Mind the step!

One of my "thinker in residence" sponsors here in Australia is VMIA, the Victoria state government insurance agency.  I had just finished having a lovely cup of coffee and conversation with one of the agency's executives, where our topic had been risk assessment and mitigation.

As I started to leave the coffee shop (not a state agency facility!), I stumbled and looked back to see a drop in the floor levels between two parts of the restaurant.  While I can be clumsy (just ask my soccer buddies!), usually I'm pretty adept at walking out of restaurants without suffering harm.  So, I looked back to reconstruct the situation.

Here's the broad scene.  The waiter above has just stepped down into the lower portion of the shop.  And indeed, there is a large sign up and to the right warning patrons of the drop in floor height.

The problem is a that there is a very eye-catching sign to the left, designed to draw your attention as you pass through this area.

So, I didn't notice the warning sign to my right.  Also, the floor area is not well lit, and there is little color difference between the step and the floor below.

Ok, that's the human factors set of circumstances. These are accidents waiting to happen.

Now, let's turn to the people side.  As I stumbled, a clerk behind the counter noticed and smiled knowingly, as if to suggest that I was not the first to have this experience.  I went back to talk with another clerk and point out the problem.  She was very apologetic and asked if I was hurt.  I said I was fine but just wanted to point out the safety hazard.  When she saw me taking pictures, she said, "You're not going to sue us, are you?"  I said no, but I thought the shop might want to devise a better warning system.  She acknowledged that the current arrangement was designed to warn people headed towards the right, i.e., going to the toilet, but not those who might be going to the left.

I left confident that the problem would not be addressed in the future.  Some day, someone will fall and be badly hurt, and the shop may, indeed, be sued.

Think through similar circumstances in health care facilities and other service establishments, as well as industrial settings.  Such patterns are highly prevalent--both in terms of the human factors issues and also in terms of the lack of empowerment felt by the front line staff.

A canary in the coal mine?

How should we think about medical malpractice claims against doctors?  Are they indicative of something about those doctors who've been sued? Are they a symptom of underlying quality and safety issues in a hospital, a kind of canary in the coal mine that suggests there might be deeper problems?  These are long-standing questions.

Perhaps part of the answer is provided in a new article in the New England Journal of Medicine, "Prevalence and Characteristics of Physicians Prone to Malpractice Claims," by David Studdert and colleagues.  (The article has a theme that is somewhat consistent to one I discussed a few days ago, which reported that a small group of doctors in Australia accounted for many patient complaints.)

The authors conducted an extensive review of US National Practitioner Data Bank information, analyzing 66,426 claims paid against 54,099 physicians from 2005 through 2014. They found that, over this 10-year period, "a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims."

Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another.

Risks also varied widely according to specialty. As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons, and obstetrician–gynecologists. The lowest risks of recurrence were seen among psychiatrists and pediatricians.

Male physicians had a 38% higher risk of recurrence than female physicians. The risk of recurrence among physicians younger than 35 years of age was approximately one third the risk among their older colleagues. Residents had a lower risk of recurrence than nonresidents, and M.D.s had a lower risk than D.O.s. 

We could stop right there and conclude that the problem lies solely with the high-risk doctors.  But, as the authors point out, these doctors practice in health systems, and those systems have the potential to intervene.

All institutions that handle large numbers of patient complaints and claims should understand the distribution of these events within their own “at risk” populations. In our experience, few do. With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims. Rather, the risk-mitigation initiatives that are in place — such as the educational and premium-discount programs that some malpractice-insurance companies offer — are generally offered en masse. Otherwise, insurers tackle the problem of claim-prone physicians primarily by raising premiums or terminating coverage. These strategies do not directly address the underlying problems that lead to many claims.

In an environment in which a small minority of physicians with multiple claims accounts for a substantial share of all claims, an ability to reliably predict who is at high risk for further claims could be very useful. . . . If reliable prediction proves to be feasible, our hope is that liability insurers and health care organizations would use the information constructively, by collaborating on interventions to address risks posed by claim-prone physicians (e.g., peer counseling, training, and supervision). It could present an exciting opportunity for the liability and risk-management enterprises to join the mainstream of efforts to improve quality.

Fostering a non-negotiable safety mindset

Apparently, my recent blog post about preventable medical errors at a Victoria community hospital was widely circulated among the local health care community.  Maybe it's helpful to have an outside observer say things about such a circumstance, but there are also local observers who fully understand the underlying issues and have been working on them for some time.

One is Cathy Balding, who wrote this article on the same situation back in November.  Here are some excerpts that go to the heart of the matter, not just in Djerriwarrh, but more generally through the state of Victoria:

Creating and maintaining consistently safe, high quality care requires an understanding of complexity, and the mix of interconnected organisational factors required: great people supported by great systems, led from the top, based on a relentless pursuit of excellence. But--we haven't yet achieved universal acceptance that this is what it takes. The belief that point of care is fundamentally clinicians' business is buried in our healthcare DNA; an unconscious attitude that drives a hands off approach to clinical governance in still too many health, community and aged care services.

So--There's a step before all the action. And that's the step that many health services miss: fostering a non-negotiable safety mindset that addresses this deeply held belief head on. I see ‘excellence’ everywhere in mission statements and strategic plans. But it doesn't take much to scratch the surface and realise that in too many cases, these words are about image, not substance. The way we'd like to be perceived, rather than the way we really are. As if saying it will somehow make it a reality. But saying it is just the beginning. 

