Hospital Blame Game: Fixable or Just Not Possible?

A reaction to an ABC report on 10% budget cuts in Victorian hospitals.

"Federal and State governments in hospital cuts blame game"
http://www.abc.net.au/7.30/content/2013/s3688997.htm

There are 3 systems effects that as yet have been ignored by Hospital Administrators and Politicians:

• "stitch in time" funding to avoid increasing total costs by over-waiting
• reduce budgets by dropping the least vital work. "cut floors, not corners"
• "Don't throw good money after bad", reduce spending where patient lifestyle affects outcomes and they won't change.

Arrogance, Ignorance and Incompetence: The State of Practice in Medical Care?

A 2010 Stanford piece on "How Teaching Hospitals could lead Medicine's Metamorphosis" details their processes for improving Patient Safety, Quality Improvement and reducing costs/improving Productivity.

I was struck by a simple question about the Stanford protocols, especially in the ICU:

If they aren't the minimum standard for non-teaching hospitals everywhere, then what do they know that Stanford doesn't?

I think that, especially in ICU, there is now no excuse for hospitals anywhere not to be following, albeit with a delay, the Best Practices researched and adopted by leading teaching hospitals. Reasonable practice would be: pick just one, or two, major teaching hospitals and mirror exactly what they adopt, but delayed by 12-18 months. You get the benefit of pick others' brains and having them iron out the bugs in the protocols for you...

For any management, including the CEO, responsible for hospitals' Quality of Care and Patient Safety, isn't ignoring known, documented Best Practice either Ignorance, Negligence, or Indolence? Any of which you'd hope in an ideal world, would be cause for instant dismissal.

Ethics of End-of-Life treatment on "Lateline"

On the day I wrote about needing a public debate on Affordability and The Rights to Basic Healthcare and the Limits of End-of-Life care, ABC's Lateline news program ran a story and interview on the ethics and implications of End-of-Life care:

• National laws needed for Living Wills
• Need for review of law on 'end of life' treatment

The Professional Mandate: Don't repeat Known Mistakes, yours or anyone else's.

[Full post on other blog.]

My formulation of the Professional mandate:

It's "unprofessional" to repeat or allow, Known Faults, Failures and Errors.

That sounds complete, perhaps obvious, but let me unpack this some more...

ISM/FoSiM: "Inversion" - Putting the Cart before the Horse in Healthcare Reform

One of the amazing arrogances and Blindspots of the fanatics and zealots of ISM and their "mini-me", FoSiM, is they've got the Healthcare Reform debate turned around completely. Colloquially, they've put the cart before the horse.

The FoSiM "Vision Statement" in their recruiting letter was:

"To reverse the current trend which sees government-funded tertiary institutions offering health care ‘science’ courses not based on scientific principles nor supported by scientific evidence”.

And from the ISM Policy paper on Regulation and Licensing all Healthcare Practitioners and Training:

As a consequence of these practitioners being legitimized through political rather than scientific means, the health of people worldwide has been put at significant risk.

Not hard to spot that both these statements aren't backed by any Evidence, any Theory but only Absolutist Assertion: it shows from the start that this is only Ideological based, not based in fact or need, nor indeed arrived at by any valid, credible process.

The "Inversion" of ISM/FoSiM is who they put at the centre of their Healthcare Reform proposal in their call for more "Science in Medicine", ignoring their one-eyed bias where they never examine the Practice or Science of their own, Medical Care.

ISM/FoSiM put "Science" at the centre of their Reform proposal and agenda.
Specifically, 'Science' applies to:

• Practitioners,
• Specialities,
• Organisations,
• Research, Academic or Commercial,
• Professional Bodies,
• Professions, and
• Governance bodies and processes, such as defined by Government Agencies.

What's completely missing is The Patient. This is the Inversion. It's Practitioner- and Profession-centric, not Patient-centric.

This is the Big Lie, the massive horn-swoggle that ISM/FoSiM are attempting to pull off:

The Patient, their Outcomes, the Quality of their Care and their Safety under Medical Care is completely absent. And most importantly, Patient Accessibility and Affordability are missing.

