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.

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.

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.

The unnoticed Crisis in Healthcare

This paper on solving the Quality of Care crisis in Healthcare, "An NTSB for Healthcare", made me wonder why nobody was talking about another long-running, endemic Crisis in Healthcare:

In trying to spend less, it costs more to provide less of a worse service.The more we try to cut costs, the more it will cost and there is no simple way out: the system is locked into this craziness.
Doing "more of the same" not only cannot break us out of the rut, it pushes us deeper into it

W. Edwards Deming, the person responsible for the Quality Improvement movement in Japan that also forced a revolution in manufacturing the United States in the 1980's, was very clear on this:

• When people and organizations focus primarily on quality, defined by the ratio (Results of Work Effort / Total Effort), quality tends to increase and costs fall over time.
• However, when people and organizations focus primarily on costs, costs tend to rise and quality declines over time.

Turning around any system spiralling out of control cannot be done by "more of the same", but needs careful attention to causes and the underlying systems. As Quality Improvement has repeatedly shown, focussing on "Doing Things Right First Time, Every Time", is a remarkably effective means of effecting even very large turn-arounds.

No sane Politician or Healthcare Administrator/Bureaucrat would intentionally do or allow this downward spiral, but the effect is slow and insidious starting and irreversible when started. That we have gone there in many US Hospital Systems is more than adequately documented in Dr. Otis Brawley's "How we Do Harm".

The good news is that there a number of high profile Hospital Systems that seem to have avoided this crisis: Mayo Clinic, Cleveland Clinic, Dartmouth-Hitchcock Medical Center, Denver Health, Geisinger Health System and Intermountain Healthcare.

All these Hospital Systems make Quality of Care their priority and indirectly achieve much better financial outcomes (20-30% less per service), illustrating Dr. Deming's assertion. Such "Systemic Quality" techniques not only yield better Patient Outcomes, but Optimal Care Costs because the Active Learning underpinning it necessarily includes Process and Performance Improvement.

You'd expect decision makers would want to lower costs, improve Quality and improve staff morale and employment conditions. And I believe they would, if they properly understood both the problem and the solution.

The central challenge with the theory posited here is twofold:

• proving its more than a theory, and
• convincing Decision Makers of the problem and that "more of the same" cannot be a solution.

The definitive theoretical works on how this counter-intuitive effect presents in Computing, Virtual Memory "Thrashing", started in 1968 with the first paper on "Working Set" theory. It's not overstating the fact that without this work (theory + proof-in-practice) computers as we know them could not exist.

A related computing theory, the "Universal Scalability Law" (USL), applies more widely than computers, as shown by this piece on Projects and the "Mythical Man Month" (adding more people to a late project makes it later).

This is the counter-intuitive world that in Computing we call "Thrashing", in Catastrophe Theory a "tipping point" and in everyday parlance "past the point of no return" or "starting down a slippery slope". Even sometimes, "in a flat spin", meaning "with no way out".

These all occur when a system or thing is irreversibly pushed past a critical point or limit and then the rules of the game change. Much like stretching out the small spring from a retractable ballpoint pen renders it useless. It cannot be properly remade because the steel has been stretched permanently past its elastic limit. There's a different effect in "Memory Metals" which return to their original shape when heated, but you can't make springs out of them, only automobile body panels.

There are a huge variety of examples of this that breakdown roughly into 4 types:

• Dynamic systems that exceed a critical threshold. E.g.:
•  a car, motorcycle, pushbike or skateboard "fishtails" or "tank slaps".
• Aeroplanes and rockets experience violent, uncontrolled oscillations like a flag: "flutter".
•  Ice Skating has the term "Death Spiral": a person can't get up from this without help once locked in.
• Dynamic systems that go below a threshold. E.g.
• Aircraft in "the Region of Reverse Command" or "behind the Power Curve". When flying too slow, with the nose pointing too high, planes are more like kites. Applying more power, pushes the nose higher and the plane flies slower. Reducing power puts you into a stall and if you're on take-off, you crash.
• Riding a pushbike or motorcycle to a stop without putting your feet down (especially when you can't reach the ground). Because the centrifugal forces from the wheels are no longer holding you up, you can quickly overbalance and not be able to right yourself. 
• Static systems that exceed a critical limit. E.g.:
• The overstretched spring cannot be put back.
• A paper-clip can be straightened, but never properly reformed without weak spots.
• Plastic items or toys that are bent too far and crease, forming weak spots.
• Letting Ice Cream melt. All the bubbles escape, it separates and won't reform easily.
• Plastic Film and Duct or Gaffer Tape: is very strong until a small nick is made in it. Then it tears easily for as long as force is applied.
• Nylon fabric in a tent or flag: very strong until nicked, then will tear along its whole length.
• Touching the inside of a tent during rain makes it leak. While the surface tension isn't broken, water doesn't drip. Once broken, the drip cannot be stopped.
• Static systems that go below a critical limit E.g.:
• Chocolate that is cooled too far assumes a white, powdery appearance as the fats/oils separate out.
• A drop of water in a hot skillet will happily float on a cushion of steam if small enough to start with, but when it gets too small it becomes unstable and explodes when it touches the skillet.
• Soap bubbles support themselves and happily float around in the air, until the film becomes too thin (from evaporation or flow) to withstand the slightly higher internal air-pressure and they explode.
• Snow Skis and sled runners 'glide' by  melting snow with pressure. In extreme cold, this effect stops because the pressure doesn't melt the snow. Unseasonably cold weather was a contributing factor in the failure of Robert Scott's Antarctic expedition. The man-hauled sledges became very hard to pull when they stopped sliding over the snow and started digging in like they were in sand. 

