Ergodicity and its application to organisational management

It is extremely interesting the link between human biology, mathematics and management.

It is often true that poor performers continue to perform poorly – for instance most hospitals with a high standardised mortality rate continue to have it for very long times, difficult to shift. In case of human body, obese people often continue to be obese. This phenomenon is true for average performers and for high performers as well.

In the human body, this phenomenon is called homeostasis.

Mathematical explanation of performance can partly be understood by the law of large numbers. According to this law, if initial seemingly random results are observed over a longer period of time, they converge to the expected average results i.e. it "guarantees" stable long-term results for the averages of some random events

Often what looks like an improvement or worsening of performance if observed over a period of time essentially reverts to the mean, which means over a period of time performance remains unchanged; this phenomenon is explained by the normal distribution of most random events.

Well, that is how nature works. We can accept that if our organisation (or our health) is a top performing one and so mostly it will stay top performing over longer period of time. What if our organisation was a poor performer; the chances are it will continue to perform poorly; that would not be acceptable for a variety of reasons, especially if our organisation is in the business of healthcare. So when an organisation wants to become better, it embraces change in the hope that change will lead to an improvement. Often this change takes the form and language of transformation, reorganisation, change and other optimism inducing terms.

Here is when the concept of ergodicity becomes useful in leadership and management.

ERGODICITY

Ergodicity is the concept which states that:

·      The time average is the same as the space average

·      A system is Ergodic when the time average is the same as the space average

As an example suppose you’re trying to figure out the most popular park in London is. One method (time average) is to follow one person over a long period of time and see which parks he visits. Alternatively you can obtain a snapshot (spacial/statistical) average by seeing how many people are in a given park at a given point in time. The degree to which the time average equals the spatial average is called ergodicity and when the time and space average are the same then it is ergodic. 

Concepts of Ergodicity applied to Organisational Management

Applying this to organisational management:
 

1)    If you take the whole organisation average on any given day vs whole organisation average over period of time (say 3 months) – if they are the same, then organisation is erogodic

2)  If you take the average of one department on a given day and the average of the whole organisation on the that given day – if they are the same, then organisation could arguably be ergodic but may not be truly so by definition.

3)    If you take the best of one department on a given day vs the best of the whole organisation on on that given day – if they are the same, then the organisation could, arguably, be erogodic but may not be truly by definition. 

The three conditions provided above can be simplified into one to arrive at a fourth condition to demonstrate that a system is ergodic (note that conditions 2 & 3 are independent of time and hence alone are not sufficient to prove that a system is ergodic):

4) If you take the whole organisation average on any given day vs the average of one department over a period of time (say 3 months) – if they are the same, then the organisation is erogodic

·      This essentially could mean that a process even if random is or could be, stable

·      This is why organisations do plenty of activity, calling it transformation, change programmes, etc but yet do not improve as it is the nature of systems to show ergodicity.

·      It is okay for good performing organisations that are high performing to be ergodic.

That is very well, but what should organisations do to enable a higher level of performance and results irrespective of whether they are high performing or poor performing organisations do to improve?

Ergodic Transformation

(https://en.wikipedia.org/wiki/Ergodic_theory#Ergodic_transformations)

Here is the example from wikipedia 

·      if the set is a quantity of hot oatmeal in a bowl, and if a spoon of syrup is dropped into the bowl, then iterations of the inverse of an ergodic transformation of the oatmeal will not allow the syrup to remain in a local subregion of the oatmeal, but will distribute the syrup evenly throughout. At the same time, these iterations will not compress or dilate any portion of the oatmeal: they preserve the measure that is density. 

·      Ergodic transformation does a thorough job of ‘stirring’ the system without disturbing the fundamental nature of the system (due to the inverse of ergodic transformation seen in oatmeal example above)

·      This becomes a Measure Preserving Transformation – which means though there has been an addition (in the oatmeal + syrup example) the system remains ergodic (space average = time average)

Ergodic Transformation applied to organisational management

This is good for systems that are already high performing and want to become even higher performing.

For systems and organisations that are poorly performing a measure preserving transformation is of no use; hence the ergodicity of the system must be broken to see if better results can be obtained.

