Scheduled airlines are safe, just like out patient clinics

There are constant comparisons between aviation and healthcare especially in terms of how safe aviation is.  There is no doubt that aviation in general has a low mortality rate for passengers. I have already written about the need to learn from how aviation achieved it, I have also pointed out to the limitations of the comparisons (http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html). The term aviation or air transport in my view, includes many things, which starts from the booking process, airport formalities, baggage, catering, flying, etc. It also includes transportation of animals and goods.

In general, the whole of aviation is considered arguably to be better than healthcare. What is not arguable is that commercial scheduled airlines have a very low mortality rate for passengers. Here is my problem, death is not one of the eventual natural outcomes of transportation when transporting essentially healthy persons from one place to another; quite rightly in aviation is mortality is unacceptable. Hospitals on the other hand are not in the business of transporting passengers, people come in with illnesses and diseases many of which are really serious; mortality is one of the eventual outcomes of serious illness and disease. In other words healthcare routinely battles against death and sometimes death wins.

To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.

Variation the enemy of quality

People talk about variation of care across hospitals and locations; it is true that there is wide variation and reducing the variation will improve outcomes.

Aviation which is often looked upon as a beacon of safety also has variation. Looking at 2004 accident rates for North American airlines Delta scored 0.30 and Value Jet/Air Tran scored 5.88 – well, you work out the how wide the variation is even in an ultra safe industry. If you start looking at international comparisons the variations are of course much worse. (http://www.airdisaster.com/statistics/) There is also a five times variation of fatalilties per million flight hours with scheduled airlines being lowest compared with general aviation.

When there is human to machine interaction as in aviation, there is such a large degree of variation. Healthcare is human to human interaction so it is hardly surprising that variation exists and could be expected to be more than other industries. Looks like variation in performance is not a problem exclusive to healthcare industry; variation is a human problem or to put it better, variation is a function of human performance.

That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.

Fatalities in Aviation

The human fatality rate is very low indeed in the scheduled airlines part of the aviation industry. The air transport of animals, however has suffered bad press. Airlines are apparently not even required to report animal deaths. The mortality rate of animals in air transport is thought to be 0.2%.(http://www.dailymail.co.uk/news/article-2102733/More-HALF-pets-died-airline-travel-year-flew-Delta.html)

The post surgical 30 day mortality for day case surgery in humans which is about 0.01%. In-hospital mortality for day cases is probably as low as the scheduled commercial aviation segment.

CRM and Simulation are of course extremely valuable tools and has a lot to teach us in healthcare. The number of air accidents and the number of fatal air accidents have remarkably decreased over the past few decades. That is truly fantastic. What is interesting though, is that the pilot error rate has been at about 50% since the 1950s to the 2000s, percentage of accidents attributed to pilot errors has not shown a significant decrease. The proportions of various reasons for crashes have also remained more or less the same. This is in a way a tribute to the aviation industry, since the planes have become technologically very superior it would not be surprising if pilot/human error played a bigger part and it has not, that is creditable. However, I wonder if it would be valid to argue that if CRM and simulation were indeed really powerful should the pilot error rates be falling?

Survival rates of passengers in aircrafts involved in fatal accidents has not improved (and averages about 25% since the 1930s to 2000s) (http://planecrashinfo.com/cause.htm) Military aircraft, fighter planes, aircraft engaged in warfare and private planes are thought to have much higher accident and fatality rate.

Some Aspects of Aviation are Safer than Others; Some Aspects of Healthcare are Safer than Others

I suppose in clinical healthcare delivery terms, scheduled airlines are possibly the equivalent of out patient care – not many patients die in out patient clinics. The risk to life is also very low for elective investigations, day case surgery and obviously the risk increases with emergencies and trauma.

