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.

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?

Australian Medicine as a Failed Profession. #1

Australian Doctors practice medicine as if it was a cottage-industry craft supported by a 'Guild', not as a modern, accountable Profession practised for the Public Good.

Guilds limit new entrants, protect and control 'the secret craft knowledge' and vigorously defend their turf. A monopoly on the practice designed for restraint-of-trade, not the benefit of clients nor the community.

Proof:

• We are entering the second decade of the doctor and specialist shortage here. Australia has more than enough resources to be producing a surplus and exporting to the world the best doctors around, like the Scottish once did for 'Engineers'.
• How can there be a shortage? It's not because its not needed nor not possible here.
• Why aren't doctors picketing every Parliament in the land on behalf of their patients and the wider community? Letting known dangerous conditions for patients and doctors continue is neither Ethical nor Professional behaviour.

• It's now more than a decade since "Minimising Harm to Patients" was broadcast here and the US Institute of Medicine released "To Err is Human: Building a Safer Health System" yet the critical first steps, gathering hard data, are not being practiced in Australia. Real Change can only be based on hard data, not abstract or distant  'scientific evidence'.
• Dr Brent James showed with hard data, not statistical inference or speculation, that Patient Injuries (unintended results of "system errors") were 80 times (eighty!) more prevalent than Adverse Events (due to human error or omission). Sentinel Events are a subset of Adverse Events that are undeniable and result in catastrophic outcomes for the patient.
• Where's the hard-data from Hospitals and GP's on one of their most critical Performance Indicators: Patient Injuries?
• The Profession can't claim ignorance of these results nor their irrelevance. So why haven't doctors and their Professional Associations been very strong activists for this necessary reform?
• One of the surprise results of Dr James work, again backed with the strongest proof, was "it's at least 20% cheaper to Do it Right, First Time". Why aren't Australian Doctors overwhelmingly lobbying all Parliaments for this reform, especially in Hospital systems?

• Five plus years on from "Dr. Death" in Bundaberg, is anything different? Is there any excuse for that?
• The Commission of Inquiry into Queensland Health (QH) determine just one of the root causes was the inability of QH to retain locally trained doctors. Why hasn't that been remedied? As a major, critical Public Health issue, why aren't doctors and their associations taking the strongest actions industrially and politically with both State and Federal Parliament to rectify this on behalf of those in their care?
• Could Jayant Patel happen again? It seems, "yes". Could he be hired again, allowed to practice in the same way, poor patient outcomes go unnoticed and unremarked, and the nursing staff who raising the alarm be comprehensively ignored and worse? After five years there is no public evidence that QH has addressed these issues, and yet the doctors and their associations remain quiet and action-free. Why the lack of activism and public action? Why is the Medical Profession silent on this issue? [And if the answer is a provable "No" as against "trust us, we've changed", why isn't that known?]
• In most states, Jayant Patel's deliberate harming of patients is not a crime. Where is the outcry and outrage from the Medical Profession? After more than 5 years, the absence of any concerted efforts by doctors and their associations to have this oversight corrected is not accidental. This non-action is now deliberate. Why are doctors and their associations not advocating for the strongest, most reasonable protections possible for their patients?
• Jayant Patel was only charged for a very small proportion of his injuries and deaths because of an antiquated legal notion, direct causality. We know that Patel killed, maimed and injured many times the number the DPP was able to charge him with. The statistics on his trail of carnage are unassailable, yet no legislative changes have been made or proposed. In one of the Engineering Professions, evidence like this would cause a practitioner to lose their license to practise and might be accepted as evidence in criminal proceedings. [I don't have legal advise on that]. Why is the Medical Profession silent on this issue when statistical analyses are at the very heart of their holy-of-holies Standard of Evidence, Randomised Controlled Trials (a.k.a. Placebo controlled double-blind randomised experiments)?

What does a modern Profession look like?

Aviation as a perfect model.

A short excursion into theory:

 In Project Management, there is the "Iron Triangle", explained as "Good, Fast, Cheap: pick any two".
[Alternatively, the "Iron Triangle" comprises: scope, schedule and cost constraints with no explicit mention of Emergent Dimensions like Safety and Quality.]

This piece of received wisdom says that Economic Profitability, Job Performance and Product/Process Quality are competing dimensions, to optimise one of them, others have to be sacrificed.

This just isn't so.

It only appears that way if a) you examine a single project (in the short-run) and b) your Project Methodology doesn't include the last half of Demings' cycle (Plan - Do - Review - Act to improve system).

