Writing my column I try to follow a fairly standard formula editors seem to really want this of commenting on topical events. Sometimes I find this preoccupation with what’s happening now really frustrating. It means that things at least in journalism are not assessed on their quality or their ‘relevance’ to our lives considered broadly, but rather their relevance to the matters of the hour.
Then again, there’s not much point in grizzling about it. It’s a matter as ever in life of trying to fit the substance to the form. The rules give you pretty wide latitude when you follow them properly, so you just stay on the lookout for ‘hooks’ which are opportunities to develop the themes you want to.
This week’s column was on the rogue doctor Jayant Patel who fled the country having performed disastrous operations in Bundaberg hospital leaving death and destruction in his wake. A lot of the focus of discussion was on how officials should have detected his shonky credentials. He left his previous port of call Oregon State in the US having been disciplined, something which he unsurprising left off his papers when he presented them to Queensland officials. The political excitement has tended to focus on this aspect, though the larger scandal is how he could have practiced for so badly for so long without being stopped.
This is despite various nurses’ complaints, (and I read in one of the news stories the gallows humour of another doctor who said things to Patel like “who are you planning to kill today”). The column argues that we could use the scandal to try to improve information and management systems in hospitals and sets out some examples of how this has been done elsewhere.
Readers will notice a quick reference to Japanese led systems of manufacturing production. I got excited about the Japanese production system when I first encountered it in the mid 1980s. I hope to post or ‘column’ on this in future, but suffice it to say as an intro to the piece, that I regard these new developments in management going variously by titles such as Total Quality Management, the Toyota production system (or ‘Kan Ban’) and ‘lean production’ as matters of considerable significance.
Adam Smith would have been interested in them, their significance in the progress of humanity and in how they can be brought to account in improving our lives. But they are of little interest to economists except as rightward shifts in the supply curve. Sad but true.
Click here for the column or read below for a slightly updated version and one that will survive the Courier Mail’s removing it from their public website.
Lets turn Dr Patel’s outrage into better hospitals
Dr Jayant Patel, butcher of Bundaberg, was a foreigner. What a relief! It gives us a nice distant target for our horror and outrage. Memo to ourselves: Foreigners can be sneaky and we should check their credentials better. Case closed.
But, though we could and should have prevented Dr Patel’s rampage altogether by checking his credentials (like we do with vets!), the bigger scandal is that internal systems didn’t detect his rampage within a few months if not weeks.
Finding and punishing the Dr Patels of this world is just fine with me. But it would be a whole lot better literally more than ten times better if we also used their outrages to radically improve hospital quality control.
Better information systems are the start. In the early 1990s experts in the New York State hospital system meticulously built a clinical database of cardiac by-pass surgery. All events were ‘risk rated’ so that outcomes were related to operations’ ‘degree of difficulty’.
It turned out that 27 surgeons who only occasionally performed cardiac surgery were performing poorly. They were moved out of cardiac heart surgery to specialise and so improve their own performance elsewhere. A win-win.
One well-regarded hospital had mysteriously high mortality rates for emergency heart patients. The data revealed the anomaly and some simple detective work discovered the cause which was remedied with new procedures. The change has saved around 11 lives a year since. The whole system saw a 41 percent decline in mortality rates over three years.
In Australia, a quite different program based on similar principles yielded similar benefits at the Wimmera Base Hospital in Horsham Victoria.
The Royal Commission should not shy away from holding responsible those who might have stopped Dr Patel’s long before he fled. Yet examples New York State’s experience shows that this is a side show compared with improving the performance of the systems under which all the well motivated members of our health professions work.
Some of the most successful initiatives have been surprisingly similar to the techniques the Japanese introduced into manufacturing in the 1970s and 80s. Firms like Toyota dramatically ramped up their productivity around a cluster of simple but subtly revolutionary ideas, based ultimately on the idea that they were not making things so much as structuring a system in which people controlled and constantly revised and optimised the complex system of which they were a part.
Central principles included:
1. When given the choice and appropriate encouragement, people prefer to work well rather than to shirk.
2. Given that complex systems are difficult to manage with surveillance from above, setting people to work and solve problems in teams helps unleash creativity and makes bad behaviour more difficult because well motivated groups police their own members.
3. In this context, fear and punishment must be driven out of the workplace, so that people can be motivated to identify and fix problems instead of watching their back and passing the buck.
4. Systems particularly systems of control and information should be built not so much to assist management direct or maintain surveillance of workers, but to assist teams of workers to improve the quality of their work.
In the American State of Utah similar principles appear to have dramatically improved the clinical quality of their hospital system. They drive out fear by encouraging practitioners to report all adverse incidents within 48 hours in return for immunity from legal liability for negligence.
The culture of safety that this engenders generates far more information about adverse events to be analysed and encourages professionals constantly to improve and optimise their own systems and performance.
The Utah system is predicated on the idea that well over 90% of adverse events arise from systems that can be improved rather than from individual idiosyncrasies and inadequacies lets face we all have those!
So this system reduces errors far more effectively than a punitive approach based on identifying individual wrongdoing. Indeed, it turns out to be much better at detecting rogues. Not only do generally lower accident rates and better information systems mean that rogues stand out like a politician at Gallipoli on Anzac Day. But there’s also a virulent culture of identifying problems and fixing them.
And, just as the Japanese discovered building cars, better quality needn’t cost money. Getting it ‘right first time’ saves squillions in rework and all the disruption that goes with it. It also facilitates constant improvement further down the production line.
If we’d had such a system in Bundaberg we’d have prevented most or all of the outrages of the Dr Patels. But we’d also prevent over ten times more problems arising from mundane errors by well intentioned and well credentialled professionals working in systems that could be improved out of sight.
Building such a system would be the most fitting monument to the victims alive and dead of the butcher of Bundaberg.
Published as “What a feeling system change evokes” in the Courier Mail on 27th April 27, 2005