I've addressed a common pyschological reaction of clinicians: everybody likes to think they are doing better than others.  It turns out that boards also fall into this trap.

Marie Bismark summarized this phenomenon in a paper delivered in May 2014: "Almost every respondent believed the overall quality of care their service delivered was as good as, or better than, the typical Victorian health service."  Here's the pertinent graphic from her talk:

I addressed this issue once with regard to US hospitals, noting:

We know that most medical harm does not derive from the individual actions of doctors. It derives from the work patterns and systems that are in place in hospitals. These are not organizational aspects in which most doctors and nurses have been trained. They are trainable with some time, effort, and resources—but those in a position of authority must encourage and demand that it happen. The “those” in this case must be the boards of trustees, the governing bodies of the hospitals. 

But it is in this arena that we have a public policy lacuna. While trustees often have a statutory responsibility for the quality of care given in their hospitals, they are never held accountable for that care. The history of involvement by lay governing bodies is heavily centered on the social and community aspects of governance. Clinical decisions are left to the clinical staff, as they should be, but oversight of clinical activities by the governing body is often rudimentary at best.

In another article, I offered a suggestion as to how transparency of clinical outcomes could help a board do its job better.

I think the issue is not the unavailability of reliable information on peer performance.  I think the issue is a failure, in the first instance, to even measure one's own performance and to share that with one's own team. After all, the issue is not so much benchmarking.  That only goes so far.  As I've often said, there is no virture in benchmarking to a substandard norm. 

So, the first step is to accurately collect one's own data and make it transparent to your own team. It is that transparency--more than benchmarking--that will establish the creative tension in an organization that will drive people to meet their own stated standard of clinical excellence.  A smart board does not have to apply pressure on its staff by drawing comparisons with others. Rather, they take governance steps to demand transparency, so that the deep sense of purpose that is inherent in the clinical staff is employed to stimulate the team to do better on their own.

In short, the conclusions reached by Dr. Balding, Dr. Bismark, and many other observers must be revisited by the broader community. Victoria, in contrast to, say, New South Wales, has determined that a highly devolved structure of health services best suits it population. That may indeed be the case for a number of reasons, but a necessary condition for such a devolved structure is that the CEOs of local hospitals are given the clear mandate from their boards that quality and safety are the first and highest measures in their performance reviews--and that the boards are given the identical clear mandate from Government.  Yes, access and cost are important factors as well, but if the underlying care delivered by health services is not safe and effective, the public service mission of these organizations has not been achieved.

Nominative determinism

Upon seeing this photo from the town of Koo Wee Rup, Victoria, that I posted on Facebook, our friend Geoffrey Irvin posited that it appeared to be a clear case of nominative determinism, which Wikipedia defines as "the hypothesis that a person's name can have a significant role in determining key aspects of job, profession or even character."  The article notes:

The term nominative determinism had its origin in the 'Feedback' column of the British popular science magazine New Scientist in 1994:

"We recently came across a new book, Pole Positions — The Polar Regions and the Future of the Planet, by Daniel Snowman. Then, a couple of weeks later, we received a copy of London Under London — A Subterranean Guide, one of the authors of which is Richard Trench. So it was interesting to see Jen Hunt of the University of Manchester stating in the October issue of The Psychologist: 

"Authors gravitate to the area of research which fits their surname." Hunt's example is an article on incontinence in the British Journal of Urology by A. J. Splatt and D. Weedon. We feel it's time to open up this whole issue to rigorous scrutiny. You are invited to send in examples of the phenomenon in the fields of science and technology (with references that check out, please) together with any hypotheses you may have on how it comes about. No prizes, other than seeing your name in print and knowing you have contributed to the advance of human knowledge."

What do you say?  Shall we see if our readers here can continue to advance human knowledge and offer other examples, either that support the hypothesis or cast doubt upon it?  Please submit your entries as comments.  Thanks!

One person's costs is another person's income

What a relief!

According to Jessica Gardner in the Sydney Morning Herald, a recent report suggesting that the growth in utilization of the Australia private health care system might slow down is off base.

Two rival private hospital leaders, Healthscope's Robert Cooke and Ramsay Health Care's Chris Rex, say a research report from Macquarie that warned of a hit to the companies' growth is premature and ignores important trends.

Macquarie's health analyst published a note on Monday warning that a federal government review of the Medicare Benefits Schedule would hit 'utilisation' of services, which is the largest driver of revenue growth for the companies.

Investors were unnerved by the analysis. On Monday Healthscope shares fell 4.8 per cent to $2.36, while Ramsay shares lost 3.2 per cent to $60.65.

In a strident statement Ramsay's Mr Rex said the report failed to consider further utilisation growth linked to the ageing population. "Macquarie's report incorrectly concludes that the modest impact of ageing in the past means that the impact will be minimal in the future," he said. "But it is the future impact of ageing – the baby boomers moving into the 60-70 year bracket - that needs to be considered... We have not yet felt the ageing impact – it is yet to come."

Whew!

When is a doctor like a bull ant?

In my previous post, I addressed the issue of bullying in Australian hospitals.  In an article published three years ago in BMJ Quality and Safety, Marie Bismark, David Studdert and colleagues addressed a topic that might be correlated in some way with that problem--or might just have importance in it own right.

The authors' objective was: 1) To determine the distribution of formal patient complaints across Australia's medical workforce and (2) to identify characteristics of doctors at high risk of incurring recurrent complaints.

What they found was:

A small group of doctors accounts for half of all patient complaints lodged with Australian Commissions. 

