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.

An answer: Why not an NTSB for Healthcare?

[Post moved to other blog.]

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

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

We believe that the question regarding an NTSB for healthcare is not why...but why not!

The Safety Leaders site has more great material than you can believe - its carefully selected, well structured and crafted; and finely targeted to various interest groups. It doesn't rely on assertion and dogma, but forceful and compelling hard-evidence from Healthcare and other high risk fields.

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

The primary answer is:

• What's in it for me?
• What's the upside of doing this, of changing how I work?

and the concomitant:

• Are there consequences for not doing this?
• What's the downside of ignoring or not doing this, or continuing "Business as Usual"?

Without changing the rewards and penalty structure, there not only won't will be, there can not be any systemic change.
"There is no reason we can't do that in Healthcare"

The first answer to the most of the "Why not" questions, the practitioner, manager and Board answer is simple:

• Why not? Because we don't have to.

A more insidious, subtle and ultimately deciding, not even pivotal, factor to consider is:

What are the blocks, active and passive, to change?

Reframing this question:

• Who has the most to win or lose from maintaining the current Status Quo?
• Who are the gatekeepers, individual, organisational and political, that can either enforce the current Status Quo, or prevent/limit change?

To stop rewarding behaviours and practices that are dysfunctional or not supportive of Societal goals and to start rewarding those things that fix the system, that address known problems. The O'bama administration has attempted to change the Healthcare system, but with extreme opposition from 'conservative' interests. It is unclear that anything will be accomplished from this initiative.

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

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

Good systems are designed deliberately to produce high quality work.
By eliminating waste, delay and the need to redo substandard work, they achieve long-term cost effectiveness." 

The Central Law of Improvement: every system is perfectly designed to achieve the results it achieves

What has changed since 1996? Was there a revolution?

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

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

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

There is another important difference between Aviation and Healthcare than must be addressed before there can be any systemic changes in the US Medical Healthcare system:

There are very few personal consequences of "poor performance" or "failures" for Doctors.

As a community, there has to be consensus support and a willingness to hold all Medical Professionals to the basic Professional standard:

• There is never an reason for a Professional to repeat, or allow, Known Errors, Faults and Failures.

Until the community embraces this as a minimum standard, nothing can change.

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

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

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.

The Budget, The Promise, The Dividend

Australia is about to pass a pivotal milestone:
 the last Federal ALP budget to run full-term for perhaps a decade.

It is already notorious because of the commitment Kevin Rudd made in 2008 that this budget would be in Surplus and the Coalition's constant carping and criticism about the ALP's "incompetence" in every area, including financial management. The clamour from economics commentators that it is not just unnecessary, but unwise, is just part of the lead-up to this event.

So, my comments on why we are getting, The Surplus We Had to Have.


The Budget

With the Australian Federal Budget under a week away, the ALP is attempting to bring down a Surplus, seemingly only for Political reasons.

We'll only know the result in 18 months, at which point, believing current trends, the Coalition will be in power and will pick a figure that:
a) makes their case that the ALP were "incompetent at everything" and
b) uses the usual rhetoric of "the situation was much worse than we were led to believe, we have to make much deeper cuts and reduce or defer some or all of our promises".

I can't add to the debate over the economic pros and cons of "The Surplus we had to have", but can point to a deeper set of concerns.


The Promise

The Rudd/Gillard governments backed themselves into a corner a number of times by making unwarranted unequivocal statements (e.g. "there will be no tax on carbon" and "we will have a surplus in 2012/13").

But leaders before have done exactly this, or made outrageous gaffs, and not felt the same need to Keep The Promise. The current ALP leaders are holding themselves to their statements and in this, having the Opposition pursue them on their promises.

• Hawke: "No child (need/will) live in poverty by 1990".
• Keating: "The recession we had to have" and "Banana Republic".
• Howard: "That wasn't a 'core' promise".

This could be the result of a generational change. All Prime Ministers up to and including Howard (e.g. Whitlam, Fraser, Hawke, Keating) literally had to have "town hall meetings" and learn to deal with hecklers without the assistance of microphones, effectively what every stand-up comedian has to learn.

Younger ALP leaders, Latham, Rudd and Gillard, differ in two important ways:

• they've had limited experience dealing with hecklers and antagonistic crowds (think of the difference between TV-only comedians and stand-ups), and
• they joined the Party Machine (or the Union movement) almost straight from school. Unlike Ben Chifley, who had a career as an engine driver before moving into paid politics.

There are other effects, such as the logical/absurdist extension of Sampling Theory and Statistical analysis of surveys invented by Gallup and used in 1936 to predict FDR's upset election.

This 'surplus', head-line or underlying, real or faked, is entirely for Political reasons, and as such is an "own goal" for the ALP. At the very least, they've shown they are inflexibly wed to any and all their policy statements and can't see a way around themselves to "adapt, improvise, overcome" in response to changing circumstances and needs.

But the real concern for every elector/taxpayer is the overwhelming message from both major parties:

Politics trumps Public Good. They don't care what harm they cause in the pursuit of a short-term political advantage or goal.

This is our future, our jobs, our money they're playing with so cavalierly. There is no "Government Money" to spend, only taxpayers wages.


The (Efficiency) Dividend

[My previous piece on the "Triple Whammy" effects of waste in I.T. is useful background for this.]

