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.

A balanced post on the EBM vs Alt.Med Debate.

[Post moved to other blog.]

I thought this article balanced and informative. I liked the stated intent "moving beyond virulence" in the title. Of course, Doctors and Friends against Alt.Med did their usual scorn and bile attack in the comments.

"Evidence-based medicine v alternative therapies: moving beyond virulence", 23-March-2012.

Main arguments:

• The absent patient
• Lack of critical reflection (on philosophies of health and the politics of medicine)
• Evidence-based medicine (the critical analysis of EBM)

There is a long comment by 'Anne Cooper', Osteopath, that I thought was good. [click on "show full comment" to see it all]
Her ending is very strong:

So instead of the FoS attempting to take a high moral ground, and at the same time appropriating the term ‘medicine’ (not to mention the title ‘Dr’), perhaps it could instead lobby for funded, high quality research that will enlighten us all as to why these unsubsidised therapies are able to attract and treat so many hundreds of thousands of Australians every day. Now that would be useful. Failing that, their campaign looks to be little more than a turf war.

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.

Systemic Quality and "The Iron Triangle" of Quality, Cost and Schedule.

The work on Safety and Quality systems by James T. Reason and Charles H. Perrow redefined the world of Quality, showing up in acceleration Safety in Aviation post-1970.

But what do you call this approach?

I'd like to suggest, "Systemic Quality".

Perrow called them "Normal Accidents" and Reason "Organisational Accidents". Both were talking about System created Accidents. Where multiple events, not individuals, are the cause of unintended poor outcomes. But neither coined a term for this approach to Safety and Quality.
My reasoning for the naming is:

Name the approach after the cause addressed, Systems create the problems, so it's Systemic Quality.

The text below is adapted from a piece on suggesting Medicine become a Modern Profession, like Aviation.

What Dr W. Edwards Deming understood so well is that Quality, Process Improvement and Performance Improvement are linked through the same fundamental:

Deliberate, focussed review of work outcomes with intentional Learning and Adaption are necessary for, and common to, all three.

This is enshrined in Deming's P-D-S-A (Plan-Do-Study-Act) cycle, which he called the Shewhart Cycle.

Systemic Quality through its design and nature improves Safety, Performance/Productivity and Economic Performance/Profitability.
Something that Apple Inc knows and Microsoft, the long-time market leader, does not.

---

What does a modern Profession look like?
Aviation as a perfect model.

In Project Management, there is the "Iron Triangle", usually explained as "Good, Fast, Cheap: pick any two".

Alternatively, the "Iron Triangle" is described as: "scope, schedule and cost constraints".
This definition, with no explicit mention of emergent or unspecified Dimensions like Safety and Quality, can lead Project Managers astray. Deming showed that Cost and Quality are intimately linked, and focusing only on costs ultimately drives costs up, while driving quality down.

This piece of received wisdom says that Economic Profitability, Job Performance and Product/Process Quality are competing dimensions, to optimise one of them, others have to be sacrificed.

This just isn't so.

It only appears that way if a) you examine a single project (in the short-run) and
 b) your Project Methodology doesn't include the last half of Demings' cycle (Plan - Do - Study - Act to improve system).

Dr Deming's proven theories on Performance and Quality rely on two fundamentals which you might recognise from the Scientific Method:

• Be inquisitive, examine your own performance, look for insights into your work and outcomes, self-examination is the precursor to insight, and
• try to constantly improve both your knowledge and practice, to consciously learn both from your failures and successes.

This "conscious, deliberate learning" mindset is a necessary condition for constant improvement in all three aspects of the Iron Triangle: Profitability, Performance and Quality.

It's a long-run, not short-run, effect. It doesn't appear within a single project, but after the execution of many. The most important part of every project is the Analysis/Learning phase after it, the Project Review.

For cottage-industry crafts, where you only practice "as learnt" skills without deliberate improvement or correction, the veracity of the "Pick any two" rule is both obvious and unbreakable.

For modern Professions which practise System Quality, i.e. "Do it Right, First Time", the 'rule' is wrong and misleading.

