Monday, June 25, 2012

An answer: Why not an NTSB for Healthcare? II

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?

There are no "smoking craters", nor any vision/images for the media to build a story upon.
There is no big story for the six o'clock News, no individuals' story is 'newsworthy' enough.
"If it bleeds, it leads" cuts both ways...

Describing 100,000 "preventable deaths" from Medical Error/year as equivalent to "10 planes crashing per week" is numerically correct, but an invalid comparison.

Patients don't die all together, they die slowly, not instantly and they are widely scattered - there is a very low density of Medical Error on a daily basis. Each death, although tragic, is invisible.

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.

Because deaths and serious injury from Medical Error is so frequent, common and widespread, only the most egregious and sad are reported, like the 2010 preventable and foreseeable injury to Grace Wang, a young first-time mother who was paralysed in Sydney, NSW, through a repeat of a well known Error.

While tragic for the family and friends of victims, those individual stories have no "news value" outside direct acquaintances.
Plus, the sheer volume of individual stories means a cut-off is needed. The time taken to just read 2,000 names every week would be hours and hours of "dead time".

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.
Chip and Dan Heath, in "Made to Stick", Why some ideas survive and others die, layout a formula for successful story-telling, or getting ideas to resonate and spread:
  • Simple
    • Makes the story accessible.
  • Unexpected
    • Makes people pay attention.
  • Concrete
    • Makes people understand and remember.
  • Credible
    • Makes people agree and believe.
  • Emotional
    • Makes people care.
  • Stories
    • Be able to act upon it
    • A story's power is twofold: It provides stimulation (Knowledge) and inspiration (motivation to act). Both benefits are geared to generating action.
That these are very hard to do altogether is shown by how few "urban myths" there really are and how little we each retain in detail from the nightly news.

What the estimable brothers Heath 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.

Sunday, June 24, 2012

An answer: Why not an NTSB for Healthcare?

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!
  • Why not use best practices that taxpayers have already paid for to prevent the more than 30 preventable deaths an hour in American hospitals?
  • Why not use methods that have been field-tested with proven results?
  • Why not save money while saving lives and bringing value to our communities?
  • Why not leverage great tools from aviation that clearly have application to healthcare?
  • Why not challenge common risk-management processes to prevent the national sharing of information?
  • Since current databases of healthcare accidents are so small, sparsely populated, and inaccessible to all hospitals, why not have a fast-track program generating "Red Cover Reports?"
  • Why not address the Health Information Technology (HIT) risks proactively, as we know unintended consequences occur when we introduce new technologies?
  • Why not learn the lesson from aviation – that we must move beyond reporting causes and aggressively move to prevention of accidents?
  • Why not give high net worth individuals like Warren Buffet who feel that tax rates are too low an opportunity to provide funds to create an NTSB-like demonstration project and prove what we already know and save lives in the process?
  • In a new report from the IOM HIT and Patient Safety; Safer Systems for better care, a committee of independent experts has called for an NTSB like body to investigate serious problems related to HIT – why not listen to them?
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.

Watching the truly outstanding series, probably from 2010 and onwards, "Surfing the Tsunami", there's a panel discussing the IOM report  "an NTSB for Healthcare".

Where they note they didn't phrase the central question as "we need to do this", but "Why not do this?"
They are truly perplexed by the lack of take-up and enquire of the audience, "Why Not?"

In "An unnoticed crisis in Healthcare", I posit a systems effect based on "thrashing" that, whilst a very well know computing problem, is almost unknown outside.
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 Organisation Dynamics driver to purse is mundane but pervasive:
  • Follow the Money!
    • Power, Influence and the ability to demand compliance or "say NO and make it stick" all track back to power over budget or positional power: Status is a proxy for pay-scale. We award high Status employees with money and, for principals and owners, individual and organisational Status determine the ability to attract paying customers and set billable rates.
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?
Again, the answers come down to self-interest and pecuniary interests.

