Design is the key for human factors. Behaviour is a small bonus.

 Design is the key for effective human factors

In a recent famous case, one surgeon and two anaesthetists were said to be anaesthetising two patients at the same time; this would be risky and unnecessary for patients to be anaesthetised for longer than absolutely essential. It is unethical.

https://theworldnews.net/gb-news/derek-mcminn-patients-put-in-danger-so-scandal-hit-surgeon-could-perform-two-operations-at-same-time

The question is: how did this even happen? There must be policy in place to prevent this. There must have been people who could and should have questioned this and prevented this. Sure. Let’s assume we had policies and people in place – do they prevent for sure two patients being anaesthetised for the same one surgeon at the same time? No.

It happened because there was the structure, infrastructure and facilities to do it.

In UK hospitals there is something called the anaesthetic room which is separate from the operation theatre. This means for one surgeon, there could be a patient anaesthetised inside the operation theatre and another patient anaesthetised in the anaesthetic room.

This is a fairly unique UK NHS practice. Historically, the subsequent patient was brought into the anaesthetic room and the process of anaesthesia began or anaesthesia given when the patient on the table in the operation theatre was nearly done. This was thought to be efficient. It worked when the so called ‘registrars’ both anaesthetic and surgical were experienced. This anaesthetic room concept was then followed by UK private hospitals.

The presence of the anaesthetic room means that it would be physically possible for two patients to be under anaesthetic simultaneously for a single surgeon.

Recently, when designing the theatres of a private hospital, we argued for not having an anaesthetic room and prevailed.

This means that in that private hospital which does not have an anaesthetic room, there is no possibility of two patients being under an anaesthetic at the same time for a single surgeon because there is no physical infrastructure/facility that enables/allows it. No policy or person(s) would have been able to achieve this.

We cannot design a problem to be built into a system and then expect policies and people to overcome it consistently.

Design is the fundamental for human factors – people and behaviours are simply an add on bonus.

© Hemadri

Doctors in India: Villains or Victims?

"We have not lost faith, but we have transferred it from God to medical profession"

- George Bernard Shaw

The doctors community in India, both in public and private sectors, is in a state of unrest. Every few days there is news about brutal attacks on doctors and these are justified by patients’ family and friends as attributable to alleged medical negligence. Thanks to social media, copycat attacks are becoming frequent. The members of the medical fraternity very actively exchange news/ideas, devise strategies to overcome the problem, go on transient strikes, get assurances from the powers that be that concrete steps would be taken to contain such attacks; only for the cycle to restart after a short period. In a study that was conducted by IMA a few years ago three fourths of the doctors surveyed said that they were physically attacked at least once. In a study published in the national medical journal of India last year, not only significant number of doctors are getting attacked but it is also grossly under reported. The trend is getting worse.

Doctors were considered Gods at one time, when did the doctors become demons? From being the rakshak why did they become raakhshas in the public perception.

"Vaidhyaraja namasthubhyam, Yamaraja sahodara!! Yamasthu harathi praanaan, vaidhyah praanaan dhanaanicha!!"

(Meaning: Salute you doctor, brother of Yama, for Yama takes away only our lives, you take away our lives and wealth too) Sanskrit subhashitha.

The problem started when the health care started shifting from public sphere to private. Up to early 1980s patients were get treated in the private sector but when they had major ailments depended on government and teaching hospitals for their treatment. With the advent of corporate hospitals who were capable of providing care for an extended range major ailments, health care cost escalated and high end health care became inaccessible to a majority of people in India. In the absence of national health insurance scheme many citizens make out of pocket payment (OOP) which pushes 32 to 39 million people every year into Catastrophic Health Expenditure (CHE), which is defined as health expenditure which threatens a family's basic standard of living. The situation is only getting worse by the fact that the government's expenditure on health is just at 1% of GDP. (MOHFW2009).

Doctors who work in private hospitals in India know very well that one of the important triggers for irrational behaviour by patient and families is financial issues, especially when the patient outcome is not favourable. The potential for catastrophic health expenditure could cause psychological havoc.

"The huge gap between the rich and the poor, globally and within nations is not only morally wrong, it is also a source of practical problems"

Dalai Lama.

A patient who is at the risk of eliminating his/her financial resources to obtain healthcare, does not realise medical science has its limitations, every illness cannot be cured and there will be an outcome which is unacceptable in some cases. Good counselling of the exact nature of the problem and probable or definite poor outcome including mortality can mitigate this misunderstanding to some extent. Most of the doctors in India have realised the importance of this only in the recent years. As we are battling out issues like large volumes of patients, limited resources and poor infrastructure in almost all public sector providers and most of the private hospitals; effective communication and empathy could be one of the ways to keep situation under control at least partially and temporarily.