Dr Deming's proven Quality Theories rely on two fundamentals which you might recognise from the Scientific Method:

• Be inquisitive, examine your own performance, look for insights into your work and outcomes, self-examination is the precursor to insight, and
• try to constantly improve both your knowledge and practice, to consciously learn both from your failures and successes.

This "conscious, deliberate learning" mindset is a necessary condition for constant improvement in all three aspects of the Iron Triangle: Profitability, Performance and Quality.

It's a long-run, not short-run, effect. It doesn't appear within a single project, but after the execution of many. The most important part of every project is the Analysis/Learning phase after it, the Project Review.

For cottage-industry crafts, where you only practice "as learnt" skills without deliberate improvement or correction, the veracity of the "Pick any two" ideology is both obvious and unbreakable.

For modern Professions practising "Do it Right, First Time", the saying is trite and wrong.

Back to Aviation, a modern Profession where, in most but not all countries, "Do it Right, First Time" is pervasive and firmly embedded in the culture and practice of each discipline and speciality, as well as in the governance of the whole Industry and its component parts.

More importantly, there is free, public data on the performance of the Industry.

Page 11 of the EASA's 2010 Annual Safety Review, has a powerful chart [Fig 2-1] showing how the Industry has progressed/improved and some words that should make the Australian Medical Profession both ashamed and envious:

The data in Figure 2-1 show that the safety of aviation has improved from 1945 onwards. Based on the measure of passenger fatalities per 100 million passenger miles flown, it took some 20 years (1948 to 1968) to achieve the first 10-fold improvement from 5 to 0.5. Another 10-fold improvement was reached in 1997, almost 30 years later, when the rate had dropped below 0.05. For the year 2010 this rate is estimated1 to have stayed at 0.01 fatalities per 100 million miles flown.

The accident rate in this figure appears to have been flat over recent years. This is the result of the scale used to reflect the high rates in the late 1940s.

Another Canadian resource site, with an inspiring graph on the improvement in Aviation Safety says:

Up to the early 1970s the number of fatalities increased with some proportionality with the growth of air traffic. By the 1970s, in spite of substantial growth levels of air traffic, fatalities undertook a downward trend. This is jointly the outcome of better aircraft designs, better navigation and control systems as well as comprehensive accident management aiming at identifying the causes and then possible mitigation strategies.

This isn't isolated or peculiarly European: 

• US Air Carrier Safety Data and Air Carrier Profile (economic and performance figures)
• US General Aviation Safety Data and General Aviation Profile.
• AOPA (Aircraft Owner and Pilots Association) General Aviation Safety record.

The reason for these massive, on-going improvements is the detail and seriousness of incident investigations. Notably, while commercial "Air Carriers" have improved their Safety and Operations by several orders of magnitude while being profitable in a cut-throat industry experiencing a 1,000-fold increase in services delivered, "General Aviation" has improved, but by only approximately 5-fold.

The difference isn't in the technology, training available or processes/procedures detailed. It's the Professional "Right First Time, Every Time" approach.

The crash in early 2009 into the Hudson River of US Airways 1549, piloted by  Capt. "Sully" Sullenberger, was dramatic, widely reported, and resulted in no fatalities and only a handful of injuries.

Yet it led to 35 "Recommendations" by the US official investigator, the NTSB (National Transport Safety Board). Think how different this is to Australian Medical practice: even injuries resulting in permanent disabling of patients, like the 2010 preventable and foreseeable injury to Grace Wang, a repeat of prior Errors, led to news reports, but no obvious investigation and certainly no consequences for anyone involved.

These NTSB "recommendations" will be implemented, will be checked upon by a regulatory body [the FAA] and failure to do so will result in proportional, direct, personal and organisational consequences.

This is completely at odds to the 550+ page report by the 2005 Queensland Public Hospitals Commission of Inquiry, triggered by Jayant Patel and others, where the Recommendations are optional, their (timely) implementation won't be checked, nor will there be consequences for anyone repeating these Known Errors, Faults and Failures.

One of the reasons for this cultural change in Aviation and resulting the on-going improvement of Safety, Quality and Performance in Aviation is the theoretical work of two men:

• Charles Perrow, creator of "Normal Accidents" (a theory of systems accidents)
• Prof. James T Reason, (ex Manchester Uni, UJ), psychologist and author of "Human Error" and originator of the "The Swiss Cheese Model" for the cause of accidents.

NASA uses Perrow [PDF] as a basis for its Safety programmes.

Prof. Reason seems to have retired from Academe, but is still listed as an advisor to "The Texas Medical Institute of Technology (TMIT)".