ISM/FoSiM want to "Fix All Ills of Healthcare and its Systems" through More Science, amusingly without evidence that this can or will help. The evidence of the last sixty years of "More Science" in Medical Care is that costs rise astronomically (5% to 18% of GDP in the USA), while more people are untreated and Public Health outcomes do not seem commensurate change.

The ISM/FoSiM advocacy for more "Science in Medicine", even taken at face value, is a clear call for:

Better Healthcare!

Which is admirable in its intent.

Only, like all their efforts, it's vague, incomplete and unfocussed. It's posturing not a useful addition to the debate.

They are advocating for Better Healthcare:

• For Whom?
• Where?
• How Measured?
• Within what Cost and Resource envelope?
• But mainly, How can their Reforms be delivered and Implmentation executed when the current Medical Care system is grossly understaffed, inefficient and already too expensive for ordinary folk?

More "Science" won't deliver Better Medical Care, it can only deliver more expensive, less accessible and less effective care, and further stress already over-worked and failing individuals and organisations.

"More Science" does involve more money for research, more expensive devices, drugs, equipment and services and, for the very few that can afford it, much more expensive interventions ("Rescue Care") for extreme conditions. It's a Bonanza for everyone making money out of the process, the Companies, Practitioners and Researchers, and a FAIL for everyone else: the Patients, the Healthcare workers and the Governments funding it.

The only group of Patients, the only reason this field of work exists at all, who might benefit aren't just the "Top 1%", but probably the "Top 0.1%".

This is a proposal that will cost a whole bunch of money, mostly Public (ISM/FoSiM are universally silent on Cost and Efficiency Improvement) and the two groups to benefit are: themselves and their rich mates.

That's a really interesting proposal for spending piles of Public Money with no sense of Accountability and where the only evidence available is "It won't help, but will cost a whole lot more."

How does "More Science" equate to "Better Healthcare"?

Not in the Real World and not at all for Ordinary People who'll be paying for it... 

This is a scheme dreamed up by the privileged, for the privileged, of the the privileged.

---

If you'd like to know what Better Healthcare looks like, here's the definitive guide, with actual research references:

"Managing Clinical Processes: Doing Good by Doing Well" by Dr Brent James.

What do we get for all that money? [slide 16]

1. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)
2. Rapid response -- the Rule of Rescue

Three classes of outcomes: [slide 65]

• Physical outcomes
• medical outcomes: complications and therapeutic goals
• includes functional status measures (patient perceptions of medical outcomes)
• Service outcomes
• satisfaction: patients and families, communities, professionals, purchasers, and employees
• includes access issues (e.g., waiting times)
• Cost outcomes
• just another outcome of a clinical process
• includes the cost of the burden of disease

Medical outcomes are of four types: [slide 66]

• appropriateness
• (referral and procedure indications)
• complications
• (process failures / defects)
• therapeutic goals / biologic function
• (when stated in the negative, merges with defects)
• the patient's ability to function
• (functional status, as reported by the patient)

• are process specific
•  (different clinical conditions have different complications, different therapeutic goals, functional status measures)
• Medical outcomes relate directly to health care costs

Service outcomes are of two types: [slide 67]

• the clinician-patient relationship
• (bedside manner: a "caring and concerned" clinician)
• access issues: convenience vs. hassle
• (scheduling, travel times, registration, physical comfort, wait times, etc.)
• operate by a separate, general process that is independent of medical outcomes
• Service outcomes directly affect market share, community perceptions and relations (that is, prestige and social status), and
•  rates of malpractice law suits

Health care consumers seek value [slide 69]

• Value = (Medical outcomes + Service outcomes) ÷ Cost outcomes
• The goal is the best possible medical outcomes at the lowest necessary cost

It'd be interesting if ISM/FoSiM ever apply their considerable talent and resource to addressing just how their call for "More Science" will deliver better Healthcare outcomes in the structure given by DR James.

Failed Professions: Definition, Impact, Consequences

[Full post on other blog.]

I'd like to assert that (Australian) Medicine, Banking and Finance & Investment Advisors and Information Technology (I.T.) are Failed Professions.

The fields of Management and Politics, whilst notable for their egregious actions and errors and not just failing expectations of good governance, but actively harming or exploiting the general public, are not Professions: they fail the basic tests of "Body of Knowledge" and "Entrance Requirements".

What do I mean by a "Failed Profession"?
How do I support that view?
I've posited a Theory of Professions to support this view.