Back to Aviation, a modern Profession where, in most but not all countries, Systemic Quality is pervasive and firmly embedded in the culture and practice of each discipline and speciality, as well as in the governance of the whole Industry and its component parts.

More importantly, there is free, public data on the performance of the Industry.

Page 11 of the EASA's 2010 Annual Safety Review, has a powerful chart [Fig 2-1] showing how the Industry has progressed/improved and some words that should make the Australian Medical Profession both ashamed and envious:

The data in Figure 2-1 show that the safety of aviation has improved from 1945 onwards. Based on the measure of passenger fatalities per 100 million passenger miles flown, it took some 20 years (1948 to 1968) to achieve the first 10-fold improvement from 5 to 0.5. Another 10-fold improvement was reached in 1997, almost 30 years later, when the rate had dropped below 0.05. For the year 2010 this rate is estimated1 to have stayed at 0.01 fatalities per 100 million miles flown.
The accident rate in this figure appears to have been flat over recent years. This is the result of the scale used to reflect the high rates in the late 1940s.

Another Canadian educational / reference site, OLD with an inspiring graph on the improvement in Aviation Safety says:

Up to the early 1970s the number of fatalities increased with some proportionality with the growth of air traffic. By the 1970s, in spite of substantial growth levels of air traffic, fatalities undertook a downward trend. This is jointly the outcome of better aircraft designs, better navigation and control systems as well as comprehensive accident management aiming at identifying the causes and then possible mitigation strategies.

This isn't isolated or peculiarly European: 

• US Air Carrier Safety Data and Air Carrier Profile (economic and performance figures)
• US General Aviation Safety Data and General Aviation Profile.
• AOPA (Aircraft Owner and Pilots Association) General Aviation Safety record.

The reason for these massive, on-going improvements is the detail and seriousness of incident investigations. Notably, while commercial "Air Carriers" have improved their Safety and Operations by several orders of magnitude while being profitable in a cut-throat industry experiencing a 1,000-fold increase in services delivered, "General Aviation" has improved, but by only approximately 5-fold. The difference isn't in the technology, training available or processes/procedures detailed. It's the Professional "Right First Time, Every Time" approach of Systemic Quality and attention to preventing Organisational Accidents.

The crash in early 2009 into the Hudson River of US Airways 1549, piloted by  Capt. "Sully" Sullenberger, was dramatic, widely reported, and resulted in no fatalities and only a handful of injuries.
In most professions, it would be regarded as a huge success and not studied.

Yet it led to 35 "Recommendations" by the US official investigator, the NTSB (National Transport Safety Board). Think how different this is to most Medical practice: even injuries resulting in permanent disabling of patients, like the 2010 preventable and foreseeable injury to Grace Wang, a repeat of a well known Error, led to news reports, but no obvious investigation and certainly no consequences for anyone involved.

These NTSB "recommendations" will be implemented, will be checked upon by a regulatory body [the FAA] and failure to do so will result in proportional, direct, personal and organisational consequences.

This is completely at odds to the 550+ page report by the 2005 Queensland Public Hospitals Commission of Inquiry, triggered by Jayant Patel and others, where the Recommendations are optional, their (timely) implementation won't be checked, nor will there be consequences for anyone repeating these Known Errors, Faults and Failures.

One of the reasons for this cultural change in Aviation and resulting the on-going improvement of Safety, Quality and Performance in Aviation is the theoretical work of two men:

• Charles Perrow, creator of "Normal Accidents" (a theory of systems accidents)
• Prof. James T Reason, (ex Manchester Uni, UJ), psychologist and author of "Human Error" and originator of the "The Swiss Cheese Model" for the cause of accidents.

NASA uses Perrow [PDF] as a basis for its Safety programmes.

Prof. Reason seems to have retired from Academe, but is still listed as an advisor to "The Texas Medical Institute of Technology (TMIT)".

James Reason's work is well known in the medical community: it was used by Dr Brent James and colleagues in the remarkable turnaround and improvement of Intermountain Healthcare, reported in "Minimising Harm to Patients". On the wikipedia page on "The Swiss Cheese Model", a large number of pieces in "Further Reading" are medical.