James Reason's work is well known in the medical community: it was used by Dr Brent James and colleagues in the remarkable turnaround and improvement of Intermountain Healthcare, reported in "Minimising Harm to Patients".

On the wikipedia page on "The Swiss Cheese Model", a large number of pieces in "Further Reading" are medical.

Where this ends is a 2012 article published in "Journal of Patient Safety", available on the TMIT site, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate", where the authors, Medicos and Aviators and authors of 100 medical papers, call for applying what is known to work in Aviation to Medicine.

An idea that seems long overdue, although they don't go as far as suggesting the second, necessary, pillar of the Aviation system, the US FAA or UK's CAA, a regulatory and compliance organisation (also responsible for provision of common services, like Air Traffic Control). These organisations are charged with first implementing and on-going checking of NTSB recommendations, bringing direct, personal consequences to those not complying.

Without "accountability", recommendations and findings have little likelihood of being fully and consistently practised.

Abstract:

Economic and medical risks threaten the national security of America.
The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. 

This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable safety innovations we have already paid for that have made the airline industry one of the safest in the world.
This first part supports the debate for a National Transportation Safety Board (NTSB) for health care, and the second supports more cross-over adoption by hospitals of methods pioneered in aviation. 

A review of aviation and healthcare leadership best practices and technologies was undertaken through literature review, reporting body research, and interviews of experts in the field of aviation principles applied to medicine.
An aviation cross-over inventory and consensus process led to a call for action to address the current crisis of healthcare waste and harm. 

The NTSB, an independent agency established by the United States Congress, was developed to investigate all significant transportation accidents to prevent recurrence.
Certain NTSB publications known as "Blue Cover Reports" used by pilots and airlines to drive safety provide a model that could be emulated for hospital accidents.
An NTSB-type organization for health care could greatly improve healthcare safety at low cost and great benefit.
A "Red Cover Report" for health care could save lives, save money, and bring value to communities. 

A call to action is made in this first paper to debate this opportunity for an NTSB for health care.
A second follow-on paper is a call to action of healthcare suppliers, providers, and purchasers to reinvigorate their adoption of aviation best practices as the market transitions from a fragmented provider-volume-centered to an integrated patient-value-centered world.

Friends of Science in Medicine: Irrelevant #2

The Dwyer/Marron Friends of Science in Medicine, finally have a public website where we can learn a little more about them.

Their constitution lists their "Objects" as:

to foster Good Science in Medicine [my capitalisation]

Their home page states:

We are currently campaigning:
"to reverse the current trend which sees government-funded tertiary institutions offering courses in the health care sciences that are not underpinned by sound scientific evidence"

I'm not aware of any usage of "to foster" that translates into attacks and calls for banning properly instituted and checked activities... Buts that's a side-show to the real game.

The Dwyer/Marron group choose to ignore multiple Elephants in the room, hospital deaths, medical adverse events and patient injuries in favour of a campaign that's been termed "a witch hunt", and even if completely successful would achieve so little as to be farcical.

The only fact I can present in support of this is: There are no facts.


Which in itself is a complete failure of Governance and Safety/Quality systems of the Australian Medical system and Profession.

What's the ratio of fatalities to Adverse Events (AE's), those caused by Human action or inaction?
We've no idea...

An early Australian report is summarised as: 18,000 fatalities due to AE's at a cost of $2B/year :

The total costs (health, economic and social) of adverse events are significant. Studies in recent years that have identified the magnitude of the economic and social cost:

• The Quality in Australian Health Care Study (QAHCS) found that 16.6% of hospital admissions were associated with an Adverse Event, and that 18.5% of these Adverse Events resulted in permanent disability or death. This equates to approximately 18,000 deaths that are attributable to Adverse Events. The estimated annual cost of Adverse Events to the Australian healthcare system is AUD$2 billion. [Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian Health Care Study. MJA. 1995;163:458-471]

Dr Ross Wilson, the author, is quoted in the media ten years later, as saying that "things are likely the same" because we still don't have figures being reported and collated.

In 2009, the SMH reported a government study or report estimating "Hospital errors claim the lives of 4550 Australians a year". A more acceptable figure? But it's still in line with the near 20,000 "Adverse Events" Dr Wilson estimated.

We do know, from the 2002 "Second National Report on Patient Safety Improving Medication Safety"  that GP visits include "400,000 of these thought to involve adverse drug events." (around 0.25%)

The much weaker figure, "Sentinel Events" is discussed in an AIHW (Australian Institute of Health and Welfare) document, "Sentinel events in Australian public hospitals 2004–05". They describe "Sentinel Events", and their need as:

there are occasions when patients suffer harm that is unexpected and unintentional. Sentinel events represent a very limited range of serious events, which can provide a ‘window’ into the vulnerabilities and safety of the health care system.

and

This report analyses 130 events that caused or had the potential to cause serious harm to some of those patients.