The distribution of complaints among doctors was highly skewed: 3% of Australia’s medical workforce accounted for 49% of complaints and 1% accounted for a quarter of complaints. Short-term risks of recurrence varied significantly among doctors: there was a strong dose-response relationship with number of previous complaints and significant differences by doctor specialty and sex. 

The research suggested:

It is feasible to predict which doctors are at high risk of incurring more complaints in the near future. Widespread use of this approach to identify high-risk doctors and target quality improvement efforts coupled with effective interventions, could help reduce adverse events and patient dissatisfaction in health systems.

The Australian bull ant (seen above) gets you coming and going.  He'll either bite you from the front or sting you from the back. This cadre of doctors do the job even better. They offer the potential of both harming the patient and the institution in which they work.

Thus far, though, "the medico-legal enterprise remains reactive, dealing primarily with the aftermath of adverse events and behaviours that lead to costly disputes." Perhaps the work produced by Bismark, Studdert and colleagues will help the AMA, health services, medical indemnity insurers, and others think more systematically about this issue.  And, as in the bullying case, the input of patients and families could certainly prove valuable in this arena.

Bullying, a multi-legged problem

Notwithstanding Bill Bryson's characterization of this "sunburned country" as a place in which there are dozens of ways to be killed by local fauna*, the chance of actually dying from a spider bite, snake bite, or in other such manner is quite small.  For example, the huntsman above looks pretty ferocious, especially given his 4" (10 cm) span, but he won't kill you.

In contrast, though, Australia shares the unenviable status of other developed countries (US, UK, and the like) in the fact that being a patient in a hospital is a significant risk.  I discussed the situation in one Victoria hospital in a previous blog post.  There, a number of babies died of a result of preventable medical errors.

In the short time I've been in the country, I've heard several people set forth one aspect of the problem, the existence of inappropriate levels of bullying and intimidation by senior members of the medical staff.  Such behavior can directly influence the safety and quality of patient care:

"Most organizations are beginning to understand that this is about patient safety," says Marty Martin, a psychologist based at DePaul University in Chicago. He co-wrote a guide book, Taming Disruptive Behavior [that] details growing evidence linking bad behavior with patient harm.

(Indeed there is reason to believe that such was part of the problem in the aforementioned hospital.)

In a November 21, 2015 article in The Age, reporter Neelima Choahan summarized a day-long summit held by the Australian Medical Association on the topic.

Now comes the question of what to do about it.  Shortly after the article, the AMA issued a position statement on the issue.  The organization's president said:

“Workplace bullying and harassment creates an unsafe and ineffectual work and learning environment due to the continued erosion of confidence, skills and initiative, and can create a negative attitude towards a chosen career.

“The medical profession must take direct responsibility for its culture, reputation, and standard of professionalism. 

“We need comprehensive policy, practices, and education to foster a safe and healthy work and training environment, and we must maintain appropriate standards of patient care.

“Employers and education providers must work closely together to develop a strong response to change the culture in workplaces."

This is a start, but this is a tough problem that has been in existence for decades. Let's hope that the Australian medical profession does indeed "take direct responsibility" for improvement in this arena; but there are important roles for other constituents as well.  In particular, there is a nascent patient advocacy movement occurring in this country. With focus and direction, those engaged patients and families can provide respectful and helpful input about the cultural environment in which they are being treated. There is no mention of this resource in the AMA'a position statement or in the president's comments on the issue.  It would behoove the AMA to join forces with such individuals and groups to help make the statement of position a reality throughout the country.

---

"It has more things that will kill you than anywhere else. Of the world's ten most poisonous snakes, all are Australian. Five of its creatures - the funnel web spider, box jellyfish, blue-ringed octopus, paralysis tick, and stonefish - are the most lethal of their type in the world."

No worries? Not so good.

Every language or region has its colloquial response to "Thank you!"  In Spanish, we say, "De nada."  "It's nothing."

In the United States, we often say, "No problem."

Here in Australia, it's "No worries."

This is fine in casual settings, as among friends.  But, in health care settings, it's the wrong answer.

I addressed this about five years ago in a blog post, noting:

One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.

When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.

Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.

So mates, try this out in clinical settings.  You'll respectfully acknowledge a person's appreciation, and you might learn something new that could be helpful to the patient, family, or your own institution.

Negotiating in Geelong

One of the pleasures in my appointment as "Thinker in Residence" at Deakin University is the chance to hold workshops for local folks on topics that might be new and interesting to them.  This week's session was an introduction to strategic negotiation for people from Deakin, GMHBA (the region's largest mutual health insurance company), the Western Victoria Primary Health Network, and Barwon Health.  Beyond learning some new approaches to this field, many folks in attendance also had a chance to meet each other for the first time.

Here are pictures of some of the attendees, responding to other parties or deep in thought as they considered their approach to negotiating some difficult roles in simulations we carried out.

Facebook: Killing the goose?

None of us who use Facebook are so naive as to think that it is a free service.  The "cost" of playing is that they use all of the data you post to direct advertisements your way.  It is simply how these applications on the Internet are monetized.

But many friends and I have noticed a dramatic upswing in the number of sponsored items on our news feeds, often showing up with the message that one or another of friends has "liked" the link.  In the past, there would have been a few of these, but now they come in a ratio of 1:10 or 1:20 among the feeds on your page.  Here are three examples of what they look like.  (I've omitted the accompanying pictures.)