My perception of the absolute blockers of this Change Programme are:
  • A pervasive "Medical Culture" of roughly:
    • The "Doctor as God": all others within the System must bow to them, to accept their unquestioned authority.
    • Doctors are Kings of their own Domain, with an inherent right to unquestioned authority and self-determination within their sphere of control.
    • Like Lords and fiefdoms of the Dark Ages, Lords do not interfere with, on comment on, the affairs in any other Domain, but still pay homage to those above them in the hierarchy.
    • "Doctors don't make Mistakes, just encounter 'difficult cases'".
  • The Medical suppliers, Big Pharma and services industries that do very nicely right now and have the inalienable commercial right to fight to retain that.
  • The all too many current Medicos in the "top 5%", and everyone with the ambition to join them.
  • The Hospital Administrators and Board Members who get paid based on how things are now.
  • The AMA, American Medical Association:
    • Is it an employee Trade Union, a Sole Practitioner or Small Business Association, a Business Owner Association or Medical Trade Association, or all of those?
    • How does it fulfil the primary role of a Professional Body in disseminating Knowledge and Current Practice, both What Works and What Doesn't?
    • How does it fulfil its Fiduciary Duty to Societal Groups that need representation and protection, but don't have the influence, knowledge or resources to make themselves heard?
    • When lobbying Government and Regulators, how does it resolve the inherent conflict of interest between "standing up for members interests" and its Fiduciary Duty to individuals and the Society its serves?
    • Does the AMA, through its elected officials, have a consistent, clear overarching vision of Serving the Public, or something else that allows savage internecine Politics and viscous wars within and without the Profession?
Clearly, the AMA is critical to the acceptance and implementation of a radical change in not just how Healthcare is delivered in the USA, but the Medical Culture and system of payments. Is it likely to recognise, let alone address, that it has inherent conflicts of interests at its core? Without acknowledging who it is and what it does, the organisation cannot change.

The obvious most effective Political change needed is in Funding.

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. This is perhaps the greatest threat in 100 years to American Democracy and Sovereignty. Nobody "in Power" within the Roman Empire saw the end coming, the inexorable march of competitors into their heartlands. Nor did those "in Power" in the USSR and Eastern Block seem to notice or prepare for the acute disruption of their system following the fall of the Berlin Wall in 1990.

This is the shape of these disruptive "step" changes: Nobody inside seems them coming.

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.
Pilots, operations and maintenance staff and Organisations face real, immediate penalties when they are discovered to have repeated, or allowed, Known Errors, Faults or Failures.

Pilots, unlike Doctors, face immediate, dire personal consequences when they catastrophically fail in their mission: they die.

Fear of death "focuses the mind". No pilot ever did less than their best when attempting to avoid a crash.

For those that have listened to the voice-cockpit recordings of Capt. Chesley Sullenberger in the 208 seconds it took Flight 1549 to end up in the Hudson river, his very calm, focussed and steady state seems to contradict any acute stress reaction as he faced imminent death, "mission failure" and the responsibility for the lives of everyone "back there".

Capt. Sullenberger suffered an actue, on-going stress reaction to those 208 seconds. For nearly three months afterwards he had significantly elevated heart-rate and blood-pressure. The immediate aftermath, of the first fatality free ditching of a jet-liner - an outstanding success, was that he couldn't sleep for at least a week. He did not return to the flight-deck of commercial aircraft after he recovered, thought I believe the First Officer did. This is not uncommon amongst anyone in Aviation who feels responsible for a fatal accident, not just pilots.

Pilots not only care about the outcomes (safe passage) for those whom entrust their lives to them, they put their own lives on the line.

Doctors may care for their patients' outcomes, but don't have "skin in the game" in nearly the same way. Their motivation to reduce adverse patient outcomes is infinitesimal when compared to pilots.

So the answer has to be simple: let Doctors suffer dire personal consequences for their failures.

Only that is the worst possible action, as Dr Brent James pointed out to me, this would guarantee perverse outcomes and worse quality of care.
People optimise what is measured, a well known management principle.
As soon as the organisation measure Errors, Faults and Failures, and assigns individual blame, rational people (Doctors included) will modify their behaviour to avoid any censure: they'll devote the majority of their resources to CYA (Cover Your Arse).