Ergodicity breaking

(https://en.wikipedia.org/wiki/Spontaneous_symmetry_breaking)

·      Spontaneous symmetry breaking: This is what wikipedia says “Is a spontaneous process It is a spontaneous process by which a system in a symmetrical state ends up in an asymmetrical state. It thus describes systems where the equations of motion or the Lagrangian obey certain symmetries, but the lowest-energy solutions do not exhibit that symmetry.”

Spontaneous Symmetry Breaking applied to organisational management

My lay application of this to organisational management is that when organisational symmetry breaks spontaneously though the overall organisation would be stable the processes and people within the organisations have changed so much that there could be significant improvement (there may be significant worsening as well, which is what the organisation has to monitor and prevent)

·      Explicit symmetry breaking (https://en.wikipedia.org/wiki/Explicit_symmetry_breaking) : This is what wikipedia states “this term is used in situations where these symmetry-breaking terms are small, so that the symmetry is approximately respected by the theory”

Explicit Symmetry Breaking applied to organisational management

·      By demanding explicit transformation we seem to end up (at least according to mathematical, physics theories) with changes that are very apparent, visible, but it does not transform the whole system. There is obviously cautiousness resulting only in very small changes, subject to resistance, these changes are planned, defined and delivered – yet the organisation does not change

Do we need to have spontaneous symmetry breaking when managing organisations?

·      Not always

·      If you have a high performing stable system you may not want this (you may want explicit symmetry breaking or measure preserving transformation so that you can get improvement without making the system unstable, improvement without the trauma of conventional transformation)

·      Yes – if you have a poor performing organisation you want spontaneous symmetry breaking so that we can have improvement with transformation – there is risk of asymmetry which may be beneficial (explicit symmetry breaking may actually be harmful by ensuring status quo while putting out an image/impression of change/improvement)

In summary

Ergodicity could be a useful principle when applied to operational management. Organisations, their systems and people have their own stability irrespective of whether they are high or low performing. To improve the performance of an organisation or to transform an organisation, it may be relevant to consider whether different approaches apply to high and low performing organisations. For high performing organisations it may be relevant to consider the concept of measure preserving transformation where there can be explicit induced changes which are absorbed as a part of good process measures which are maintained as the average increases.  For poorly performing organisations, it may be relevant to consider the concept of spontaneous symmetry breaking where beneficial asymmetry within the organisation is sought out to enable transformation; this means looking for areas within the organisation where people are attempting to or doing things differently and when they are beneficial to capture and systematise them even though the changes may not be compatible to what was externally mandated or top down defined for them; in poor performing organisations demanding explicit changes which are externally mandated or defined top down may result in status quo if lucky or could result in poorer performance making the organisation worse.

PS: Any mathematician, statistician, probability expert or physicist can educate me on this topic, especially enlighten me where I am wrong, I would be very grateful.

Acknowledgement: The above writing was advised and supported by Mr B. Patel

©M HEMADRI

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BME doctors: From recruitment to embitterment

THE ELEPHANT IN THE ROOM: the Life and Times of a BME Doctor in the NHS - from Recruitment to Embitterment

Suresh Rao

These are my personal observations and experience of working for thirty five years in countries of three continents (India, Canada and UK). Till I became the President of the Indian Orthopedic Society of UK (IOS-U-K) around 2005 I had no reason to acknowledge the existence of discrimination in the NHS. I had passed all my examinations at the first attempt, I had become a consultant in the early 1990s at the same average age (about 37 years) of any UK born white male doctor in orthopaedics at that time. It was only after I had blown the whistle while actually observing the horrendous treatment meted out to my colleague orthopaedic surgeons did I actually personally experience racial discrimination in the NHS in its ugliest form.

I have now come to recognize that the traditional attitude to recruiting and retaining BME doctors and nurses into the NHS is no different from the ‘Discard After Single Use Only’ policy of the slave trade. There is little security or safety and no fairness of treatment. The system of incentives and reward for hard work and competence simply do not seem to apply to BME staff. Unlike others, the course of life of a BME professional whether doctor or nurse seems to follow several distinct stages.