"To effectively communicate, we must realise that we are all different in the way we perceive the world and use this understanding as a guide to our communication with others"

Tony Robbins

Even as we doctors condemn unacceptable behaviour by patients and their relatives, can we absolve ourselves of wrong doings? Doctors say that there are some irregularities by a few individuals and a few hospitals and that should not be reason enough to portray the entire community adversely. True, that should not be the case but is it only a few individuals or hospitals? If we believe so, then we may need a reality check. Have we not heard of hospitals expecting their consultants to work to a target? Are we not aware of conversion rates, referral fees, unnecessary laboratory investigations by doctors and cross referrals, indicated or not?

"I am dying from treatment of too many physicians"

- Alexander the great.

This commercialisation and greed has become worse by the entry of unscrupulous businessmen, liquor barons and politicians into the ‘business’ of medical colleges and hospital ownership. Some/many, with their clout seem to flout every rule, manage accreditation yet unable to provide infrastructure or sufficient human resources.

"I have always tried to avoid politics because most politicians I know are quite dirty in terms of human dignity, ethics and morals"

- Steven Seagal

The reality is, when an idealistic young doctor comes to practice with noble intentions he/she is caught in this web of helplessness because of the lack of the right conditions needed practice his/her profession. This is highlighted by Dr Arun Garde, from Pune, in his book in Marathi "Voices of conscience from the medical profession".

"Every truth has two sides; it is as well to look at both before we commit ourselves to either"

- Aesop

So who are the one who get attacked and is physical attack of doctors justified?

The ones who are attacked are residents, doctors who are on duty in high risk areas, especially in government  hospitals, charitable trust hospitals, small nursing homes and occasionally resident doctors on duty in bigger corporate hospitals though the vicarious responsibility of treating these patients rest with the consultants. The corporate hospital owners or senior consultants who are in many ways responsible for the impression (or truth) that hospitals are primarily profit seeking places, never get attacked. Like every battle, it is only the foot soldiers who get attacked. By doing this the patients further alienate the residents who are already overworked, under suboptimal working conditions which results in worsening of already acrimonious situations.

"Soldiers win battles, generals get credit for them."

Napoleon Bonaparte.

(In this case they get attacked!!)

Are patients justified in attacking the doctors, whatever the grievance? If money is an issue, why do such attacks take place in government hospitals where treatment is free? While there may be many reasons, here is mine. We are living in a society which is becoming increasingly uncivil and aggressive. There are many people who throw shoes and slippers at politicians; vandalise houses of cricketers when there is something as trivial as defeat in cricket match. So when a major tragedy like a loss of life of a dear one happens they indulge in violence. Further, many of them come to a government hospital after exhausting their financial resources they have, this results in their desperate but bad behaviour.

The health benefit schemes introduced by some of the state governments have benefited the private hospitals and insurance companies; that government money could have been better used to improve the infrastructure in major hospitals. In a recent survey by the citizen engagement platform more than 40% of the participants said that they don't trust the private hospitals but 80% visited private hospitals when there was an illness in the family.

"There are far too many silent sufferers.

Not because they don't yearn to reach out but because they have tried and found no one who cares"

- Richelle E Goodrich

The media do not play a constructive role. The police choose to stay away because they believe it is natural for the patients to be distressed and use that as a justification. In some cases the hospitals and doctors don't help their own cause by criticising the treatment given at another facility either because they are not thoughtful enough or they think it will help in their own defence, thereby indulging in medical jousting. The already vitiated atmosphere is made worse by this, making an irate mob, violent.

"We are all connected, when one arm or foot is poisoned the whole body is infected"

Suzy Kassem.

We doctors often become defensive or even play the victim and say we sacrifice everything to continue as a doctor. Every profession in this competitive world has its own difficulties. Because we deal with human lives we seem to run the additional risk of getting attacked immediately by a crowd which gets provoked when things happen contrary to their expectations. However, we can demand stringent laws and better security in the work place. This is more easily said than done.

