When Less is More in Healthcare Spending: The "Region of Reverse Command"

A letter [30-Apr-2012] to an administrator inside "Healthcare Improvement".
It is related to a previous post: The Unnoticed Crisis in Healthcare.

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I was hoping you could tell me if there have been any discussions amongst Healthcare Professionals about an effect known in Aviation as "Region of Reverse Command" or "being behind the power curve".

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.

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 Ugly Truth underpinning New Age Medical Care: What price a Life?

Update: Lateline ran a story on the ethics of End-of-Life care. They stopped short of examining Affordability and Rights to Basic Healthcare.

I was reminded on the radio yesterday of the simple question, "What price a life?"

This is the fundamental underpinning of Aged Care and End-of-Life Medical Care where a huge fraction, heading to 50%, of our total taxes gets spent.

As we Baby Boomers move to retirement and needing increasing levels of Healthcare and Residential Care, this is a question that must be answered, we can't adopt a Policy of "Head in Sand", "just do the Max".

If we don't have a nation-wide debate on this, consider it explicitly, we will have bureaucrats and politicians decide it for us, implicitly. The decisions they make and inherent resulting bias and who is selected as "privileged" won't please anyone, and probably not even the favoured few.

This is real, this is near, this is important, this affects every one of us.

State of the Art is the Oregon Healthcare Plan, formed with the explicit intention of more accessible, equitable care ("effective and efficient use of public money") and rationing benefits.

Your money and your life: What the AMA and Friends of Science in Medicine won't tell you.

This piece in Business Spectator has a bunch of 'interesting' facts that both Friends of Science in Medicine and the Medical Industry body, the AMA, ignore.

Why is this??

I'd have thought it was in the Medical Profession's interest to run their operations as efficiently as possible in order to maximise their result and the benefit to individuals and to the community. That is, if that's what their Prime Mission is.

As Don Berwick formulated in 1996 with his Central Law of Improvement:

Every system is perfectly designed to achieve the results it achieves.

So, if Medical Healthcare and Hospitals aren't run efficiently and 'accidentally' kill far too many people, Why is this so?

Just what is the current system designed to achieve, if its not Patient Safety, Quality of Care or Efficient, Effective use of Public Monies?

A superficial, simplistic analysis can't tell us...
But we do know that incumbents must benefit from the system: How?

The currently quoted figure for Healthcare costs as percentage of GDP is 9% in Australia [vs 23% in the USA]. The two growth figures quoted (38% rise in 20 years and a 40% rise in last 15 years) should alarm every taxpayer, patient and politician.

Especially the internal inconsistency: Medical Healthcare costs have grown at an increasing rate per capita for many decades, why would the rate suddenly decrease? Based on the last 15 years, we should be expecting 12.6% GDP in 2027, if not higher due to increased end-of-life care costs of Baby Boomers.

Here are my take-aways from the article. It is notionally about the PCEHR (Personally Controlled Electronic Health Record) introduced on 1-July-2012 by the Federal Government, but I find the other facts the author quotes much more interesting:

• health spending is forecast to rise to 12.4 per cent of GDP in the next two decades [from 9% in ~2007]
• That’s on top of a 40 per cent rise in healthcare costs per capita since 1997 [15 just years!].

• A review by the National Health and Hospitals Reform Commission found that in Australia each year, the equivalent of 350 jumbo jets crashing and killing all on board is attributable to highly preventable medical ‘adverse effects’
• these events can account for up to 15 per cent of a hospital’s costs. 

• One new private hospital – Medica Centre in Sydney’s South – is seeing huge efficiency gains from simple management tools like inventory control and more effective scheduling of surgeries.
• Clinical director Matt McKay says that for the first time he truly knows what a procedure should cost.
• Matt McKay at Medica Centre says that so far, he has seen an increase in efficiency of 30 to 40 per cent, not only from managing his inventory better but also scheduling his surgeries to minimise theatre turnaround times.

• If such inventory management existed in a competitive business, the company would have been sent broke long ago.
• But in the health sector, those costs get shifted onto the patients, the insurers or the taxpayer.

• A report by the OECD suggests that as much as 42 per cent of costs could be cut from common hospital procedures.
• Australia’s Productivity Commission says that figure is about 25 per cent.

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PRODUCTIVITY SPECTATOR: Your money and your life
Jackson Hewett
Published 7:33 AM, 9 Jul 2012 Last update 7:33 AM, 9 Jul 2012

Three hundred and six. 

That’s the number of people who signed up last week to the government’s new program to slash the cost of our medical spending.

It was a very soft launch for the Personally Controlled E-Health Record but the motivation behind it is right. An easily accessible database that ensures medical professionals have access to all of our medical activities should, if utilised correctly, reduce the enormous amount of waste and duplicate activities that drain federal and state health budgets. It also should help reduce mistakes caused by patients forgetting what previous symptoms they’ve had or drugs they’ve taken. 

Why is it so important? Because health spending is forecast to rise to 12.4 per cent of GDP in the next two decades. That’s on top of a 40 per cent rise in healthcare costs per capita since 1997.

A review by the National Health and Hospitals Reform Commission found that in Australia each year, the equivalent of 350 jumbo jets crashing and killing all on board is attributable to highly preventable medical ‘adverse effects’ – things like bad reactions to medication, incidents of infection, and medical device problems. Aside from the terrible human toll, these events can account for up to 15 per cent of a hospital’s costs. 

More complete records such as the PEHCR will hopefully reduce such incidents.

But there are many more ways for our tax dollars to be better put to work. One new private hospital – Medica Centre in Sydney’s South – is seeing huge efficiency gains from simple management tools like inventory control and more effective scheduling of surgeries. 

Medica Centre uses a highly technologically advanced dispensary called Pyxiss to allocate products for a surgery. Nurses must fingerprint scan to access items, and a computer will only let them take the exact number of products as defined by the surgeon. That means the hospital can track costs by surgeon and by patient, something they say is a first in Australia.

Clinical director Matt McKay says that for the first time he truly knows what a procedure should cost. At his former employers in both public and private hospitals, the best figure he could get for a procedure like a knee arthroscopy was $250 per patient in terms of consumables like bandages, syringes, sutures and the like. That was a figure derived by simple stocktaking. After a year using the Pyxis system, McKay now knows that figure should be closer to $500. The knowledge allows McKay to be far more effective in monitoring which surgeons overuse products, and react accordingly. He’s also using just-in-time ordering to reduce working capital. 

If such inventory management existed in a competitive business, the company would have been sent broke long ago. But in the health sector, those costs get shifted onto the patients, the insurers or the taxpayer.

A report by the OECD suggests that as much as 42 per cent of costs could be cut from common hospital procedures. Australia’s Productivity Commission says that figure is about 25 per cent. Matt McKay at Medica Centre says that so far, he has seen an increase in efficiency of 30 to 40 per cent, not only from managing his inventory better but also scheduling his surgeries to minimise theatre turnaround times. One surgeon has become so efficient that he has that number down to two minutes, and can do an arthroscopy in 20 minutes. By comparison, another surgeon takes up to an hour for the same procedure, and 20 minutes between them. That means more nurses, more downtime and higher costs. 

As a private hospital, Medica Centre can pick and choose what surgeries it will take, and what doctors will do them. Good doctors like to work there because the quicker they can get patients through, the more money they can make.

The public sector has little choice in either doctor or patient. But that doesn’t mean it can’t use some private sector ideas to save money along the way.

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.

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.