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.

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