"Doctors are only doing KRIYA, that is earning their livelihood through this profession, not doing KARMA, that is doing charity for betterment of mankind"

Dr Pankaj Chaturvedi, quoting Bhagavath Gita

The educated people rarely resort to this kind of physical violence against doctors. I know of instances where frank negligence on the part of  doctors resulted  in mortality and morbidity. I know how a middle aged executive became disabled because of inordinate delay and inappropriate treatment; an elderly surgeon who succumbed to negligent care following a surgery and another elderly gentleman never recovered from an easily treatable problem because it was identified late. All these hospitals are well equipped, high end hospitals and what happened there was definite provable negligence. The families of these patients because of their education and politeness did not indulge in unruly behaviour despite spending huge amounts of money for treatment.

"Human behavior flows from three main sources, desire, emotion and knowledge"

- Plato.

Is it not an option to go to the consumer forum? According to a study, cases in the consumer forum has gone up by 400% in the last decade, the inordinate delay to get justice in Indian legal system adds to the frustration. Recently there was consumer forum ruling which was pronounced in 2017 for a case filed in 1998. More over the economically underprivileged ones are left with very little to fight a legal battle after they have spent their money in treatment, so they resort to their version of instant justice.

"Do not expect justice where might is right"

- Plato.

We are not Gods and cannot save all patients, we live at a time and age where practice of defensive medicine is almost a norm. We have not been able to address our issues of poor patient doctor ratio, infrastructure, abysmal working condition and inappropriate financial compensations.

Too many questions. Too few answers. The way forward.

We need a mechanism where we can make the patients our partners and communicate our difficulties to them. We have to spread awareness among public the factual and realistic capabilities and limitations of today's medical science.  We ought to stop advertising treatment modalities which may not be of benefit. We have to stop advertising treatment which could be inaccessible to many.

The doctor - patient trust and relationship is at its lowest point. Is the only way ‘up’?

While we demand a civil behaviour from our patients, it is important for us to do some soul searching and take that extra step and walk that extra mile to restore the trust and confidence of patients in doctors, medical profession and hospitals.

This in no way is a justification of violence against doctors. Every challenge is an opportunity and this is an opportunity for doctors for course correction where appropriate. The argument is advocatus diaboli.

"As doctors we generally don't tell outright lies. We don't speak the truth fully."

Dr.Allan Hamilton.

Are the patients ready for it? More importantly are we doctors ready for it?

Dr Usha

Physician

Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)

©M HEMADRI

Follow me M HEMADRI on Twitter @HemadriTweets

M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Micro Culture within Organisations: What is it? Why does it matter?

Culture is the ideas, customs and social behaviour of a particular people or society (Oxford English Dictionary). Organisational culture is the behaviour of humans within an organisation and the meaning that people attach to those behaviours (Wikipedia). The operative part of the ‘definition’ of organisational culture is the ‘meaning that people attach to behaviours’. It immediately becomes apparent that it is not about how we behave; it is all about what others who work with us think what our behaviour means. That is why getting organisational culture right is very tricky if not impossible. Understanding the concept of microcultures could help us in this difficult area.

Culture in Society

The society we live in has macro and micro-cultures. Macro-cultures are thought to be the majority groups whose norms are very visible and these become dominant, overarching and can be seen across historical timelines which means they are often long lasting. Interestingly within the macro-cultures there may be dominant small groups whose influence on the macro-culture is significant and overwhelming. For instance, parliamentarians are a small group who have disproportionate influence on society, they are representative which means we choose them to influence us. An example of a dominant small group within the macroculture who are non-representative are Oxbridge. There are many other examples of dominant small groups.

Society also has micro-cultures. The microcultures are generally thought of as being numerically small, voluntary, short-lived, situation specific, weak, non-dominant and not so visible.  However there are very numerically large groups within the population who form microcultures, for instance ‘women’ and unions amongst others. We can also see micro-cultures that have been around for a very long time such as the Amish and yoga. There are also microcultures that are very powerful such as think-tanks, activists, extremists, etc; some microcultures have been so powerful in their times as to change the society in permanent terms for instance the antislavery movement in the west. Microculture has always been viewed by the macroculture of any specific period in time with suspicion, as a threat, as very different and generally poorly understood.

There is another cultural entity called subculture which is distinctly different from yet often misunderstood as being a dominant small group within macrocultures or being a microculture.

It seems that macro-culture is similarity based who do not mind, often understand and even tolerant of reduced values. Microcultures are value based meaning that there are strong traits of equality, morality, ethicality and other traits held precious with microcultures feeling that they are forced to tolerate similarity. Subcultures are based on difference and variance ‘I am better than you. You are worse than us’ etc and exploit those differences without exploring the contexts adequately, often to personal benefit or detriment of the members of the subculture.