Not only is a fundamental shift in the funding model of US Medical Healthcare required to create improved Quality of Care, real change is needed in the rewards and penalty structure:
  • Failure to promptly report "Adverse Event Incidents" by any Medical Staff must lead to Professional penalties.
  • Prompt personal reporting of real or potential "Errors, Faults and Failures" must be protected, to have no Professional or Personal consequence beyond retraining or reassignment.
  • Medical Error litigation against employed individuals must be banned, with only Organisations being held responsible and able to be sued.
    • The high-cost of "Professional Indemnity Insurance" has to be addressed.
    • Organisations and individual Medical Professionals need to be able speak to families and victims of Medical Errors openly and fully without concern for legal liabilities.
  • On-going care for, or compensation of, Medical Error victims and their families has to be automatic, fixed and reasonable. Awards are not windfalls of the legal lottery, nor an encouragement for the legal system.
    • A significant step forward must be removing the incentives for legal practices to pursue Medical Error litigation.
  • Hospital Administrators and to a lesser extent, Board Members, have to assume direct, personal liability for Patient Care outcomes.
    • This requires a legislative change.
    • Most importantly, the legal basis of evidence needs to be altered
      • This is not about single individuals, but the aggregate Quality of Care and Patient Safety delivered across all patients within a system.
      • People can be barred as Directors of Companies for poor behaviour, so should those in Positions of Trust within Medical Healthcare.
  • Collection and full public reporting of Patient Safety data is critical.
    • Falsifying, interfering with or manipulating Patient Safety data should be a severe criminal offence.
  • Public Root Causes Analyses of all fatalities and severely harmful Medical Errors need to be conducted and published within 'reasonable' timeframes by independent, properly resourced and trained experts.
    • Civil and Criminal charges must be possible against:
      • anyone repeating a Known Error, Fault of Failure.
      • anyone charged with preventing Known Errors etc from failing to do so.
      • Any and all owners and managers who fail in their Duty to Prevent Harm.
      • Organisations and managers/office bearers within them that fail to disseminate Harm Prevention information and processes/procedures in an effective and timely manner.
      • "Wilful Blindness" provisions are needed as well. Practitioners, Administrators and Owners/Managers that do not actively pursue Quality Improvement or Knowledge dissemination are culpable through an act of omission.
  • New Criminal Offences for Medical Practitioners are needed on the statue books:
    • intention to Harm, (ie. deliberate malfeasance) and
    • Professional Negligence demonstrated by persistently low Quality of Care indices or excessive Patient Safety violations.
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.

Thursday, June 21, 2012

A Theory of Professions

[Full post on other blog.]

Here I attempt to lay out a Theory of Professions that can be used to guide and inform practitioners, Professional Bodies, Regulators, Governments and the general Public.

The original contribution here is an attempt to layout a framework to categorise Professions by their Duty to Others and suggest that these duties apply at multiple levels: Practitioners, Organisations, Whole Profession.

Wednesday, June 13, 2012

On Being a Professional: 3 Axions. Right Reasons, Attitude, Aptitude.

[Full post on other blog.]

I've stated for a time my rubric of Professional Practice as a rhetorical question:
When it is ever acceptable for a Professional to repeat, or allow, a Known Fault, Failure or Error? [A: Never]
Some larger questions arise but won't be dealt with here, but they imply a meta-level, the "Profession":
  • Define 'Known' (which needs a means of transmission), and
  • What are, or should be, the Consequences of unprofessional conduct or performance?
Healthcare, Medicine and the Learned Professions (eg. Law) have a special (higher) onus of responsibility on them. In the scale of Professional Duty, they are the most stringent and demanding:
  • Fiduciary Duty or Trust:
    •  "involving trust, esp. with regard to the relationship between a trustee and a beneficiary" [Oxford American Writer's Thesaurus]
  • Fair Go, Fair Treatment.
  • No Rules, Buyer Beware.
I'm positing three axions of Professional Practitioners, especially those with a Fiduciary Duty to their clients:
  • Clean Motivation of Entry into and Practice in the Discipline: not Money, not Status, not Power/Prestige/Influence.
  • Continuous Active Learning and Improvement.
  • A trusting and safe environment, "The fundamental Clinical Requirement", for the patient to "open up" into a full, frank and unstinting clinical communication.
Lastly, there's the matter of Talent.

Some people are gifted in a field and given the same degree of training and practice, outperform us "mere mortals" by many times. Some might say "orders of magnitude".

The proof is Elite Athletes and Professional Sports. Talent counts, not just perseverance, determination and desire. Talent counts as much in the clinical setting as on the sports field - and the results are similarly different.

Professions don't do themselves favours by allowing those of limited Talent to practice.
It diminishes the field and fails the patients.

Ironically, through the Dunning-Kruger effect (tone-deaf performers self-assess as virtuosos), this can institutionalise perverse selection and assessment regimes:
   when the professors are tone-deaf, they reward those like themselves and remove all others.

Exemplified by the claim: "I'm the Best XXX in the South-West/North/Area/City/State/..."
It's an error of logic of the kind: "compared to what? by whom?"

The Dawkins Appropriation: Not just wrong, dangerous

Richard Dawkins is credited with the observation:
there is no alternative medicine. There is only medicine that works and medicine that doesn't work. [italics added]
Sounds reasonable, sounds obvious, sounds good. But it is wrong.

As Medical practice subsumes other techniques and modalities, how well does it do it? How well can it do it?

What is lost in translation?

This is the same problem as learning a new language.
Without the Culture and Context, the learning is seriously compromised.

Yes, you might have some fluency, some ability to get yourself understood and able to hold modest conversations.

Do you understand the humour? Know the sensitivities and 'no-go' areas? Do you have dreams in the language?