1. Stage of Denial: We work hard to keep the home and family together, crediting our limited successes to the support of others. Any perceived failures are almost always attributed to bad luck, never to the possibility of discrimination.

2. Stage of Panic: Naively believing that blowing the whistle is good for the sake of our patients, we publicly voice our concerns forgetting that those responsible for the cock-ups in the establishment will not thank a BME for exposing their incompetence. Such persons will not hesitate in recruiting others even less scrupulous than themselves to intimidate and harass you for the loss of their ‘private empire’ style of working. They usually have no difficulty colluding with your colleagues who are probably already dreading the loss of their private practice to others. The establishment leviathan is now ready to turn against you for stirring up a hornet’s nest when you were least expecting this response.

3. Stage of silence: We are made to feel guilty for creating a conflict in the department where none had supposedly existed previously. We become vulnerable to subtle emotional blackmail by promising to avoid future conflicts and agreeing to behave in a more ‘civil manner’, i.e. accept that we should next time bring up any issues ‘face to face’ for a ‘negotiated’ resolution of ‘confusions and misunderstandings’ rather than going through the employer. We are later reminded of this sword of Damocles hanging on our heads and we become too frightened to think rationally, instead we too begin to behave like any victim would. We invite others to quash us underfoot like a worm by tacitly acquiescing to the rules of their game. This not only bolsters the opposition but also puts our relationship with our employer in jeopardy. We now enter a state of limbo in our career progression to the extent of even questioning our own achievements and wondering whether we had truly deserved our CEA points, if we managed to get any. We convince ourselves that this was just a favour granted to us by our generous employer but only with the benevolent support of our well-meaning colleagues. We begin to lose our self-esteem and any frame of reference we may have for our sense of self-identity, our moral character is disabled and allows us to do peculiar things we would never normally do. We are soon at risk of losing our raison d’être.

4. Stage of Escalation: Unfortunately a number of us cannot or will not read the writing on the wall. We may injudiciously allow the situation to escalate out of control and pave the way leading to our own harassment and intimidation at the hands of the abusers in the establishment. If this does not succeed to cow us down we are then threatened with disciplinary action including the possibility of instant dismissal for supposedly ‘serious charges’ including criminal prosecutions for what are really minor infractions. The establishment will not hesitate to dispense summary retribution through Dismissal Orders under ‘MHPS’ for trumped-up charges and enforce redundancy despite any findings of  the Employment Tribunals. It is not uncommon for us to be referred to the GMC by this stage as the latter is hand in glove with the Medical Directors against the BME and feels obliged to take up investigating all such matters despite no evidence being submitted by the Establishment, a clear case of disproportionately handing out injustices to BME.   

5. Stage of ‘Resolution of Conflagration’: this usually means a ‘negotiated settlement for enforced retirement’ and it is most diabolical that this sometimes comes about because the innocent BME cannot bear the humiliation of a criminal trial or a GMC hearing and will most likely be on the verge of deciding to commit suicide.

Suggestions to avoid such a fate:

This is difficult because everyone reacts to crises in completely different and unpredictable ways. Following is just commonsense, not rocket-science:

1.    Maintain good medical practice (and relations with colleagues)

2.    Know the law (including the latest version of MHPS and PIDA)

3.    Take advice from a mentor (and follow every step correctly)

4.    Anticipate trouble (band up together, join BAPIO and MDS)

5.    Use local procedures fully (keep meticulous documentation)

6.    Involve regulatory bodies at an early stage (NCAS, GMC, CQC, CPS)

7.    Remain vigilant and focused, be discreet, stay calm and never say die

The elephant in the room is discrimination, name it, call it out, learn to effectively deal with it and work to reduce its harmful effects on yourself and others.