In healthcare we talk about morbidity as well. Airlines perhaps should take into consideration DVTs, respiratory illnesses, musculo-skeletal problems and other health issues that happen after a flight. Non-health related morbidity for aviation perhaps include lost baggage, wrong meals............... no let me stop there before it gets silly. Hold on, why not, non-flying errors are also errors and results in 'airline industry morbidity' to passengers, perhaps not that silly.

What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.

There is a fundamental problem with my writing here. I am not comparing like for like, I am comparing apples to pears. In my defense, I did not start that comparison. Comparing aviation to healthcare was not my original idea. There is a second problem with this manner of writing, it may sound like I am being defensive of healthcare and its practices, I am certainly not defending any poor healthcare practice or result. I acknowledge the superior results that aviation has had as a result of dedicated persistent efforts in the field of human transportation in scheduled airlines. I recognise the need for healthcare to learn from every source possible including commercial scheduled airlines. All I am saying is, let us stop comparisons and let us focus on learning. Let us look for clinical adaptations of these techniques rather than attempted direct transfer of airline techniques. Let us recognise the uniqueness and the intimacy of human to human interaction that healthcare involves.

A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Letter to my nieces

A letter to my nieces

Sam (USA)

– who has just joined med school this year

&

Mayank (India)
- who completes med school this year

Dear Sam and Mayank

Congratulations. Sam you have done well to get to med school. Mayank you have done great and will finish med school later this year. You are in the top 2% of the academic performers and you will continue to remain there at least till you begin independent clinical practice, hopefully many decades into your clinical practice.

I write this in joy but more relevantly to provide you another window for your intellect and for your practical development.

I did Anatomy, Physiology and Biochemistry in my first year at med school. There are not many more accurate and fact based subjects than these in medical education. Fact after fact, learnt day after day. We realised that these facts were the foundations of our future careers, we took it really seriously. We demonstrated our mastery (okay, personally I just demonstrated my mere competence) by passing tests and exams. It was tough. It was worth it. I was satisfied that my foundations were good.

These fact based subjects left an indelible impression in my mind that medicine and its practice was based on accuracy and facts. When the facts varied, such as when the cystic artery was double or it was low lying and so on, they were grouped into sub-facts to be remembered for future reference and practice. Some facts were actually a range of facts as in the normal range of plasma sodium values and so on. Later on while attending physiology classes at the Royal College of Surgeons at Edinburgh, the tutor would squeal in dominant delight ‘either you know it or you don’t’; no more powerful, explicit message for post-graduate doctors about the need to be precise and accurate. A message that I heard many years earlier in first year med school and repeatedly thereafter.

As we moved along we recognised that subjects like pathology and microbiology begin to interfere with subjects like anatomy and physiology and gives rise to trouble in real people. Help was at hand for us to understand that. Pathology text books showed clear microscopic slides on how every pathology looked, again where there were variations they were classified as yet another group of facts.  I got the impression at that time that if that’s how it looked, that is what it must be. That kind of thinking was compatible with the fact based approach of anatomy and physiology. All this knowledge was then put to practical use by learning even more glamorous and glorious subjects such as surgery, internal medicine, gynaecology, et al. Those were exciting days.

We continued to learn from revered text books on the one hand and from revered teachers on the other. Patients had clinical problems, we used our knowledge to diagnose them (CT scans were extremely rare when we were medical students and ultrasound scans were just taking off and x-rays in general provided basic support) and applied our knowledge to treat them. Of course things did not always go well for patients, we still call them complications or morbidity, sometimes patients died, we classify that as mortality.

As we gained experience often as post-graduate doctors we began to realise that all of our revered teachers did stuff very differently from each other while they were dealing with similar problems. The cleverer of the lot justified their different styles of practice by references to science, the rest told us that their experience suggested that their practises were valid. Our professors and consultants told us that they acquired their wealth of knowledge so that they can give their opinions. One sudden day we recognise that we learn medicine on the basis of knowledge and practise it on the basis of opinion. On the basis of very very widely varying opinion.