I searched the web to see if this upswing in such ads is a new deal, but found nothing.  But I did find this "helpful" suggestion on the Facebook "Help Community" from a few months ago:

Alison asked:

How do I stop the bombardment of advertising posts on my newsfeed - almost all totally irrelevant to me, and some against all my principles.

Hailey provided this non-answer:

Alison replied:

I know all about the options not to see ads from particular advertisers, but the bombardment I have been getting recently is beyond belief. And opting out of each on individually takes time which I don't have to spare. I want to be able to opt out of ALL ads and sponsored links. I'd never follow them anyway - I take word of mouth and recommendations from friends as the best advertising, not people who need to pay to advertise.

There was no response. 

So we know that we can delete the ads we don't like, but who wants to spend the time doing that as you scroll through looking for news from your friends?  As my buddy Lyette noted: "I've already found myself checking less often, because I know they don't even show me half of my friends' updates."

So, what do you think?  Is Facebook over-reaching now?  Will it change your viewing habits?

Too quick to judge, Jerry.

Jerry Groopman is such an admirable person and has so much good to say that when he is off track, it hurts to see it.  In a recent article in the New England Journal of Medicine, he and Pamela Hartzband conflate two issues.  One the one hand, there are their legitimate complaints about the depersonalization and attacks on professional judgment that derive from so much that is wrong with the health care system today.  On the other hand, there is a complete misrepresentation of the tenets and application of Lean (or Toyota Production System) in clinical settings.

I'll not go through all the details.  Mark Graban does that in excellent fashion here.

No, what hurts more is the fact that our clinical staff at BIDMC, where the authors reside, were overwhelmingly engaged in the the philosophy and practice of Lean--at least during the time I was there.  What's more, they enjoyed it and found that it made their lives better.  Indeed, Mark Zeidel, our Chief of Medicine, regularly offered many positive thoughts on these matters in his missives to his staff, called Kaizen Corner.

The same is true in many other hospitals and physician practices.  I've told many of these stories in my companion blog, "This is Not 'Not Running a Hospital." Gene Lindsey has done the same on his blog posts.

In his marvelous book, How Doctors Think, Jerry explains the occurrence of diagnostic anchoring among physicians, noting the power of confirmation bias--the tendency to see and believe evidence that supports your view and ignore facts that don't. I fear that this NEJM article is infected by this cognitive error.

How do you pronounce Djerriwarrh?

In my travels around the world, I've come to realize that the normal state of hospital quality and safety is pretty consistent.  As Captain Sullenberger put it: "Islands of excellence in a sea of systemic failures." That's no reason to give up hope that things will improve, but this description does offer a metric of sorts and acts to prompt a number of us in the field to continue to push for better care and offer training and assistance to health care professionals.

But Sully's summary is inadequate in one respect in that it doesn't reflect those institutions that are remarkably worse than even the substandard norm.  There are examples everywhere. In the US, it was exemplified by Parkland Memorial Hospital in Texas. In the UK, it was Mid Staffordshire. Here in the state of Victoria, it is Djerriwarrh.

I'd heard about this story of the Bacchus Marsh hospital unit of Djerriwarrh Health Services well before arriving in Australia.  Preventable deaths of babies is news that spreads worldwide, and this cluster from 2013-2015 at this low-risk maternity center was no exception.

There is a lot of blame going around still, months later. There is also thoughtful analysis.

[A] review led by Professor Euan Wallace found the perinatal mortality rate at the hospital was significantly higher than the state average and much higher than expected for a "low risk" unit.
He also identified misuse or misinterpretation of foetal heart rate monitors by "inadequately skilled" staff and a lack of "high quality staff education" as key problems.

But that's only part of the problem. It is evident that this hospital suffered from a serious failure of governance.  Indeed, the community board has since been sacked by the state government.  Beyond their own lack of expertise, the board countenanced a committee structure that reported only to the CEO and not to the board.  There was essentially no quality and safety committee, and adverse events that occurred were improperly categorized as of lower acuity, so that root cause analyses were not undertaken.  Doctors also were practicing outside of their scope of authority, delivering babies in higher risk situations than their hospital was authorized to perform.

But the place also suffered from a "compliance" mindset on the part of the hospital's leadership: As long as forms were on file and reports filed in timely fashion, the job was being done well. This attitude may have been reinforced by the ACHS, the Australia equivalent of the Joint Commission, which had graded the hospital highly in the survey before these disclosures.

(In a wonderful bit of irony, the Health Services still posts this message on its website, even though its most recent, post-disclosure ACHS review was less than stellar:

The Health service is an industry leader in a number of quality standards that cover a wide variety of issues including actual clinical care, how the organisation is managed, infection control, risk management and emergency procedure planning. Djerriwarrh Health Services is currently accredited through the Australian Council of Healthcare Standards (ACHS) as well as the Aged Care Standards Agency.)

Things were compounded by a failure of the AHPRA, the national board of physician registration, to conduct timely and accurate reviews of complaints about physicians, and their failure to inform hospital officials that such reviews were even in progress. Meanwhile, Professor Wallace also found that the state Department of Health, itself, had failed to use the data at its disposal to notice adverse trends in clinical outcomes.  It was not until March 2015 that the Department noted the hospital's problems in the maternity arena.

Sorry to say, but none of this is a surprise. And I wouldn't be surprised if future investigations turned up more typical aspects of such cases.  I'd bet that there was a culture of bullying and intimidation.  I'd bet that there was poor communication among the elements of the medical staff who were involved in obstetrical care.  I'd bet that there was poor team dynamics.  I'd bet, too, that once people look back further in history, they will find still more cases of preventable harm.  And I'd bet that they will find it in other clinical areas delivered by Djerriwarrh Health Services.