Where this ends is a 2012 article published in "Journal of Patient Safety", available on the TMIT site, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate", where the authors, Medicos and Aviators and authors of 100 medical papers, call for applying what is known to work in Aviation to Medicine.

An idea that seems long overdue, although they don't go as far as suggesting the second, necessary, pillar of the Aviation system, the US FAA or UK's CAA, a regulatory and compliance organisation (also responsible for provision of common services, like Air Traffic Control). These organisations are charged with first implementing and on-going checking of NTSB recommendations, bringing direct, personal consequences to those not complying.

Without "accountability", recommendations and findings have little likelihood of being fully and consistently practised.
Abstract:

Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. 

This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable safety innovations we have already paid for that have made the airline industry one of the safest in the world. This first part supports the debate for a National Transportation Safety Board (NTSB) for health care, and the second supports more cross-over adoption by hospitals of methods pioneered in aviation. 

A review of aviation and healthcare leadership best practices and technologies was undertaken through literature review, reporting body research, and interviews of experts in the field of aviation principles applied to medicine. An aviation cross-over inventory and consensus process led to a call for action to address the current crisis of healthcare waste and harm. 

The NTSB, an independent agency established by the United States Congress, was developed to investigate all significant transportation accidents to prevent recurrence. Certain NTSB publications known as "Blue Cover Reports" used by pilots and airlines to drive safety provide a model that could be emulated for hospital accidents. An NTSB-type organization for health care could greatly improve healthcare safety at low cost and great benefit. A "Red Cover Report" for health care could save lives, save money, and bring value to communities. 

A call to action is made in this first paper to debate this opportunity for an NTSB for health care. A second follow-on paper is a call to action of healthcare suppliers, providers, and purchasers to reinvigorate their adoption of aviation best practices as the market transitions from a fragmented provider-volume-centered to an integrated patient-value-centered world.

EBM's and RCT: Doubt, Scientism and unquestioned Ideologies

[Full post moved to other blog.]

update 8-Apr-2012: Quotes from "Evidence-Based Medicine: Neither Good Evidence nor Good Medicine" by Steve Hickey, PhD and Hilary Roberts, PhD.

• The current approach to medicine is "evidence-based." This sounds obvious but, in practice, it means relying on a few large-scale studies and statistical techniques to choose the treatment for each patient. Practitioners of EBM incorrectly call this process using the "best evidence."
• Significant Does Not Mean Important...
• Large trials are powerful methods for detecting small differences.
• There is a further problem with the dangerous assertion implicit in EBM that large-scale studies are the best evidence for decisions concerning individual patients.
• As we have mentioned, EBM restricts variety to what it considers the "best evidence."
• A doctor who arrives at a correct diagnosis and treatment in an efficient manner is called, in cybernetic terms, a good regulator. 
• According to Roger Conant and Ross Ashby, every good regulator of a system must be a model of that system. Good regulators achieve their goal in the simplest way possible.
• In order to achieve this, the diagnostic processes must model the systems of the body, which is why doctors undergo years of training in all aspects of medical science.
• In addition, each patient must be treated as an individual.
• EBM's group statistics are irrelevant, since large-scale clinical trials do not model an individual patient and his or her condition, they model a population-albeit somewhat crudely.
• They are thus not good regulators.
• Once again, a rational patient would reject EBM as a poor method for finding an effective treatment for an illness.
• Diagnosing medical conditions is challenging, because we are each biochemically individual.
•  As explained by an originator of this concept, nutritional pioneer Dr. Roger Williams,
• "Nutrition is for real people. Statistical humans are of little interest."

---

The Friends of Doctors espouse an uncritical Ideological belief in a simplistic doctrine:

Evidence Based Medicine is the only source of Good Science and hence Good Medicine.
All else is, by definition, irrelevant, invalid and, at worst, quackery.

Which is a variation on Scientism, "the universal applicability of the scientific method and approach".