Organisations and MicroCultures

Organisations mirror society and within organisations there are micro-cultures. In organizations, especially in healthcare organizations, ‘micro-cultures’ have not been subject to proper study. There is a general assumption that it is best for everyone in an organisation to have a similar culture i.e. an overarching organisational culture. In reality, there are numerous cultures within an organizational culture, which is only normal. However, there may be some good micro-cultures which may want to observe and learn.

The micro-cultures have similar structure, activities, qualifications, finance, job descriptions, titles and staff specifications as the macro-culture but the expressions and the results of these vary significantly from the organisational macro-culture.

How To Do It

What or how are the specifics of a good microculture that enable a different expression and better results?

In the micro-culture that I experienced, we did whatever was statutorily required of our organization and mandatorily required by our organization. The micro-culture related methods and behaviour are over-and-above what was required of us; it was not a replacement behaviour neither did we think it was an add-on. It was just the essence of the way we worked.

My observation suggests that what we do more of some things and less of others. Here is a brief list:

We did more of	We did just the amount required of us
Feed-forward	Feedback
Support	Challenge
Direct specific communication	Emails/memos/ ‘cascade’
Generic incremental ‘planning’	Formal planning
Taking responsibility for others	Holding to account
Praise	Criticism/complaint
Learn small & frequent	‘Formal’ learning
Routines for us	Variations for the patients
Upstream	Downstream
Talk often and short	Long speeches and big meetings
Internal recognition	External recognition
Yes	No

Due to these methods and techniques we were able to have a supportive and friendly environment.

MEASURING THE SUCCESS OF ORGANISATIONAL MICROCULTURE

We may attempt to measure the successes of micro-culture in many ways. Since culture is often defined as the ‘way we do things here’, I have chosen to measure it by some of the things we did differently. Many of these methods were exclusive to us, some have been done much ahead of time before other areas. I have chosen our record of innovation as a ‘measure’ to demonstrate the success of our micro-culture. I have already published about the innovations http://successinhealthcare.blogspot.co.uk/2014/10/innovations-in-small-hospital.html

The results in general principle, result in happier staff, lower costs, quicker times for patients, often better results, better retained learning and such other positive impacts.

Culture and its effects are difficult to measure. Surveys have been used with staff self-reported scores and users perceptions. These are useful up to a point. The tangible link between micro-culture methods, processes and behaviours to outcomes will always difficult to elucidate. However, we believe that while a happy working environment is vitally important, we also believe that such an environment should result in some relevant outcomes. We believe that while our structure, activities, specifications, qualifications and knowledge are more or less similar to any organization and its specific departments our expressions of these and our results are different and take the form of the innovations which have been described above.

What can we do with the concept of Organisational MicroCulture?

Microcultures are often appreciated but at the same time often criticized. Some microcultures seek attention, some often shun the limelight.

The point is to assess the micro-culture on the basis of contextual impact, what is good for one may not be good for another, what works at one time may not work another time, what is seen as bad may become acceptable at a later point of time. (Mandela, IRA, PLO)

In organizations firstly micro-cultures should be allowed. We know that often there is no single recognizable so called organizational culture especially within the healthcare context. Next, more importantly supported on the basis of results that matter for the patients (and not on some vague notions of what a pan-organisation culture ought to be).

If you were a senior person in an organization, as you support a micro-culture you will also have this burning desire to ‘spread out’ ‘roll out’ an identified brilliant culture and reap the benefits of results and happiness for the whole organization; unfortunately it does not work like that. We may love the way that the Amish live today but we will be unable to roll it across the world or even use it for us. Products can be rolled out, packaged popular cultures can also be rolled out (eg MTV) but work place behaviours seem to be too personal, too individual, too variable, hence too complex to roll out.

What we can do is to grow our own, micro-propagate. We can become aware and make others aware of effective micro-cultures, managers can encourage and enable interaction with micro-cultures. Managers should be aiming for an environment of varying positive microcultures (and not necessarily one large single positive culture which generally exists in management books). Managers should not be aiming for a coalescing of cultures, though that sometimes happens on its own. Processes and activities can be copied, a culture cannot be copied.

Though I have described our observed methods, there is no real ‘model’ and hence there is no proper way to ‘replicate’ it. However, there are principles which can be reflected upon which can then result in growing your own micro-culture. We are not issuing a self-assembly kit – we are sowing some ideas some of which you may want to use to create your own beneficial micro-culture. It is our view that micro-culture cannot be replicated but can be propagated.