Prof Suresh Rao

Consultant Orthopaedic & Trauma Surgeon

North Cumbria University Hospitals NHS Trust

Hon. Professor, University of Cumbria

(The above is from the talk given by Suresh Rao at a meeting in Manchester on 26 March 2013. All the content are the personal views of Suresh Rao)

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Busting Myths in Healthcare Management

Busting myths in healthcare management

A dozen at a time

Myth 1

Quality can be measured

No

(But, Quality Improvement can be measured)

Myth 2

Publications and guidelines (national) are a good source of evidence (for QI)

No

(Often published evidence is invalid, not robust enough or gets outdated soon. Guidelines are rarely tried in their totality before being recommended)

Myth 3

Increasing Quality Increases Cost

No

(Improving Quality Decreases Cost)

Myth 4

Improving Quality Improves Safety

Often No

(Improving Quality Improves Quality, Improving Safety Improves Safety. According to definitions they are two different things.)

Myth 5

Management by Objectives/Targets are good (for QI)

No

(Targets especially mandatory ones are prone to scamming)

Myth 6

Above Average is a Good Indicator of Quality

No

(Averages are flawed. Averages are not real)

Myth 7

A high percentages of good things and a low percentages of bad things are good indicators of quality improvement

May be but not really

(Percentages could be misleading. Percentages are not real numbers)

Myth 8

Culture Can Be Changed

No

(Processes can be changed and that may change culture)

Myth 9

All Directors in the Board of Directors are Leaders

No

(Leaders are follower defined not position defined)

Myth 10

Management Principles are the same for Healthcare as in any other field

No

(The frontline in healthcare is unique and very different)

Myth 11

Errors can be eliminated (in healthcare)

No

(Errors can be reduced but cannot be eliminated. But harm can be eliminated.)

Myth 12

Human Factors is about Changing Behaviour

No

(Human Factors is about changing Design)

 You can learn more about these from many sources (eg. University of Hull http://successinhealthcare.blogspot.co.uk/2015/06/msc-in-healthcare-improvement-leadership.html or enquire about a bespoke course http://www.successatmedicalinterviews.co.uk/Courses.aspx )

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Standardised Management Conversation

The Book

I have written a mini-ebook called Standardised ManagementConversation (SMC) which I think is essential for healthcare directors, managers and senior clinicians. The SMC is a model which is to be used when various healthcare managers talk to those who report to them. It will also be useful for non-healthcare professionals and managers as the fundamental principles are more or less the same.

Since the conversation is standardised in the model, it makes conversation between people predictable and stable with no surprises. The model is based on sound principles, years of observations and practical experience. It draws on conventional management, clinical ‘lean’ management and some lateral thinking.

It is a small booklet. It is priced at £0.99 for UK and $0.99 for USA (equivalent prices for other countries) published in the ebook format via Amazon available at this link http://www.amazon.co.uk/gp/product/B018AWBJTU

The Cause

I will be donating all the money that I get from the first year (November 2015 to December 2016) sales of this mini-ebook to a charity called Udavum Karangal in India ( http://www.udavumkarangal.org/  ) for the purpose of sponsoring an orphan child all the way through childhood till the child finishes education and leaves the orphanage. This scheme costs about $1000 or £600 which is actually a great value for money to see a child through childhood and education, thus providing a solid foundation for a stable adult life. I like long term thinking and long term benefits, that is why I have chosen this charity. I have personal experience of sponsoring children through this scheme. I have no other relationship with this charity, they do not know that I am doing this.

So here we go, if you are a director or manager in any field or have aspirations to become one in the future, especially if you are in healthcare, if you are a clinician with an interest in management, buy the mini-ebook SMC - Standardised Management Conversation. If you like it and use it and you are successful it is a win for you as a reader of SMC booklet, it is a success for me as an author and it is a success for a child till he/she becomes an adult. Well, if you do not like it, your £0.99 is pure charity.

It is a win-win-win whichever way you look at it. You may perhaps now want to make a guess on the gist of the content of the SMC mini-ebook.

Thank you for your support.

©M HEMADRI

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PS: As a new author, new to e-publishing, if there are issues with it kindly provide me feedback so that I can improve on it.

Is there an ethics deficit in the delivery of healthcare?

Ethics of quality in Healthcare Delivery

Is there is an ethics deficit in the delivery of healthcare?