There are some other dynamic systems that most drivers are very aware of:

• Overbraking leads to the tyres skidding as the friction melts the rubber and you're suddenly sliding on a thin film of liquid rubber. For drivers encountering this for the first time, the though of releasing the brakes, not pushing harder, is usually terrifying. "ABS" braking solves this by automatically releasing the brakes and re-applying them.
• The opposite effect is high-powered cars spinning their wheels when accelerating. The wheels continue to slide until power is reduced enough to regain traction.
• Cornering or swerving too fast, usually in slippery conditions like ice, mud or rain, results in some or all the wheels losing traction. There are no good recovery techniques for an all-wheel slide. When only the back wheels have lost traction, the classic "steer into the slide" technique works - which for those new to it, is usually counter-intuitive.

In all these situations, once "traction is lost", control is lost unless specific recovery measures are taken.

Once a rubber tyre starts to slide, it will continue to slide at that and previously tractable speeds.

Recovery isn't just a matter of reverting just a little, but often quite a lot until the rubber stops melting or sliding. Once traction is restored, it will again stay adhering until the critical limit is reached again. "Good car control" is often staying just below the critical limit and maintaining maximum friction without slipping.

These counter-intuitive effects are well understood in General Systems Theory. One of the essential understandings is that to optimise whole system output, at most one sub-system can be optimised. All others have to run with some "slack" to allow the best outcomes of the whole system.

The necessary ingredient to create a system which can sink into "Reversal of Command" type dysfunction is two opposing system response curves:

• The "normal" response curve where increasing staff numbers (i.e.higher staff costs, more time per patient and more individual "slack" time) results in more throughput, but at the cost of lower "cost effectiveness" per patient, and
• The "stressed" response curve, where low staff numbers creates higher absentee and sickness rates, increases Medical Errors and Adverse Events, increases staff-overtime for those able to work, increased time-pressure creates more stressed staff, reduces their job satisfaction and radically increases turn-over. Because the total demand for care has not reduced, extra staff have to be found: either through overtime, substitution of under-qualified staff or hiring expensive Agency staff. Overly tired staff not only work slower, but miscommunicate more, are worse at detecting errors and omissions  and make inordinately more clerical errors, requiring extra time to correct.

There is an Optimum Staff Cost point: the most cases are treated for the lowest staff costs.

Attempting to reduce staff costs below this point is counter-productive. The "stressed" response curve takes over and increases staff costs whilst the overworked staff produce significantly worse outcomes.

The problem with large Healthcare and Hospital systems, is that nobody is tracking the dysfunction curve, only the headline "staff costs".

Generally, you can reduce average treatment costs by reducing staff, at the cost of increasing patient wait time. But, the average cost of patient treatment increases with very long wait times. If you don't know what those limits are, and aren't providing staffing levels sufficient to keep below them, then the institution will blindly wander into the counter-productive zone.

An example from Dr. Brawley: A breast-cancer case caught early in stage-1 may be treated for $30,000 with very good patient outcomes. Each year the person has to wait for treatment, the cost of treatment increases and their outcomes reduce. Brawley tells the story of  woman who waited for 7-8 years until her breast cancer had become stage-5. The treating oncologist estimated a treatment cost of $150,000 at this time and survival of only 12-24 months...

At every level it was more expensive for her treatment to have been delayed, yet "the system" had no ability to properly measure and model these costs, nor to even notice that it had been 'efficient' by not 'effective' when she did finally consume a massive lump of funding.

Because these events go unnoticed and unreported, total System Costs are much higher than they need be.

But without measuring them, who's going to believe it?

And if you don't believe it, why would you measure?

Teams and Departments can suffer similar system breakdowns in their culture, as described in this: the "Blame Spiral".

The crucial point is that the "Do it Right, First Time" Quality Improvement methodology, because it is based in real measurement and relevant reporting, catches these issues early and prevents minor culture issues from descending into massive dysfunction.