Saturday, July 21, 2012

I2P #1: First, Do No Harm.

This is my first post written for "Information to Pharmacists", an interesting Industry Newsletter with a typically idiosyncratic Aussie approach: they welcome authors of any viewpoint and profession, as long as they are respectful to others, not libellous and can write on medical/pharmaceutical issues. And "no dot points, please!" - a challenge for me, leaving behind my favourite organising technique.

"Fist, do no Harm" not only embraces Systemic Quality, but better Economic outcomes and improved Efficiency and Effectiveness with reduced waste and Continuous Improvement. Learning and Process Improvement are common to both efforts as are monitoring outcomes: costs, clinical results and "process deviations", a.k.a. "errors".

Computing/I.T. and Medicine share a Fiduciary Duty to their clients, with the Amplifier effects of I.T. now the most cost-effective means of improving Patient Safety, Quality of Care and Treatment Effectiveness.

The enemy of Quality Improvement isn't only "Change Resistance" but faddism, like a cargo-cult adopting the outward signs whilst ignoring the underlying causes and principles.

This, not technical problems, will be the major obstacle to realising the benefits of e-Health initiatives here and overseas. Successful practice transformations have stemmed from Quality Improvement programs with electronic system assisting, not from the blind adoption of automation.

Who am I and what do I have to say that's interesting or useful to Pharmacists and related readers?

I'm a second-generation Computing professional, starting in 1974: in the first group since commercial computers arrived in 1950 to gain undergraduate degrees in Computing. It was still possible to cover in depth the whole field: transistors, hardware, systems, software, operations, business analysis and User Experience.

During a wide-ranging career, I developed an interest in Quality and Turnarounds, for the way out of a mess lies in Working Smarter and stopping wasted effort.
From working in one of the most technically demanding fields, Telco Exchanges where one hour of downtime a year is tolerated, I was imbued with the notion of "Client Service", the same "Fiduciary Duty" that underlies Medicine.
I also discovered for myself the maxim: "Quality isn't just Free, it's cheaper and faster to Do it Right, First Time" defining "Systemic Quality" that, through the work of James T. Reason and Charles Perrow, transformed Aviation after the mid-1970s.

Computers and I.T. are "Cognitive Amplifiers" in the same way that machines are force and skill amplifiers. They allow ordinary folk to easily perform extraordinarily, day after day.

Notionally, automated electronic systems are added to Business Processes to "provide a Business Benefit". Not unlike Marketing, for those Benefits to be realised, they have to be measured  and cannot be measured unless defined and designed in from the start, a practice rarely undertaken.

These ideas have often put me at odds with other technical staff and managers: they are antithetical to the untutored or Default Management Style of business which insists "Just Do It!" is more important than "think before you leap".

Don't all I.T. practitioners suffer the Occupational Hazard of "knowing everything about everything"?

Just about, with the worst offenders often in "Help Desks": everyone else is a fool, which is their experience from on-going "idiot user" calls.
This is a trap that I consciously try to avoid: any reminders from readers are welcomed.

Automated computing/I.T. systems cut across every part of an Organisation, often extending into other Organisations in ways few appreciate. No other Profession does this, not even management and accounting, requiring Business Analysts and Programmers to understand the work of other Professions better than they know themselves.

Programs and Systems are crystallised thought processes: they are exact, detailed, and hopefully complete, descriptions of the cognitive processes people use to execute tasks.
Often the hardest part of this work is uncovering Implicit Knowledge and converging on correct task definitions that will become universal for the first time.
Politics always trumps the Technical in this work, creating inconsistencies and contradictions in tasks.

To be good at Computing/I.T., you need to be both a 'quick study' of other Fields of Practice and be able to apply a raft of tools allowing you to understand their work better than they do.

Which often leads to a certain arrogance and hubris. It takes some humility and courage to admit that true Domain Experts have great talent and skill: Experts make their work look effortless and obvious, as seen in performances of sporting stars.

The irony is that the best Computing/I.T. experts have the same problem with 'management' and business owners: What they do looks simple and obvious to outsiders and is undervalued.

For completeness, many I.T. practitioners are not expert in this way. They make the job look hard, with the resulting systems being slow, difficult to use and wrong or buggy: for which they often get promoted for their "heroic efforts" slaying the Project Beast.

I.T. is fine, as long as it stays out of my way...

If this is you after too many fads, management or I.T., being foisted on you without consultation or thought for local consequences, you have my condolences and understanding.

I absorbed the many fads in the first 15 years of my career before wondering why nothing really changed and digging back into history. Fredrick W. Taylor and Henri Fayol wrote comprehensively about Management and Quality Improvement more than a century ago with Dr W Edwards Deming adding a definitive theoretical base sixty years ago.
Why then, did Michael Hammer re-invent, badly, the work of Taylor et al in the 1990's, then need to resile from it a decade later?

The Japanese transformed their Industrial processes this way, taking 3 decades to out compete the USA in making cars. During the 1990's, the US experienced fads of "the Japanese Way", but generally never understood or adopted Deming's core principles.
Then the "outsourcing" and "right sizing" fads took over with messy manufacturing being sent off-shore, becoming "Someone Else's Problem".

Systemic Quality: tying it all together.

Aviation proves three things about Systemic Quality: it can be achieved every day with ordinary people, it's the most cost-effective approach available and arises from a pervasive Safety Culture supported from the very top down.

There are some notable efforts to bring Systemic Quality to Medicine/Healthcare: Intermountain Healthcare with Dr Brent James, trained by Dr Deming, being responsible for 20 years of Quality Improvement, "Safety Leaders" website from Texas Medical Institute of Technology, National Academy of Science's Institute of Medicine and Donald Berwick's Institute for Healthcare Improvement.

Not only do they have hard data on their Cost, Safety and Error outcomes, they can show that it's 20-30% cheaper for them to Do it Right, First Time.

And for Pharmacists... You're important.

In the interview Dr James gave to Norman Swan in 2001, "Minimising Harm to Patients in Hospital", he said they used their Drug Information Systems to identify many Adverse Events, such as an opiate overdose requiring 'narcan' to be administered.

They also found these system-related Adverse Events 30-times more prevalent than reported Human Errors. Dr James said:

For ten consecutive years we tracked every adverse drug event and in parallel with that we tracked classic human errors. In ten years we had 4,155 confirmed human errors. In parallel with that we had 3,996 confirmed moderate or severe adverse drug events.
Norman Swan: In other words, what was actually happening to the patient him or herself?
Injuries. Those were injuries, those 3,996. The fascinating thing was the overlap. Among 3,996 confirmed injuries, 138 or 3.5% resulted because of a human error.
Norman Swan: So in other words most of the human errors didn't result in an injury.

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