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.

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.

---

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.

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

[Post moved to other blog.]

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

Why is this??

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

As Don Berwick formulated in 1996 with his Central Law of Improvement:

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

So, if Medical Healthcare and Hospitals aren't run efficiently and 'accidentally' kill far too many people, Why is this so?

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

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

An answer: Why not an NTSB for Healthcare? II

[Post moved to other blog.]

Continuing this topic: In the seminal Institute of Medicine (IOM) report, "An NTSB for Healthcare", a central question is posed:

Not Why an NTSB for Healthcare ... Why Not?

Medical Healthcare is often compared to Aviation on Quality of Care and Patient Safety, but the comparison is wrong and ineffectual: the story is poor and we're not yet ready to hear the message.

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

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

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

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

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

We are our own worst enemies as a society, when we need to address endemic problems:

• Without "something out of the ordinary", stories have no "news value".
• We suffer boredom and "compassion fatigue" from long running stories, no matter how terrible.
• Statistics are not personal, there is no emotional connection, hence little "news value".
• Nobody is forcing Medical Healthcare to report and categorise 100% of Medical Errors. This removes the possibility of even a larger, investigative story.

What the estimable brothers Heath, authors of "Made to Stick", don't make much of is a zeroth requirement:

There is nothing more powerful than an idea whose time has come, and
there is nothing less interesting than idea before its time.

The efforts being made to report and address the epidemic of Medical Healthcare Error are earnest, "real", well-crafted and creative. In another time they'd succeed, wildly.

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

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

Egoless Practice: Becoming the Best in your Field

Jerry Weinberg coined the term, "egoless programming" in his 1971 book "Psychology of Computer Programming". Jerry describes the practice and mindset, and in 1977 co-wrote with Friedman, the definitive manual for practitioners:  "Handbook of Walkthroughs, Inspections, and Technical Reviews: Evaluating Programs, Projects, and Products".

Is there a precise definition of "egoless programming" that could be expanded to a generic Professional Behaviour of "egoless practice"?

Johana Rothman is quoted by Jeff Atwood, presumably from a book, as saying:

Egoless programming occurs when a technical peer group uses frequent and often peer reviews to find defects in software under development. The objective is for everyone to find defects, including the author, not to prove the work product has no defects. [my italics]

When asked for a modern definition, Jerry pointed at Jeff's Ten Commandments of Egoless Programming.

The field of Reliability Engineering is aimed at creating near-Perfect (i.e. highly reliable) operation from imperfect parts and sub-systems. This approach can work very well, even when maintenance and fixes can't be done: the NASA Mars Rovers, Spirit and Opportunity, exceeded their 90-day design life by around 15 times, working from 2004-2010.

A working definition (unfortunately, of many parts):

• Egoless Practice is
• a Professional Behaviour
• designed to 
• routinely and reliably achieve
• as Perfect as Possible outcomes
• for the Client or Service Recipient
• by knowledgable and skilful
• Practitioners
• supported by systems, processes and procedures
• that actively monitor, examine and report performances,
• for both failures and successes,
• to systematically and without-backsliding improve 
• Quality, Performance and Process
• of Individuals, Teams and Organisations.

To Err is Human isn't a syllogism, it is an Iron-Clad Law.

It's the basis of the unending, relentless Professional Challenge:

• we're not machines,
• we cannot ever exactly repeat a process, not even twice, let alone the many times every day needed in Professional Practice, and
• our Minds and Bodies are always letting us down or tricking us in some way.

Simply stated: We are constantly making mistakes, inadvertently or not.

As people become older and wiser, they routinely report the veracity of "The more you Know, the more you understand how little you Know".

All Quality and Performance Improvement is predicated on engagement and care-and-concern for the people affected and the outcomes.

In the Quality Improvement approach, led by Dr Deming, the Fundamental Attribution Error, that Mistakes are due to people who have been inattentive, incompetent or negligent (or worse), is taught as a leading to The Blame Cycle, not corrective action.

Deming's Quality Improvement methodology/process is based on the tenet:

People, even the most competent and with the best will in the world, will make mistakes. The system is responsible for preventing or catching these incipient Errors before they turn into an Error, Defect or Accident. 