We begin to wonder. If the learning in undergraduate medicine was based on accurate facts, why is the practice of real world medicine on the basis of hugely varied opinion? We brush aside these discomforting thoughts. We have not only made a huge investment in our knowledge but also in our method of acquiring and practising that knowledge.

Pathology text books did not tell us that two pathologists looking at the same slide could give you two different opinions, not often but certainly possible in the definition of complex cases. We were never told that the text books that we read were by definition about five years out of date or that at worse some of the editors edited those books while travelling in their ultra-luxury cars between various locations of their private practices or at best after a couple premium alcoholic drinks in their study. We were realised that when our teachers said the words ‘in my experience’ it did not mean objectively measured operational experience but meant their personal subjective understanding of how they thought they performed.

In medical practice there is evidence for everything and there is evidence for nothing. This provoked David Eddy, the American father of evidence based practice (oh, by the way evidence based practice has two fathers one American and one British) I believe to say something like that you can find two physicians to testify in court to the exact opposite views.

Nobody will tell you yet that

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence
Substantial activity in clinical medicine cannot after care delivery find evidence to back it
Substantial clinical care is delivered incompletely
Substantial amount of errors are found in the delivery of care
Substantial numbers of clinicians are either unable or unwilling to accept the above

These issues are not just academic, they have great direct impact on patients and their lives. We did not know at med school that there was an entity called avoidable mortality; when we first heard about it we found it unbelievable for the reason that if it was avoidable us clever and experienced doctors would have already avoided it. We did not know at med school that practice of healthcare is highly error prone and extremely unsafe; when we came to know about it we did not believe it. Despite this we and the public, trust ourselves - the medical profession; we trust our high intelligence, our extreme hard work or proven record of success for ourselves and for our profession. We are brilliant and we have faith in ourselves.  The brilliance of the medical profession is also blinding itself.

The lack of evidence and the opinion based practice results in hierarchical power games. Those who are unable to play become bad apples initially and ‘poor performers’ later. Now, imagine that, top scores at school graduation, long mind numbing hours of hard work for years, proven success in exams and other challenges, then eventually being called incompetent or poor performer or some other derogatory term by people who practice the art of medicine while imagining it to be based on facts and evidence. Worse still these phenomena perpetuate the wide clinician generated variations in practice. Doctors are intelligent and learned enough to be able to justify their individual practices as evidence based; that is of course true. What is important to understand is that their justification is based on the evidence they choose to base it upon. My evidence is the truth and nothing but the truth but not the whole truth. Simply because firstly the whole truth probably is not already known, secondly the whole truth is too vast to know and thirdly in healthcare the whole truth often has a tendency to contradict itself.

I write this not in despair, not to distract you, but to give you hope. Because the solutions for embracing a world of wrongness and still do good to the maximum number of your patients are already out there. I want to briefly introduce you to that world and I want you to be aware of it. These are the shades that you wear when you are out in the bright sun, it will also make you look cool. It might make you comfortable in a world of contradictory evidence.

In conventional science based research oriented world there is probably nothing that is absolutely true; there is a current hypothesis which we attempt to validate or reject and the hypothesis stands till it is rejected. You will find that most hypothesis in medicine are rejected over a period of time, this gives rise to problems in clinical practise as the research that is good today becomes ‘false’ very soon. However, that is how research and science works. That is how it should work. However, in our routine clinical practice we do not work as researchers, we work as operational practitioners. My suggestion therefore is to look at operational methods for a good clinical practise and use to them to the best benefit for your patients. These derive from the shared baseline approaches devised by Brent James and his team at Utah.