Particularly, the level of Duty practitioners, organisations and the Profession owe towards their clients and their Community.

Of my list, Medicine and Banking/Finance/Investment-Advisors Professions, have the highest level of Duty towards their patients and clients: a Fiduciary Trust or Duty.

They are required to always put the concerns and welfare of their clients/patients before all else, particularly ahead of their own interests (especially pecuniary), ahead of their colleagues, employer and organisation and ahead of their Profession.

A first attempt at Medicine as a Failed Profession.

Aviation: A model for what can be done

Aviation is not Perfect, but it is the closest thing we have to it.

It shows that whole Industries, on a global scale, can embrace Quality Improvement and Safety programs whilst still being Profitable and advancing new technologies.

It's a culture and mindset and a willingness to admit weakness and error as a first step to correcting them.

Aviation succinctly answers the Professional Question:

When is it acceptable for a Professional to repeat, or allow, a Known Error, Fault or Failure?
Never...
When, not if, they are discovered, individuals and organisations will be held to account and suffer direct, personal consequences.

So why are other Professions allowed to practice outside this minimum standard?

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.

Unsolicited advice for the new Queensland Government

[Full post on other blog.]

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 [On ICT and Healthcare]
Not very original of me I know, but I hope it gives a useful insight to them.

The Accountability Paradox: Personal Consequences and Blame

[Full post on other blog.]

A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate" by experienced, highly-competent Aviators and Medicos prompted me to ask a question about on the subject of Dr Brent James, Chief Quality Officer of Intermountain Healthcare:

The NTSB only recommends, the FAA makes sure those things (and more) are done.
As a regulatory and compliance organisation, the FAA is able to hand out "direct, personal consequences" - and make them stick. [Natural Justice suggests proportionality as well].

Any Aviation Professional who repeats, or allows, a Known Error, Fault or Failure will be discovered and will suffer the consequences. [Hence would a medical version need two bodies?]

Dr James kindly responded to me and I was gently reminded of James Reason's "Blame Cycle" [below] and Dr James own comments on the 2001 ABC's Health Report, "Minimising Harm to Patients in Hospital":

Norman Swan: So remove the culture of blame, sort out the legal liability problems, without ignoring the fact that there will be the odd rogue doctor or rogue nurse who needs to be sorted out. What we should be seeing here, we haven't really emphasised it up till now, is that most of the problems that occur when injuries occur, are system problems, the hospital, the management, the organisation of the hospital, rather than an individual going wrong?

Brent James: Exactly. We know that the individuals will have problems. How do we create an environment in which it's easier to do it right, and hard to fail? That's the real issue. It's an institutional responsibility not an individual responsibility. The next thing that we need is an organisational structure. In the United States we're calling them Patient Safety Officers, and in the Institute of Medicine Report we asked that all care delivery groups appoint Patient Safety Officer, usually from existing personnel, usually a good clinician.

My central concern with the NTSB-for-Medicine proposal is the necessity for the organisation to not be a "toothless tiger", to have the power to cause change, but simultaneously engender a "Safety Culture" where Openness and Transparency are the norm and individuals do not feel threatened by the system.

Audit reports and Commissions of Inquiry into major failures (QLD) say what's wrong, but have no powers to cause change. They are equivalent to the NTSB, but lack the ability of the FAA to implement, to cause or require necessary change and to check that it is done.

Reason's "Blame Cycle", and my own more extreme "Blame Spiral", require Dr Demings' exhortation to "Drive out Fear" be scrupulously and systemically be applied.

How can these two conflicting objectives be achieved? I've no experience in this.

This is The Accountability Paradox:

For real change in the system, any person who repeats, or allows, a Known Error, Fault or Failure, must be held personally liable (including criminally if they caused death or severe injury/disability),
BUT if that is perceived as the Primary Role of the compliance and governance organisation, then it will be ineffective, instead it will engender the "Blame Cycle" as a minimum.

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Some references to Prof. Reasons' "Blame Cycle":
"Diagnosing “vulnerable system syndrome”: an essential prerequisite to efffective risk management" (2001, Qual Health Care 2001;10:ii21-ii25 doi:10.1136/qhc.0100021) and
"Managing the Risks of Organizational Accidents" [1997].