Dunning-Kruger effect: "unskilled and unaware of it" - doesn't go far enough. American Idol demonstrates, infinite self-belief without objective base: "I'm The Greatest, the Judges don't know anything!".

Psych Effects: We see what we expect to see, and cannot see things outside our 'range'.

Human Minds are "editing machines" par excellence, we all have very efficient perceptual filters, part of our competitive advantage over other species. We've learnt to leverage by many times the compute capacity we have by ignoring the unimportant, predicting what we expect to see and quickly generically classifying actions, words and behaviours.
Our brains silently select, delete, add and change what we sense in real-time and also from our memories.
It a necessary outcome of the processing problem: Our brains don't have the compute capacity to process (receive, recognise, analyse, classify, predict, react) the full input streams from our senses.
To reduce the load, we increase our focus and ignore everything else, even shutting down irrelevant senses and heightening those that are useful. This shows most clearly in extreme circumstances like accidents ("everything slowed down") or in a "killing zone" (those who can see, experience 'tunnel vision' of the danger, or their hearing is much heightened).

Our brains "edit" what our senses provide to avoid being overwhelmed and being able to react in real-time. Our brains develop models of the world, the objects and actors in it and of ourselves, then

Hence the immutable law of Quality: You cannot check your own work, you'll only see what you expect to see, not what's 'there'.

This is more than just "proof-readning".

Virginia Satir pointed out that the two most important faculties for perfect communication were denied us:

• We cannot 'see' inside anothers' head. We can't know what they are thinking and feeling, only infer it, and
• We can't see/experience ourselves as others see/experience us. (Which is why teaching communications skills with video/playback is a radical advance in the last 50 years.)

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].

Friends of Science in Medicine: What's the Agenda?

[Post moved to other blog.]

The more research I do, the more amazed I am at the Agenda of "Friends of Doctors and Maintaining the Status Quo".

• They are a thinly disguised branch of a very shady reactionary group.  Most, if not all, the 'Executive' of FoSiM have garnered awards from "Australian Skeptics Inc". [More on A.S. Inc's machinations and their real politck.]

• "Inconvenient Truths" are simply ignored or edited out by FoSiM. Would you expect less of these folk with their doctrinal attitude and blinkered views?
• In "Doctors, Nurses Often Use Holistic Medicine for Themselves", it is reported that in the USA around 25% more Healthcare Professionals than the general population (76% vs 63%). Should as the FoSiM stance implies, they all be drummed out of the Profession? Or do they know what they doing and actually look after themselves in the best possible ways?

• Fundamentals are ignored by FoSiM:
• "Show us the Data!" FoSiM are violently and implacably opposed to "CAM" (presumably Complementary and Alternative Medicines), roundly criticise and vilify therapies they do not approve of and loudly call for all Alternative Medicine/Therapies to be justify themselves with EBM and RCT, so beloved by FoSiM. Only no data are provided to suggest this is warranted, only opinion and non-peer reviewed articles. Compared to Establishment Medical and Hospital practice and outcomes, are alternative methods etc unsafe enough to be called into question? No data, no case...
   
• This is an argument first and foremost about Patient Safety, then Quality of Care and lastly about Effacy of treatment, therapies, medicines. But there is no definitive data for the outcomes of Establishment Medicine, despite them consuming consuming 10-15% of National GDP in mature, western economies to use as a baseline in discussing Efficacy.
    
• Science is not Practice. Substantially more than a few studies is needed to convert some Theory or data into reliable, repeatable Real World Practice. We know this, because it is being done intentionally and deliberately by at least one significant Healthcare System in the world, Intermountain Healthcare, Utah.

There is a well-known, perfect model for how to create an Industry-wide Quality and Safety Culture, in one of the most cut-throat profit-driven businesses ever: Aviation.

• A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate"  by both experienced, highly-competent Aviators and Medicos makes a very strong case for in both describing the systemic problems (the figures on waste, fraud and over-servicing are horrifying) and for outlining a solution.

Adopt what is known to work in Aviation, and has been proven to be Cheaper, Safer and Better on every metric for coming up to 2 decades by Intermountain Healthcare with their "Do it Right, First Time" Quality approach.

Isn't it odd that the self-appointed, self-proclaimed "experts in all things Medical", the FoSiM, haven't suggested this approach nor flagged that our Hospitals and Medical system are far from World's Best Practice.