Keating introduced the Efficiency Dividend, or really Automatic Budget Reduction, to Federal Government in 1986. Notionally, it was a systematic attempt for Departments and Agencies to be forced to realise, and hand back, the productivity gains due to Technology, I.T./I.C.T. particularly.

Which is fine sounding until you pick apart the assumptions and implementation.

I was caught up in the first I.T. Recession in Australia, at the end of 1990. Westpac laid off 500 contractors (for the abandoned project CS90) at Christmas. It was 1994 before Computing and I.T. graduates were back to 100% employment. For a while, a Chemistry or Geology graduate had a better chance of finding work in their field - very different to the industry cries beforehand of "we have a staff shortage crisis" and "I.T. it's a job for life".

That first I.T. Recession was because all the low-hanging fruit was picked: all Australian businesses and Government Agencies had hired more I.T. staff to automate their back-office functions and replace (low-level) clerical staff.

In 1990/1, I.T. staff were cut, just like all other staff.

Why is this problematic? Consider these three related points:

• If this was 1965 and government Agencies had to supply all now current services, would we ever have an unemployment problem? [How many people would it take for Centrelink, ATO, Medicare, etc to do their work and handle 800,000 unemployed?]
• I.T., like Marketing, is an intangible and an indirect cost. We do them both for a Business Benefit. But we don't measure, report or analyse I.T. benefits.
• I.T. is a Cognitive Amplifier. We use it to automate business processes and increase staff productivity. Rough estimates suggest a 10-100 times 'amplification'.

The Keating Efficiency Dividend is recognising all three points:  from all the money invested in Federal Government I.T. Systems, rather large savings should have been realised.

The workload, and notionally the workforce, of many or most Federal Government Agencies should scale with population size - growing at a long-term average of 1.5%. [18M in 1996, five times the 1901 size]

But after 30+ years of I.T. Automation, for the Public Service to have only achieved a 1% total savings either suggests:

• gross incompetence in either failed or unproductive/irrelevant projects,
• management fakery in reallocating savings to increasing empires, or
• an increased level of service, either numbers served or complexity and number of services provided.

But we don't know what's happened: what staff productivity or organisational efficiencies have been realised?

This is a massive management and reporting failure on behalf of the permanent Public Service, but an even greater failure of governance and insight on behalf of the Parliament they report to.

This leads to another set of points:

• Not all Government Agencies can achieve the same efficiencies as their workload and workforce are dependant on different factors,
• Different areas within Agencies cannot be expected to yield the same "efficiency gains" for the same reasons, their inherent workload scales from different factors, and
• "Percent maximum potential efficiency" is not calculated nor taken into account. The past improvement by individual Agencies, and the future savings possible, are seen as irrelevant.

The Productivity Commission [2004] reported that ICT was still the single largest factor driving (staff) productivity growth, yet there appears no intensive study of the APS (Australian Public Service) to which it has special access and interest, nor does there seem to be a recognition or refutation of this is Agency management practice.

If investing in I.T./I.C.T. is still the most cost-effective way of improving productivity, and hence of meeting the Efficiency Dividend, why are any Government Agencies apply the full 4% 'dividend' across all their organisational units?

If I.T./I.C.T investment is judged as not improving productivity, where is the evidence?
Pointing to a glaring omission of all Government Agency Annual Reports. Although they all have detailed reporting against "Key Outcome Areas", there are no output metrics.

Productivity is a measure of Output per unit of Input. Within the APS reporting schemes and managerial system/requirements, only Inputs (staff numbers and on-costs) are measured. Failing to even notice this gap, let alone address it, seems to me to be another monumental failure of the APS's management and culture.

Politicians, as managers of the APS, make decisions/directions are unpredictable, capricious and irrational. This is simply the nature of the beast. Politics is the Art of the Possible.

Which means senior managers in the APS have to deal with this insane world.

Down the organisation structures, staff never learn to relate their time input into economic value output. The simple cost/benefit equation at the heart of every business transaction that any 16-yo at MacDonald's learns is missing: wages have to be paid for.

This has led to an incredible blind-spot within the Public Service, resulting in systemic management and reporting failures such as not defining and collecting/reporting staff output data so year-on-year Productivity can be tracked.

What we can absolutely say about the 4% (1.5%+2.5%) Swan/Gillard Efficiency Dividend:

• it should not be evenly applied across all Agencies, but has to be because the necessary management data is missing.
• it should not be evenly applied within Agencies because the necessary data is missing.
• without evidence, APS managers are blindly acting. Should they be investing in more I.T./I.C.T. or reducing I.T. staff/budgets more than 4%?
• There will be uneven and disproportionate effects on the delivery of Government services.

Just because Politicians live in an extreme world is no excuse that they don't properly fulfil their Fiduciary Duty towards their constituents - the people who've entrusted to them their future livelihoods and living standard.

We, as taxpayers and electors, need to be demanding a much higher standard of management and governance from the Politicians representing us.

Is there any reason that the Public Service is not the best organised, best managed and provably most productive and efficient/effective organisation in the country? Why should the Public Service be less than the definitive model of good management and good governance? The standard that every organisation is judged by.

The only reason is that we haven't held our Politicians accountable for their performance.

We have let them get away with putting their interests ahead of what they are elected and paid to do:  husband the public purse, the taxpayer dollar, for the best possible outcomes and sustained benefits to the citizenry.

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.

---

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.

---

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.