So, where does this lead, for Djerriwarrh Health Services and for the state? Victoria is characterized by a very high number of very small health services.  Here's a map of the state showing the distribution of public hospitals.

This large number of very small rural hospitals is the result of political forces, not a rationalized plan based on geography, demographics, health needs, or critical masses.  It means that several dozen small hospitals function essentially in the same manner as Djerriwarrh, with isolated medical staff and well meaning, but medically inexperienced boards.

Does the Djerriwarrh story suggest that the state should move to a more hub-and-spoke system of hospital organization, with greater reliance on regional higher acuity centers?  That's for the body politic to consider.  (It is not for a visitor to offer opinions on that kind of issue!)

Regardless of whether the state moves in that direction, though, there's a clear need to raise the level of the lay governing boards--to train them how to govern quality and safety--and to institute more rigorous clinical governance systems among the medical staff themselves.  The case also suggests that some review of the regulatory and accreditation bodies is in order.  Among other things, shouldn't the ACHS survey findings be made public as a matter of course? Quis custodiet ipsos custodes?

And finally, transparency.  The sunshine that comes from public display of real time (not historical) clinical outcome trends is the most certain way achieve the standard of care that clinicians desire for their communities.  As I noted years ago:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Djerriwarrh stands in the middle of one of the fastest growing regions in Victoria.  The current and future residents of that area deserve the best in clinical services.  There is nothing standing in the way of the well meaning people at Djerriwarrh Health Services from committing themselves to deliver the best.

Quizzify doesn't hurt!

Al Lewis and Vik Khanna have been at the forefront of debunking useless, intrusive, demeaning, and coercive wellness programs that have been codified into law by the Affordable Care Act and that have become the favorite of corporate human resources folks who have to justify higher insurance premiums to their employees and of insurance companies looking for new profit lines.  In this article, for example, they noted:

Now, more than four years into the ACA, we conclude that these programs increase, rather than decrease employer spending on health care with no net health benefit. The programs also cause overutilization of screening and check-ups in generally healthy working age adult populations, put undue stress on employees, and incentivize unhealthy forms of weight-loss.

Not content to merely throw stones, the pair and some friends have started a venture called Quizzify, an on-line service for employers that "teaches your employees to make smarter, better healthcare decisions."  The founders believe that people can learn from playing an engaging and humorous set of quizzes that comprise a bunch of questions about nutrition, life style issues, surgical procedures, and medical care in general.

And they do so in a very unintrusive way:

Al says in a note to me (and now to you!): You can go to app.quizzify.com and where it says "your employer" scroll to "guest."   This is the "Launch Quiz," the non-employer-customized generic version.  Try it out.

I did.  (Don't be put off by this sample.  It is a bit long, with 25 questions.  The ones being offered commercially are more targeted.)

I intentionally answered some questions incorrectly to see what would pop up.  Here's one example in the nutrition category:

And here's one I got right in that category, about one of the world's favorite energy bars:

I could show you more, but it will be more fun if you try it out yourself.  I think you will be surprised with some of the answers.

If I were in the corporate world, I'd seriously consider offering this service to my employees.  The messages learned are much more likely to have a beneficial effect on people's health and on their use of the health care system than a lot of the more invasive programs being forced on employees.

(Note: I have no financial relationship with this venture. And when I play Boggle and Taboo with Al, no money changes hands.)

Is this any way to run a transit system? You bet!

Not many cities have books written about their transit system and its impact on the urban environment.  But Boston does.  In the book Street Car Suburbs, The Process of Growth in Boston, Sam Bass Warner explained how the city of Boston grew and prospered between 1870 and 1900 from the interaction between growth of the transit system, creation of new neighborhoods, and expansion of the city.

So, you'd think that the elected leaders of Massachusetts would have a sense of the importance of a properly running--and constantly growing--transist system and their hopes and desires for Boston to remain a world class city.  But that realization seems sorely lacking, and the region often devolves into arguments over routes and fares, "reform," and the like.

Riders of the system suffer from what might be termed "a readiness to be injured." I don't mean physically injured.  I mean a depressed, resentful expectation that service quality will be inconsistent at best and slowly deteriorating at worst.

As I've traveled to other world class cities, I see a different attitude and a different set of expectations.  Transit is a key determinant of growth and a pleasant urban environment.  Service quality, in the form of polite and friendly drivers and other workers, is the norm.

Here's a simple example from Melbourne, Australia, where I am living for a few months.  One of the tram lines was about to experience an upgrade of tracks and construction of a new handicapped accessible platform stop.  No effort was spared in informing the riding public that service would be disrupted on this line, with buses running as substitutes.  Among other things, these hanger cards were hung throughout all the vehicles for several days before the disruptions.  "Please take me," noted the cards on the obverse.  On the back, a succinct and clear explanation of the situation and the transit alternatives available was presented.

And how well did it work? Like a charm. On each day service was disrupted and passengers were to disembark the tram and ride a bus, they were greeted by friendly staff members and shown where to walk, about 100 meters down the street.  To make sure you wouldn't get lost en route, the sidewalks had these adhesive signs.

At the bus stop, there was more clear signage and, again, helpful and friendly people were there to point the way.