My thesis:
 the Culture, Theory, Practices and implicit knowledge and models underpinning a technique, therapy, practice or modality cannot be separated from it.
 Secondly, it's called "practice" for a reason. Like playing a musical instrument, to become accomplished in the art, you need a lot of practice to build the skill. But then you have to maintain the level of practice to maintain the skill. Mere performances won't maintain concert-level skill, and worse, infrequent performing result in lessening of skills. At some point you are back to "amateur" status.

"Cherry Picking" can only lead to sub-optimal results, or worse, real harm to patients through ignorance and poor techniques.

There is massive Hubris and Arrogance that's implied by the thought: "I can learn a technique in a single day/week that dedicated practitioners take years to learn and much longer to refine and perfect."

Can Doctors perform Acupuncture or Spinal Manipulations as well as native trained, specialist practitioners? Those who practice their craft daily.

I argue, not nearly.

Can cross-trained MD's perform basic practices? Possibly.
Can they perform those practices consistently well? Unequivocally, No.
Can they blindly stumble in and screw things up for the patient, errors that no competent specialist practitioner would make? Not only assuredly, but guaranteed to do so.

The test ('razor') is simple:
If Primary Care Physicians (G.P.'s) don't ordinarily perform specialist procedures like surgery, why would they take it on themselves to perform other specialist procedures they are not constantly practicing? It's unsafe, unethical and unprofessional.

Similarly, in hospitals and specialist clinics, would the specialists expect to perform procedures that are the domain of other specialities? Again,  unsafe, unethical and unprofessional.
The only way for new treatments, techniques, procedures and modalities to be introduced into Medical Healthcare is for new specialities to be formed and codes of practice developed, including guidelines for occasional, low-skilled use, or non-use.

So why does Dawkins make his statement, if it works, it ours? It's so trivially wrong and dangerous as to be absurd.

At best it is an ignorant and unwise sentiment, at worst disingenuous and mendacious.

It's a great sound-bite and simplistic rationalisation - and has been endlessly repeated by the proponents of the Medical Healthcare Treatment Only (all other banned/illegal) school of thought.

If Dawkins had said:
Medical Healthcare will embrace and accept as whole specialities what are now regarded as Alternative Modalities or Treatment when they are shown "Safe and Effective",
then I'd agree with him.

Dawkins thinking on this seems to be mechanistic, based on the Classical Science/Physic notions of absolute knowledge and predictability. The Universe as a set of Billiard Balls, once set in motion, everything is deterministic. There is no uncertainty, nothing subject to probability and no free-will. A single cause and a slow, unalterable, inevitable unfolding of events...

Quantum Physics destroyed the Deterministic model of Classic Physics and replaced it with a far more complex, nuanced world: Odd things happen, accept it.

We are very far from knowing everything about our bodies and how they work and fail. The worldview underlying the Fundamentalist Evidence Based Medicine Only movement/school of thought is this Deterministic Classical Physics model, with the tacit assumption:
 we currently know everything there is to know about human biological processes, their problems and correction/amelioration.
Hence anything outside our current understanding and worldview is, ipso facto, "non scientific" and invalid.

Here's a News Flash: We don't nearly understand everything about our human biology, individual differences and the idiopathic progression of diseases and conditions.

To imply or accept that "There is Only One True Way of Medicine, Science as 'we' define it", is ignorant, arrogant and self-delusional - and if you're in the Profession making your livelihood from it, self-serving.

Acknowledging ignorance is the first step towards knowledge...
Accept that we don't nearly know everything that's needed for Healthcare, preserving Health and improving "Wellness".

If current "science" can't understand or disprove a modality or treatment, perhaps its like Mr Rutherford's little alpha-particle that bounced straight back at him, leading Physics to abandon a couple of Millennia of "proven Classical Physics" and to discover Quantum Physics, sub-atomic particles and the basis for the semi-conductor revolution amongst other things.

As an aside, the Medical Establishment appropriating treatments, procedures and methods from other modalities is similar to the Microsoft strategy of "Embrace, Extend, Extinguish".

It is a short-term tactic design to "crush the opposition". As such, it is amoral and many regard it as dubious or outright unethical.

For Microsoft, the paucity of this approach has become apparent:

  • In 2000, they were Kings of the Industry,
  • In 2005, they were The Corporate Desktop Owner.
  • In 2012, they are a joke with a stalled share-price, poor public image, unloved software and a CEO whom Forbes has publicly assessed as "the worst there is".
 Compare them to Apple who've always had a positive, service-based design ethic. Apple has defined three brand new markets (iTunes-music, smartphone, tablets) in the last decade - whilst achieving massive sales growth and 40+% annual returns to stockholders.

Yes, "Embrace, Extend, Extinguish" did crush some of their opposition. But it didn't win them the War, nor assure them of on-going success.