We've no information if the "Sentinel Event" causes identified in the AIHW report have been eliminated in all Hospitals and Health systems. But why would they be after only five years? It's not like people are dying needlessly every day, is it? [apologies for using sarcasm.]

The responsibility for collecting and reporting "Sentinel Events" was devolved to the states.

Sadly, from the AIHM website, which you'd expect to be definitive, it appears that only WA and Victoria have taken up Sentinel Event collection and reporting.

WA reports 1 Sentinel Event in 10,000 patient separations, and that they'd achieved a 10% improvement in the year. The WA figures (96 events or 0.01% of separations) don't exactly tally with the AIHW figures for patient separation. The WA figures report 0.96M separations in WA of 2.3M population. For the whole 22M Australian population, it would be 9.1M separations, versus the 8.5M reported by the AIHW.

This seems to demonstrate a convincing, overpowering view by administrators of the other Hospital systems that such data is unnecessary and not useful... A very disturbing view to me.

What's the ratio of "Sentinel Events" in hospitals to Adverse Events?

From the estimates available this is 130:18,000, or about 140:1, possibly worst case because the definition of "Sentinel Event" is still being refined and increasing.
Which is why the "Sentinels" were chosen, as "canaries in the coal mine". Simple to measure and quickly and easily show if things are getting better or worse...

We know from the hard-data reported by Dr Brent James around 1999, that the ratio of Adverse Events to "Patient Injuries" is 80:1 (eighty times).

If we are conservative in our assumptions and use the WA Sentinel Event rate (0.01%), a lower ratio of Sentinel to Adverse Events (1:100) and a lower ratio of Adverse Events to Patients Injuries, then the 8.5M patient separations reported by the AIHW for 2009-2010 (costing $33.7B for Public Hospitals),
resulted in:

Sentinel Events: 850 (÷ 10,000)
Adverse Events: 85,000 (* 100)
Patient Injuries: 4.25M (*50)

 More in keeping with Dr Wilson's estimate, would be an SE:AE ratio of 20:1, giving:

Sentinel Events: 850 (÷ 10,000)
Adverse Events: 17,000 (* 20)
Patient Injuries: 850,000 (*50)

Which is still an incredible figure indicating a massive, needless waste of money, not to mention the impact of unnecessary injuries and treatment upon patients.

The Irrelevance of Friends of Science in Medicine:

The Dwyer/Marron group make no claims for the numbers of Patient Injuries, nor their severity, attributed to their foes, "Complementary and Alternative Medicine" (CAM).

Are they claiming figures of 1,000,000 injuries and a few thousand fatalities: in the ball-park of known good estimates for Medical and Hospital systems?

If they aren't then:

• They should say nothing until they go out can get some hard-data on the actual injury and fatality rates.
• Unfortunately, a single media appearance by Lorreta Marron exposing and shutting down one uncertified backyard operator, while preventing a few injuries, does NOT constitute research or evidence.
• Friends of Science in Medicine need to apply their own standards to themselves.
  Without strong evidence, what anyone says is completely irrelevant, misleading and potentially harmful.

• Estimates of use of Alternative Medicine and Therapies in the general population vary between 40-60%. How many visits and treatments does this translate into? NOT anywhere close to the 100M/year visits to GP's? What about the total patient injury rate via CAM?
• Even the anecdotal evidence doesn't support the view that there are close to the same number of patient injuries as from doctors and hospitals.
• Get some data before you criticise everyone else.

If even a guesstimate (that's a valid Engineering term and process) put the total Patient Injuries by CAM at 10% of mainstream Medical and Hospital, I'd be very surprised.

And if fatalities were even has high as 1,000th of the known, preventable deaths in Hospitals, I'd be astonished. Do we lose as many as 5 people to certified, registered Alternative Therapy practitioners in a year? You'd have to make some outrageous assumptions to even get there.

So why do these people want to shine a light in an area where the total potential for harm and injury is not even a rounding error in the statistics of the practices they are so virulently supporting?

The irrelevance and hypocrisy of Dwyer/Marron and their The Friends of Science in Medicine is that they know full well the scale and scope of the preventable failures of mainstream Medical and Hospital system, but they then choose to "raise Cain" about areas of relative inconsequence. What's going on?

My message to the Dwyer/Marron group:

Practice what you Preach and Get your own house in order first.