I compare this to days on which my local transit line in Boston is out of service and replacement buses are put in place.  That situation is often characterized by poor signage and sour staff members (if any).  Your task as a rider is to figure out what is going on and how to get to work.

I wish there were a way to persuade Massachusetts politicians that excellent transit service quality is not only possible, but essential to the future prosperity of the capital city.  I wish there were a way to help the public understand that resentment and depression are not normal emotional responses to using a transit system. Instead, I see our fair "city upon a hill" falling behind in this essential infrastructure and ever so slowly sinking from its natural place among the firmament of world class cities.

The paradox of unanimity: When intuition is badly informed

This article by Lisa Zyga summarizes a forthcoming Lachlan J. Gunn, et al article in Proceedings of The Royal Society A, "Too good to be true: when overwhelming evidence fails to convince." It offers some interesting thoughts.  This is a useful discussion, especially for those in leadership positions.  See, especially, #5 below.

Excerpts from the article:

Under ancient Jewish law, if a suspect on trial was unanimously found guilty by all judges, then the suspect was acquitted. This reasoning sounds counterintuitive, but the legislators of the time had noticed that unanimous agreement often indicates the presence of systemic error in the judicial process, even if the exact nature of the error is yet to be discovered. They intuitively reasoned that when something seems too good to be true, most likely a mistake was made. 

The researchers demonstrated the paradox in the case of a modern-day police line-up, in which witnesses try to identify the suspect out of a line-up of several people. The researchers showed that, as the group of unanimously agreeing witnesses increases, the chance of them being correct decreases until it is no better than a random guess.

In police line-ups, the systemic error may be any kind of bias, such as how the line-up is presented to the witnesses or a personal bias held by the witnesses themselves. Importantly, the researchers showed that even a tiny bit of bias can have a very large impact on the results overall.

The paradox of unanimity may be counterintuitive, but the researchers explain that it makes sense once we have complete information at our disposal.

"As with most 'paradoxes,' it is not that our intuition is necessarily bad, but that our intuition has been badly informed," Abbott said.

Other areas where the paradox of unanimity emerges are numerous and diverse.

1) The recent Volkswagen scandal is a good example. The company fraudulently programmed a computer chip to run the engine in a mode that minimized diesel fuel emissions during emission tests. But in reality, the emissions did not meet standards when the cars were running on the road. The low emissions were too consistent and 'too good to be true.' The emissions team that outed Volkswagen initially got suspicious when they found that emissions were almost at the same level whether a car was new or five years old! The consistency betrayed the systemic bias introduced by the nefarious computer chip.

2) A famous case where overwhelming evidence was 'too good to be true' occurred in the 1993-2008 period. Police in Europe found the same female DNA in about 15 crime scenes across France, Germany, and Austria. This mysterious killer was dubbed the Phantom of Heilbronn and the police never found her. The DNA evidence was consistent and overwhelming, yet it was wrong. It turned out to be a systemic error. The cotton swabs used to collect the DNA samples were accidentally contaminated, by the same lady, in the factory that made the swabs.

3) When a government wins an election, one laments that the party of one's choice often wins with a relatively small margin. We often wish for our favored political party to win with unanimous votes. However, should that ever happen we would be led to suspect a systemic bias caused by vote rigging.

4) In science, theory and experiment go hand in hand and must support each other. In every experiment there is always 'noise,' and we must therefore expect some error.  If results are too clean and do not contain expected noise and outliers, then we can be led to suspect a form of confirmation bias introduced by an experimenter who cherry-picks the data.

5) In many committee meetings, in today's big organizations, there is a trend towards the idea that decisions must be unanimous. For example, a committee that ranks job applicants or evaluates key performance indicators (KPIs) often will argue until everyone in the room is in agreement. If one or two members are in disagreement, there is a tendency for the rest of the committee to win them over before moving on. A take-home message of our analysis is that the dissenting voice should be welcomed. A wise committee should accept that difference of opinion and simply record there was a disagreement. The recording of the disagreement is not a negative, but a positive that demonstrates that a systemic bias is less likely.

Maybe "1,2,3" isn't a good password.

PCA (patient-controlled analgesia) pumps are very useful devices, enabling patients to push a button to control the amount of intravenous pain-killer they want to use depending on how they are feeling.  Of course, the pumps have a limit to how much can be drawn--so the patient doesn't get an overdose.

The pumps can also be set to deliver a "basal rate," a constant infusion of narcotic pain medication, in addition to the dose the patient gets when he or she pushes the button. No matter how sleepy the patient is, the pump will continue infusing narcotics. Normally, without a basal rate, patients using a PCA can only receive medication when they are awake enough to push the button, which serves as a safeguard against receiving an overdose.

As I have noted, PCA pumps need to be carefully employed and can be dangerous without appropriate monitoring:

The Happy Hospitalist explains:

Why is PCA morphine dangerous?  Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea.  This is the cause of death in a heroin overdose.  This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news.  Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms.  This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside.   

The Joint Commission published a sentinel event alert on the matter in August 2012. 

In many parts of many hospitals, the basal rate is not used, precisely because of how dangerous it is. There are other options for those patients with high narcotic needs, such as having a nurse give the patient a scheduled dose of narcotic every few hours after making sure it is safe for the patient to receive it.

All this background is to set up a recent event at an academic medical center:

A drug addicted patient "hacked" his PCA pump and gave himself a basal rate of 2mg dilaudid per hour with a 1mg self-administered PCA dose every 5 minutes.  This would have resulted in respiratory arrest if the nursing staff had not quickly realized what was going on. (I'm advised that most people stop breathing at about 2-4mg per hour.  Since this person was tolerant, he probably could have lasted a few hours but inevitably would have overdosed overnight). The staff took the PCA away.

