F/0/0, 0]
• Small Business: up to [20F/0/0, 1] and for low-intentsity manufacturing [100/0/0, 1]
• Large Business: over [500F, s/x/y, z], where x and y greater 0, and z greater 4.
• Medium Business: [10-500F, s/x/y, z], where x greater than 0.

Examples of Management Burden

The cost of managers is related to two things:

• the "fan-out". The number of people that report to a manager.
• the hierarchical multiplier. For each level increase in the hierarchy, what's the percentage increase in salary, assuming a constant multiplier?

The fan-out cannot be under two.
For that to be true, at least one manager has a direct-report count of 1, which violates a basic rule:

We have managers because there is too much work for one person to do.

I expect fan-out and hierarchical multiplier to be related: a larger multiplier if there are more reports.

Using Telstra as a rough model:

• There are ~30,000 (2¹⁶) employees.
• Front-line staff are paid ~$40,000, and, in the days of Sol Trujillo, the CEO got ~$10M, or 256 (2⁸) times the average front-line staff wage.

If there was a fan-out of 2, there'd be 15 levels of hierarchy and 50% of the workforce would be first-line and 50% management and supervisors.

Lets say it was 16 levels, so for every two levels of hierarchy, pay is doubled.
Each level would have a 1.414 (square-root 2) multiplier.

The table below contains some examples of Management Burden, B. In a real organisation with access to the accounting system, B would be calculated, not estimated like this.

The assumptions made in this example:

• 'Fairness' and consistency in apportioning the wage differential between every level of management, from supervisors to Top-line manager.
• More realistically, the gap between first-level employees and supervisors will be smaller than the gaps between management levels, as well as the supervisory fan-out, F_S, will be larger.
• "the senior management team", the Top-line manager and their direct reports, are likely to be on their own payscale.
• The effects of F_T, and difference to, F_M are ignored.

Columns:

• W = first-line workforce
• M = managerial workforce
• W + M = total workforce
• F_M = Fan-out of management
• D = Hierarchical Depth, layers above first-line employees.
• Max Wage Ratio = ratio of highest wage (CEO) to average first-line wage
• Hierarchical wages multiplier = assumed fair multiplier between each level of management.
• Avg Wage mult = Average (mean) wage of enterprise, as a multiple of average first-line wage.
• Wages multiplier = Total wages as a number of multiples of first-line wages.
• Mgt Burden = Management Burden, management wages as a percentage of total staff costs.

Management Burden with varying Maximum Wage Ratios

W	W+M	FM	D	Max	Hierarchial	Avg	Wages	Mgt
				Wage	wages	Wage	multiplier	Burden
				Ratio	multiplier	mult
16,384	32,767	2.0	14	128	1.414	1.698	3.395	70.54 %
16,384	32,767	2.0	14	32	1.281	1.389	2.778	64.00 %
16,384	32,767	2.0	14	256	1.486	1.923	3.846	74.00 %
16,384	32,767	2.0	14	1024	1.641	2.640	5.281	81.06 %
16,384	21,845	4.0	7	32	1.641	1.271	1.694	40.96 %
16,384	21,845	4.0	7	256	2.208	1.666	2.213	54.81 %
16,384	21,845	4.0	7	1024	2.692	2.197	2.929	65.86 %
32,768	37,449	8.0	5	32	2	1.167	1.333	24.98 %
32,768	37,449	8.0	5	256	3.031	1.405	1.605	37.7 %
32,768	37,449	8.0	5	1024	4	1.723	1.969	49.21 %

Discussion

The Wage Ratios chosen are indicative of:

• 32 = pre-1980
• 256 = a typical current multiple
• 1024 = high current multiple, but not extreme.

The worst case, giving both the maximum Hierarchical Depth and highest numbers of managers is with the lowest possible fan-out number, F_M = 2.

Organisations with higher Depth have slower lines of communication and more players involved in every decision and report. This was the observation behind the 1980's push to "flatten the organisation".

The management burden reduces considerably with a flattening of the hierarchy, with high management fan-outs. I would expect high fan-outs would only be possible with more routine operations. Organisations with complex, highly variable tasks require more communications in all directions and more management action, causing managerial workloads to quickly increase and hence obtainable fan-outs to decrease.

Whilst the Average Wage multiplier might seem modest, say the middle entry (F_M = 4, D = 7, Ratio = 32), with the organisation's wage being 27% higher than the first-line average wage (eg. $40,000 and ~$60,000), the wages paid to management are a significant proportion of total wages: 41%, quickly rising to be two-thirds of total wages, for no direct contribution to output.

For investors and prospective purchasers of organisations, the management fan-out and management burden provide a new insight into where input costs arise and how gross productivity is effected by them.