Instead of seeking to improve their own failed Profession, they are seeking to attack and discredit "The Competition", or at least those that they can identify and target.

First, Do no harm: Patient Safety and the central fallacy of the "Friends of Science in Medicine" position.

[Post moved to other blog.]

"First, Do no harm"... Or so the Hippocratic Oath is presumed to begin.

The Dwyer/Marron "Friends of Science in Medicine" campaign against the teaching, insurance/reimbursement-for and ultimately practice of Alternative Therapies and Medicines of which they, and they alone, do not approve, is based on a central fallacy:

People are much safer being treated by the Medical Establishment not using Alternative Therapies and Medicines, but exactly the reverse is true. 

This debate is "all about Evidence", as in hard-data, but Patient Safety and Quality of Care must be examined first before any debate on Effectiveness can even be started.

The flip-side is the erroneous logic that "Good Science" is somehow causally linked to "Good Patient Care", but FoSiM ignore the Golden Rule of Execution: 

Science and Knowledge don't deliver outcomes, Practice does.

Before the Dwyer/Marron group can argue against any Therapy, Treatment or Medicine, by its own strict rules ("there must always be very strong Evidence"), it must:

Show us the Data! 

Where is their Evidence, the "Good Science" they want from everyone else, to demand any changes?

The worst logical trick and intellectual swindle played by the Dwyer/Marron group is their conflation and confusion of terms:

• A slew of unrelated practices are strung together in one long line of gibberish, with no distinction between recognised, well-controlled modalities and others, with all presumed to be 'equivalent'.
  If the Dwyer/Marron group cannot, or will not, distinguish between a piece of crud and a gem, what relevance or vracity do their arguments have?

• In Australia, there is a trivial and essential differentiator between all Medical Therapies, Practices and Medicines:
  • Is there a AHPRA Registration Board? and hence
  • Do Practitioners have a Medicare Provider Number?
  
  The failure of the Dwyer/Marron group to make this simple and essential distinction invalidates all their arguments, just who are they vociferously and ferociously objecting to?

• For the Dwyer/Marron group to disagree with Government Policy and Processes is their Democratic right.
  For them to not understand the way these decisions and processes are changed is via Lobbying and the Political process is both ludicrous and naive.

Whilst the Dwyer/Marron group and their FoSiM purport a wish "to foster Good Science in Medicine", their actions and statements belie a rabid bigotry, bias and prejudice.

Even in their Constitutions' statement of Object, they don't define or elaborate on their terms:

• "Good Science" is a vague, ill-defind term. To quote Shakespeare's Macbeth:
  "it is a tale told by an idiot, full of sound and fury, signifying nothing".

• There are "scientific methodologies" (hypotheses, test, result) and "(apparently) good or valid studies/experiments" with "strong evidence", but "Good Science" is at best a lay-person's term, not something any Professional in the field would use.

• Likewise, "Medicine" is a broad church...
  There is no definition ever offered for FoSiM's frequently used acronym, "CAM", presumably "Complementary and Alternative Medicine". This has some mysterious meaning only known to the Inner Sanctum of the Dwyer/Marron group. I expect it falls in the category of "I know it when I see it", a throughly undisciplined, non-rigourous and unscientific methodology - because it is inexact, ill-defined and non-repeatable.

Where does the Richard Dawkins comment that "there is only medicine that works" leave the Dwyer/Marron definition of "CAM"?

Invalid and irrelevant, like the rest of their bluster, assertion, dogma and prejudice parading as "the opinion of experts", because they can provide no test or Evidence to show, as Dawkins says, "what works and what doesn't".

The very real risk they face with their simplistic and naive thinking is that if they ever construct testable definitions, then a good deal of their own Establishment Medicine would be found wanting.

It comes down to this:

The Dwyer/Marron group have no documented process or methodology to define the Alternative Therapies and Medicines of which they, and they alone, do not approve. They have a loose, informal, self-referential definition: "Good Science, it's what we say it is".

They are self-appointed experts and judges, without credentials, special expertise or relevant experience, who are presuming to force their opinions, biases and prejudices upon the rest of us.

Whenever they cry "Show us The Evidence" or "That's not Good Science", all they are displaying is their own ignorance, ineptitude and biases.