©M HEMADRI

Follow me on Twitter @HemadriTweets

PS:
A) There is a particular academic reference to the first few paragraphs of this blog which I have misfiled and will post it here when I find it
B) This topic was presented at the Clinical Microsystems Festival, Jonkoping, Sweden in 2015 

Healthcare has no Red Teams - we need them

NHS has no red teams - we need them

Defence forces have red teams. The US defence has had red teams since the early 2000s, soon the UK defence forces followed with their own version with slight variation. A few private companies such as IBM use red teams.

An internet search did not reveal healthcare especially the NHS using Red Teams.

What is Red Team?

A red team is an 'independent' team within an organisation that is deliberately created by the organisation  to critically analyse from a variety of perspectives (especially from an opponent or competitors perspective) and challenge the organisations' strategies, assumptions, operations  and all other aspects with a view to helping the operational part of the organisation get to a better position.

Basically you hire and pay a team of people to stuff you so that when you get out in the big bad world you don't get stuffed real time.

Red Team is something  but not fully like the opposition in the parliament whose job is to oppose the ruling party yet work for the benefit of the country. The opposition in the parliament provides an alternate view of the issue in question which the government must consider but need not necessarily act upon. A good government would willingly adopt the opposition's ideas if it would benefit the country. Of course given the unsavory political overtones and entrenched positions of political parties these days, this may not be the best example in practice but I think you get the gist. A red team in your organisation is a paid opposition without the baggage of politics - the ability to thoroughly analyse and provide an alternative point of view to the powers that be but no inherent ability to act on their own views.

A Red Team is not................

Red Team is not about providing innovation or offering solutions. Red Teaming is not strategy formulation by the management or organisation. Red Teaming process runs either in parallel to the strategy formulation or immediately after the strategy formulation but before it is finalised, signed off for implementation.

Red Team is not made up of union reps, protestors, resistors, laggards, innovators, management cronies, enthusiasts and so on. Red team is not a group with representatives from any area. Red Teams are not the same as whistle-blowers. They are certainly not people from 'risk', 'clinical governance' or any other over used cliched terms. They are not part of management or operations.

Executives are not obliged to follow the red team's advice or recommendations; they are only obliged to listen carefully and consider if they are suitable for implementation. Post-implementation, executives will be obliged to review their operations in the light of the prior recommendations of the red teams so that better learning can happen and be captured for future operations. The red team does not do operations, it is not the boss. The executives are responsible for the operations and results. The red team provides feedback, reflections but has no power to implement, reward or punish. Red team never says 'I told you so' irrespective of whether things have gone right or wrong; they take no credit or flak for success or failure of operations - that belongs purely to the executives.

Red Teaming

Red Teaming are a large set of tools and techniques that take time to learn, taught to people with prior operational experience and high level of maturity. Red Teams are friends who are playing the role of the enemy. Red Teams will face resistance and hostility. Red Teams are people who will pick holes in your plans and shred your strategy during the day and yet party with you in the night. Their level of development is such that they will have to think and act like the enemy, be the enemy so that they can help their friends. Red Teams often do not have automatic rights on most things, they will have to engage and negotiate at every turn. They have to be nice to you to you before you will consider their help in tearing down your own plans - see the complexity in human interactions here? Red Team exists to falsify the organisations' and its executives' theory.

It is important to remember that Red Teams and Red Teaming is not 'process driven', it has been described as an art, something to help with intuitive decision making. To convert them into 'tick boxing' so that we can claim we have a Red Team who have done the Red Teaming is very tempting so that operations staff can move on with carrying out their high pressure functions on a day to day basis but would be an expensive same side goal.

Healthcare needs Red Teams

Essentially, one of the fundamentals of the army is the business of protecting lives and minimising loss of life; like healthcare I suppose. Evidence based healthcare has huge problems and still in its infancy. Even if enough good evidence was available the complexity of healthcare means that the decisions will still be very different from many other industries. While other industries will need Red Teaming to look at from the competition's perspective, healthcare especially the NHS, needs Red Teams to look at itself. That will be an even more specialised art. We need that art and those artists urgently.

Do we in healthcare have the guts or the maturity to have red teams?

© HEMADRI

Follow me on twitter @HemadriTweets

Further reading

UK version of Red Team https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142533/20130301_red_teaming_ed2.pdf

US version of Red Team http://usacac.army.mil/cac2/UFMCS/Repository/RT_Handbook_v6.pdf