Ethics are paramount in clinical research. Currently there is emerging requirement for ethical values and oversight of quality improvement projects. However, it seems unclear if strong ethical principles underpin the delivery of routine healthcare. By routine delivery of healthcare I mean activities such as scheduling/rescheduling appointments, communication methods when non-clinical staff are dealing with patients, staffing levels (numbers, skill mix, acuity matching,etc) and similar. I also mean most of strategy, planning and operations at the provider level.

It is well recognised that it is the huge variation in processes of care delivery results in large disparities in healthcare outcomes. I subscribe to the view that it is not the science or the individual that causes bad results; it is the vagaries of the processes of care delivery that causes poor outcomes.

Policy making is subject to ethical ideas that are broadly utilitarian. Individuals are also subject to ethical principles. Ethics for healthcare professionals especially doctors are specifically person centric irrespective of whether they are individual professionals or patients. Between policy and individuals lies the system, group or team, whose operations are not in reality tested against ethical principles. There seems no clear group based ethics on which care can be delivered though there are innumerable rule based arrangements that seem not to satisfy the cause of quality in healthcare delivery.

In other words, individuals are held to account for quality deficits using ethical principles- groups and systems are not. A group of individuals who practise sound ethical principles do not constitute a ‘group ethic’. The lack of group ethics seems to be preventing known good outcomes from being achieved.

How can this quality gap due to the variation of processes and outcomes be assigned with relevant ethical principles or frameworks with a view to resolving them?

My main argument would be that it is unethical not to aim to achieve or not to achieve a desired result:

-          in the absence of any material restricting factors and

-          when the knowledge and methods have been described and publicly available

However, since medical ethics is effectively applicable to individuals and other ethical theories are applicable to policy making, there seems either a lack of ethical theory/reasoning or a lack of application of ethical theories to understand the ethicality of group operations in healthcare delivery.

My assumption is when the issue of ethics for operational groups who are implementing care delivery are defined, available and clarified a contextual framework could become available to bridge the quality delivery gap where healthcare delivery outcome deficits can be seen as ethical deficits; thus ethics becoming a powerful lever in ensuring highest known optimum outcomes.

The utilitarian policy making at one end, with medical ethics (a mixed application of various basic principles) at the other end, seems not be served very well by the current version of possibly deontological 'operations'. Is that the case? If that was the case, how do we resolve it?

©M HEMADRI

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MSc in Healthcare Improvement Leadership

Applications are now open for the second cohort of the MSc in Healthcare Improvement Leadership starting in October 2015.  This is a bespoke programme that has been developed jointly between University of Hull (Faculty of Health Sciences) Hull University Business School and Hull and East Yorkshire Hospitals and is open to all Healthcare Professionals.  

The first cohort (a mixture of clinical and non-clinical staff) have reported that the programme is “interesting, enjoyable and thought-provoking” as well as “blowing my mind with different perspectives of quality”

If you are interested in being a part of the second cohort and for further information please contact:-

Tracey Heath – Director of Enterprise

University of Hull

T.N.Heath@hull.ac.uk 01482464519

Further information:

MSc in Healthcare Improvement Leadership

A unique opportunity has arisen to undertake a Masters in Healthcare Improvement
Leadership at Hull University. This MSc programme is developed jointly between Hull
University, Hull Business School and Hull and East Yorkshire NHS Trust. This programme is
open to all healthcare professionals from primary, secondary and other health care sectors.

Aims

- To provide the participants with theoretical and practical understanding of the
concepts of quality improvement in healthcare delivery

- To equip the participants with practical tools to enable quality improvement

- To equip the participants with the attitude and ability to be a leader of healthcare
quality improvement

Objectives

- To explore the links between evidence, experts, experience, policy and practice.

- To understand the relationship between quality and cost

- To understand the concepts of shared baselines, local clinical protocols and the
improvement method

- To understand the modelling of the process of quality improvement

- To review tools available for healthcare delivery improvement

- To understand the relevance of measurement in improvement and to learn about
the tools to do so

- To understand the various kinds of leadership that brings about the preferred
response from colleagues using a selection of human factors and communication
methods thus defining the human face of quality improvement leadership

- To appreciate the importance of learning from immediate peers and colleagues.