What are some possible lessons from this near miss?  At a minimum, it might be worth thinking about changing the PCA pump passcode from "1,2,3" to something more difficult to guess. Maybe it would also pay to eliminate the basal rate option all together on the machines in parts of the hospital where constant monitoring is not available.

Remembering Black Saturday

Every part of the world, it seems, has its meteorological hazards with the potential for death and destruction.  There are monsoons, typhoons, hurricanes, tornadoes, and blizzards.  But I'm guessing that one of the most frightening is a fast-moving bushfire in southern Australia.

Standing like sentinels over the Steavenson River in Marysville, Victoria, are these towering burnt out trees.  They are some of the remains of Black Saturday, 7 February 2009, when bushfires spread--well, like wildfire--throughout this region just northeast of Melbourne.  After extensive drought and daytime temperatures of close to 50 degrees Celsius, several blazes began.  The fronts of the fires traveled at 100 kilometers per hour, and cinders and branches were pushed ahead of the firestorm for extensive distances.  Fire tornadoes were witnessed.

Beyond the property damage, leaving over 7000 people homeless, 173 lives were lost.  The small historic town of Marysville was one of the hardest hit, in terms of the percentage of its population who died. The town's cemetery listing above tells part of the story.  The entire story is told in this documentary.

Here's a satellite picture of the fire just before the winds shifted and sent the front through Marysville.

The town is set in a bowl-shaped area, surrounded by ridges. The fires traveled up those ridges in seconds and then sent projectiles down into the town, igniting and destroying almost everything and leaving people with little chance of escape.

In the image below, people take shelter in the cricket oval in the middle of town.  It was the safest place to wait.  But as they waited, they saw virtually the entire towning burning around them.  Among those waiting were the local firefighters who had to suffer through the constant pinging of their pagers and cell phones as people called for help.  But they were unable to help.  There was simply no way to defeat this fast moving set of fires.  To attempt would have meant death for the firefighters.

Meanwhile, down by the river, huge updrafts pulled large trees up out of the soil, including their root balls, and then lay them down:

Until this set of fires, the general rule in the region was to stay home and protect your property when bush fires came through.  That rule has now been changed to "protect yourself."

Sentinels remain to remind people of the events that occurred seven years ago next month. Mourning of loved ones, survivor guilt, loneliness, and physical and emotional disorientation remain as symptoms.

Queensland exploration of the prophetical approach to leadership training

Queensland Health was an organization under a great deal of pressure several years ago because of safety and quality issues.  In fact, in 2005, the Queensland Government announced an independent review of QH’s administrative, workforce and performance management systems, with focus on issues of bullying and intimidatory behavior in the workplace.  Among other things, what developed was an interesting approach to leadership training employed during the remediation of those issues. I had not heard about this method and was curious to learn more.  What I discovered is that the approach is qualitatively equivalent to the kind of simulation used to teach clinicians how to deal with unexpected situations.  Here, though, the vehicle is a drama-based interactive case study, a "prophetical."  Here are some excerpts from the article (sorry, payment required):

The prophetical is a form of applied theatre which draws inspiration from two words. In the prophetical, the players create a prophecy (which foretells of possible future events) which is also a hypothetical proposition.... The prophetica then blends truth and fiction to present dramatic scenarios which are reasoned speculations on the future. From the prophetical it is possible for participants to see versions of the future, especially flawed futures which can be corrected or transformed through their interventions and actions.

The power of the prophetical as a method of transformatory learning arises from the playing out of a dramatic scenario which has been carefully constructed for the participants. The scenario results from a rigorous research process so that it is grounded in the lived experience of the participants who can recognise and critique what they see playing out before them. Participant interest is also heightened when the chronology of events played out in the prophetical are treated in a highly elastic way; with flashbacks and jumps in time to move the action (and the participants backwards and forwards across time. The manipulation of the sequence of events, and the way the participants engage with them, is in the hands of a facilitator (known as a midwife — “the person who brings about change”) who uses the scenario and its reality as raw material to be adapted and extended to deepen learning for participants. The midwife’s interventions arise from assessing the impact of the action in the moment and quickly judging what would be most beneficial for participants.

What resulted was a scenario which could be played out in 12 scenes by five fictional characters. As workshop participants followed the scenario they could identify the highly ambitious and youthful Area Manager intent on self-promotion through his political connections and his advocacy of the NSI (nursing-sensitive indicators). They could empathise strongly with young Chloe, the well-meaning but not always politically astute Acting District Manager, who failed to project manage the NSI into service. They were quite taken by the cynical and hard-nosed clinical staff, the Director of Nursing and the Medical Superintendent, who had little faith in the system (or Chloe) to deliver on its promises. And they had very little sympathy for the overworked senior bureaucrat, more concerned about the Minister and press reporting than patients.

Together these characters played out a scenario characterised by poor planning, high egocentricity, bullying and the failure to accept responsibility. As the scenes were played out, discussed, replayed and reviewed, participants drew on the Queensland Health Leadership Qualities Framework to critique the behaviour they saw, model alternative leadership approaches for the group and then compare these approaches.

Responses of participants to the prophetical were overwhelmingly positive, with 70% rating it as “successfully opening up the key issues of the workshop.” Similarly, 71% of participants felt that the issues raised in the prophetical were effectively integrated throughout the workshop.