In 1898 you might've excused a Great Expert from declaring "We know everything and have invented everything" [paraphrased] - but in the 21st Century, for anyone to have the arrogance and hubris to make universal/absolute statements that are not dissimilar is unbelievable.
Doubly so, if like FoSiM, they hold themselves up as Great Experts (Professors with many awards and decades of experience).

I have a very specific objection to the FoSiM position, roughly, EBM/RCT's are OK as far as they go, but are far from being the only thing:

RCT's are a necessary, but not sufficient, way to gather evidence, but can never provide proof. Popper's "falsification" notion says theories can never be proven, only disprove with 1 counter-example. The source of the economics/finance term "Black Swan" - something completely new and unexpected.

Why would a group of eminent persons go out of their way to make themselves look complete fools, espousing an entrenched and immovable position that is obviously flawed?

The only reasonable answer I can come up with is:

They are fighting a Turf War and using EBM/RCT's as an overwhelming strength with which to beat-up their opponents. But if the opponents start to provide RCT's, then they can either play "Change the Rules" or "Move the Goal Posts" to force the opponents to waste time and resources.

The unreasonable explanation is these folks are uncritically and intractably wedded to the Ideology, "EBM and RCT's are everything".


In summary:

Medical Science uses RCT's because it's the best thing they've got, but belief in them "should be held lightly", they are not infallible nor free of serious deficiencies.

Evidence Based Medicine is a good servant and a poor Master. The emphasis must be on Medicine, not 'Evidence', on providing good patient care and outcomes. Chief of which is focussing on Patient Safety, not the glittering bauble of "efficacy". "First, do NO harm"...

Friends of Doctors: What the figures say...

[Post moved to other blog.]

An analysis of the 11-March-2012 members list of "Friends of Science in Medicine":

• They can claim 28 'Friends' outside the field or their parent body and who still work.

Calling the group "Friends of Doctors" is far more accurate.

Note: A full count of members of the parent Organisation, "Australian Skeptics" is not possible without a public membership list (4,000 subscribers are claimed to "The Sketpic").

The organisation's own analysis, (494 members, 25-Feb-2012) is:

Of the 494 individuals were a total of 226 (45%) medical doctors (212 Australian, 14 Overseas) and other disciplines (243 Australian, 25 Overseas).

My analysis:

• 502 unique names,
• 1 duplicate record, "Prof Jon Emery"
• 123 with title "Dr"
• 5 non-health related
• 334 with title "Prof" (including A/Prof)
• 4 FoSiM Executive members
• 34 Emeritus or retired
• 165 MBBS, MD, BMedSci, FRACP, FRCP, FANZCA, FRACGP, Obstetrics & Gynaecology, Medical Oncology, Psychiatry, Pharmacy/Pharmacology, RN
• 131 remaining:
• 15 in non-health areas
• 41 not "Dr", "Prof" or on the Executive.
• 7 declare or publicly state membership of the parent Organisation, "Australian Skeptics"
• 17 are in Medicine/Medical Science or allied disciplines (Pharmacy, Nursing, paramedic)
• 18 "non medical" vocations [counts not given].
• health/biology related
• 8 non-health related
• Information Technology 
• MSc(Astronomy) BSc(Finance & Economics) 
• Science, eLearning Officer
• legal researcher, solicitor
• science writer/editor/creative director

Censorship in 300 words or less. What's up at Fairfax?

[Post moved to other blog.]

An article in the Fairfax media entitled "Homeopathy | Alternative Medicine | Ian Gawler" drew my attention. I went to the effort of registering and making a comment. It didn't appear, having been "moderated", presumably breaking the Fairfax Rules for Commenting on articles and blogs :-

... any comments that can be reasonably considered offensive, threatening or obscene will not be allowed.

• Do not post material that may incite violence or hatred.
• Gratuitous abuse - be it of the author, subjects of the story or other commentators - will not be accepted.
• Please keep your comments relevant to the discussion at hand.
• Do not use the comments section for commercial purposes or spam.

Herewith my comment and the original article... [See full post]