Attendance Requirement
There will be 10 contact classes in the first year which participants are required to attend.
Other aspects of the course will be delivered by a combination of e-learning and support as
needed.

Modular progression
At the successful completion of first year there will be the option to take the qualification of
Certificate in Healthcare Improvement Leadership and to progress to a Diploma and Masters

©M HEMADRI

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Declaration of interest: I teach some parts of the course. No current financial interest.

Deliberate Redundancy and Intelligent Management

DELIBERATE REDUNDANCY AND INTELLIGENT MANAGEMENT MAY BE THE NATURAL WAY FORWARD FOR HEALTHCARE SYSTEMS 


Redundancy (slack in the system) is normal in the human body. Nature has provided the human body far too much capacity than what is needed for day to day living. Most of the capability of the human body lies unused for most of the time. Human anatomy is full of many muscles all doing small parts of the same movement and/or many muscles doing same or nearly same movements. There is often two of many organs. Two eyes may be needed for depth perception but two nostrils, two breasts, two ovaries, two testicles cannot be explained within the logic of efficient systems. It is also not just the anatomy, the way the anatomy works also reflects enormous over capacity of human systems. About one eighth of the kidney or one seventh of the liver is adequate for normal living. Similarly much lesser length of colon or much lesser sperm counts will still be abundantly compatible with digestion or reproduction. The scope of the surplus is truly amazing, for instance every part of the body is pain and pressure sensitive – we are used to it but is that needed or if we were building a system would we not consider that as wasted resource. There are many ways of providing energy and and many ways to eliminate end products. Well amazing is probably and understatement.

It is normal for the human body to have excessive capacity with only part utilisation at most times - i.e. functioning as though it was an inefficient system for the majority of the time. Even after doing so the human system needs significant amounts of rest and recovery at regular intervals at low utilisation levels and certainly much higher rest and recovery when systems are stressed (achy muscles and joints even after exercise and worse effects after fever, or surgery etc)

Interestingly that is how the rest of the nature is. There is more water than needed, more sun than needed, more air than needed, one could even argue that there is more food than needed (though it is distributed unevenly and too much is wasted).


My argument is that such a pattern is actually essential for healthcare systems. There is a lesson for healthcare professionals on how to manage healthcare systems which care for redundantly built humans. We should not be averse to a system with significant redundancy deliberately built into it and managed intelligently.



High reliability, high efficiency, narrow variation is valid for system architecture, system performance and output delivery in mechanised or electronic or technology based systems (i.e. machines). Humans dealing with healthcare will almost never be high reliability, high efficiency or narrow variation - they only give the impression of being so. In other words healthcare systems with human beings showing high 'efficiency' may well turn out quite simply to be an illusion. It is simply anti-natural, anti-anatomical, anti-physiological and anti-biochemical - humans are not built to perform that way. Well, most of the humans anyway with the few exceptions of outliers such as high end sports persons, highly narrow specialists, etc – even they need much 'down' time.




However, it is imperative to insist that a high redundancy system simply cannot mean that delivery, output and/or outcome can be all over the place in healthcare - that would to put it simply - kill the ill; apart from causing significant morbidity.



So while the overall infrastructure is 'poor' by technology standards the output performance by humans delivering healthcare has to be pretty slick. A 'poor' 'system' (with high level of redundancy/slack, over-capacity and similar) has to deliver 'great' results. That is exactly what the human body does for us human beings - poor 'systems' delivering 'great' results.



That can only be done by building deliberate redundancy, planned slack in the system, over-capacity by design with specific high intelligence management. A large system which only uses small parts of it most of the time to deliver great results. A large system which kicks in fully only occasionally to cope with specific pressures and then goes to rest again. A large system that under extreme crisis shuts off most of its activity and concentrates on the vital few to survive and once it survives goes back to its normal (for human) inefficient (as per technology definitions) self.

This will require a completely contrary understanding to the one that we currently possess, We will need a new kind of intelligent management that may be non-existent right now. We need to learn from nature about the need for redundancy and over-capacity to live a normal life. Any one who is unable or refuses to learn from nature will be defeated by it – we cannot afford that in healthcare as our failure will affect our patients more than us.

©M HEMADRI

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