The final recurring comment from participants centred on their responses to the characters in the prophetical. Strong empathy, support and sympathy were felt towards Chloe, the well-meaning but poorly skilled middle manager who finally was held responsible for the unravelling debacle. On the other hand, open hostility and anger were expressed towards the superficial, politically manipulative and well connected bureaucrat whose style-over-substance actually orchestrated the events. The emotional engagement of participants with these characters was palpable and stimulated energetic discussion about their leadership and integrity, caused many to leap to their feet to demonstrate alternative behaviours, and sharpened insights into their strengths and weaknesses as leaders.

Weariness subdued by the dull compulsion of rhythm

Longstaff: Arrival of Burke, Wills, and King at the deserted camp at Cooper's Creek

Burke and Wills are Australia's equivalent of the United States' Lewis and Clarke, men who walked the south to north length of the continent--from Melbourne 1,500 miles to the Gulf of Carpentaria--exploring its deepest reaches. Unfortunately, the result was fatal to both men and several others. When they returned exhausted and weakened after several months to the base camp at Cooper's Creek, those waiting had left earlier that very same day, leaving Burke and Wills to die in the wilderness several weeks later. A rescue party found their companion King on the site shortly after, emaciated and confused, but alive because of help from native people.  He lived to tell the story from his point of view, and the buried diaries kept by the protagonists were also recovered.

Alan Moorehead wrote an strikingly evocative version of the story.  Here's an excerpt about the northward trek:

It was never easy walking. Anyone who has been in the centre of Australia will bear witness to those sharp, ankle-twisting stones, the clay as hard as concrete and full of cracks, the peculiar stickiness of mud in the swamps. After the first few steps the sweat starts out and one has to keep one hand free and swing across one's face to deal with pestilential, never-ending flies. One sees and hears and smells far more, of course, when one is one foot, but the mechanical monotony of this tremendous walk is something not easily understood by a twentieth-century mind; hour after hour, mile after mile and always the same plain ahead; never to arrive at anywhere really significant; always to get up in the morning with the prospect of doing the same thing all over again.  The world narrows in these conditions; one's boots have the disembodied fascination of a clockwork pendulum, weariness is subdued by the dull compulsion of the rhythm, and ground is not ground but simply distance to put behind one.  In this apathy of movement, this concentration merely upon keeping going, this coma of walking, any intrusion is resented, and any call upon the mind is an effort.

And then there is this extraordinary depiction of the natural scene, presented in ironic combination with an indication of what life was like for William Brahe's group left behind at the Cooper's Creek base camp:

It must have been a life of extraordinary dullness; one suspects that they sat around for hour after hour drinking tea and simply gazing at the campfire; without books, without work, without amusement of any kind, what else was there for them to do? [But] despite its drabness and its heavy stillness and silence the bush had its moments of spectacle as well. In central Australia fantastic dawns and sunsets break across the sky; colours of such leaping brilliance that all the earth, ever bush and tree and the dry ground itself, is illuminated for a few minutes in shades of scarlet, orange, pink and gold. 

. . . As the full fierce blaze of the sun begins to soften at last, the white cockatoos, the corellas, come in by the thousand, screeching hideously, and they settle on one tree after another, never quite able to make up their minds.  On the ground the timid little coots that have been hiding in the reeds all day emerge into the open and come nervously down to the water to drink. The slightest disturbance is enough to make them scuttle back into cover again, and with their black feathers and red beaks they look like frightened chickens as they run. Now everywhere the trees are alive with parrots and coackatoos--the mulgas skimming by in green flocks, the parrot-cockatoos in grey, the Major Mitchells in pink--and it is not possible for the eye to follow all the arrivals and departures, the plovers, the eagles, crows, and harlequin colours of the blue-bonnets, the little waxbills, the ring-necks and the herons.

Galahs

. . . As the light fades the colour of the pool turns to gold, and this is the moment when the galahs, two by two, come in to drink from the bank, anxiously jerking up their heads to look around between each sip, and the bright pink of their breast feathers is reflected in the gold. With darkness silence and stillness return, but then some idiot corella falls off the rotten twig on which it has perched and the whole white flock wheels screeching in the air again. One can expect this to happen half a dozen times but in the end all is quiet.

And then there's the truly tragic moment when Brahe returns to Cooper's Creek one last time, just in case Burke and Wills might have shown up after all.  But Burke and Wills and King had set out on what was to be an aborted attempt to try to return home. At this moment, the two groups were just a few miles apart, and Brahe's freshly reinforced group could easily have caught up with the slow-moving explorers. But Brahe fell victim to anchoring and confirmation bias:

The place was silent and deserted. They tethered their horse to the trees and went inside the stockade. The cache appeared to be undisturbed, the camel-dung raked over the ground as it had been before. They saw camel tracks about the camp, but Brahe presumed that those had been left by his own animals before he left the depot. It was true that there were the ashes of three fresh campfires on the ground, but the blacks were always making such fires, and no doubt, Brahe decided, some of them had camped here since his departure. . . . Brahe did not notice that the rake had been moved, nor the bits of rag that King had hung there, nor the square that had been cut out of the leather door.  He did not see the billy that King had left behind, or at any rate placed no significance upon it. The blazes were there on the trees with nothing added.  In other words, Brahe saw what, no doubt, he wanted to see: that nothing had been disturbed, that he had been right to come away from the depot when he did.

Brahe's conscience was clear. He went off feeling . . . that he could do no more.