At a basic level, a good shared baseline method looks like this

-         - You agree with your immediate and local colleagues on a protocol for most common problems that are seen in your clinical practise

-         - You track the outcomes over time of some of the process and outcome parameters of the protocol that you have agree

      - You amend your protocol based on the outcome tracking

-         - You show deep and genuine respect for everyone who works with you

-         - You share and learn operational clinical day-to-day practise first and primarily with/from your immediate and local colleagues before you do so with the rest of the world

Intermountain Healthcare does this, they probably discovered this method. IHI recommends it (I suggest you become members of IHI open school), people at Mayo, Virginia Mason, Jonkoping and a few others have their own versions of this. The method though, is not one of a pick and mix buffet, one has to do them all or get no benefits from them.

I suggest that you start exploring this kind of thinking in parallel with your conventional learning, not for fact based subjects but for the rest of them. We are all creatures of habit, attitude and cultures. It will be very difficult to change once certain mindsets are established. The energy and effort required to do it now in parallel is much less than to do it later. Your patients will get remarkably far better results and your systems (your patients, insurance, hospital, yourself) will spend far less on a like for like basis.

Many doctors will understandably be either uncomfortable or unwilling to accept or follow this kind of practice. They will deride it as cook-book medicine run by technical managers interfering in clinical work. Obviously the ignorant will be prone to say what they want, that will be a reason to work to remove the ignorance not to forget the observed truth, unlike conventional healthcare practices and religion with its believed truth, this method is really the observed and demonstrated truth. Of course if you decide to choose conventional scientific research as a career then these methods are not suitable for you but if your life is that of a normal operational clinician then these are entirely relevant. I do not expect you to understand the new method fully, it will be a reason to learn it in due course. Enough for now to be aware that there are plenty of problems and there are proven solutions – just a matter of putting them together at the right time.

The wrongness that exists in medicine will not go away, that can only be solved by scientific research and one day you may in your lifetime find that medicine is based purely on scientific evidence. Till that time, awareness of, learning and practising the shared baseline method will give you superior results despite the wrongness around you.

As you stand on the threshold of entering into a new world, I wish you every success and great happiness in the practise of your profession. There can of course be no greater professional joy for a doctor than to see more of their patients get better.

Affectionately

HEMADRI

August 2012

©M HEMADRI 

Follow me on twitter @HemadriTweets

Recurring 'errors', learning and some fundamental issues

Recurring errors

Many of you could be familiar with the Elaine Bromiley case where a young lady for a routine ENT procedure died due to intubation difficulty (http://www.chfg.org/resources/07_qrt04/Anonymous_Report_Verdict_and_Corrected_Timeline_Oct_07.pdf). There it was found that there was lack of situational awareness, poor decision making and poor leadership. This happened in 2005.The Harmer report on the tragedy is dated July 2005, the coroner inquest in October 2005. Marin Bromiley, Elaine's husband, an airline pilot, chairs the CHFG to promote human factors with a view to reducing avoidable errors.

Gordon Ewing died in May 2006 and the Scottish Sherriff’s fatal accident enquiry determination has been published (http://www.scotcourts.gov.uk/opinions/2010FAI15.html). I recommend that all of us read all the 108 pages patiently. Here the patient was scheduled for open reduction and internal fixation of terminal phalanx of little finger and died due to airway related difficulty.

Again, similar factors such as poor decision making and poor leadership has come up along with a host of other factors. The unwillingness to stop has been a common factor in both cases. I suspect it is just not these cases.


The link below is about 3 post cholecystectomy deaths in a 3 month period in 2006

http://www.scotcourts.gov.uk/opinions/FAI13%2014%2015.html



I feel that recurrence is probably an essential feature of an error, my guess is that there are no errors that have ever happened only once. It might have happened only once to a person or a location but the error itself would have happened a number of times. Vincristine and nuclear leaks come to mind.


Who should learn?

In meetings where we discuss morbidity, mortality and learning from SUIs, a phrase you might often hear is 'for the benefit of the juniors/residents/trainees', as though 'seniors' do not commit 'errors' or have nothing to learn from the discussion. Well, all the above cases are about very senior and experienced doctors; so these reports are not for ‘the benefit of the trainees’ or ‘for the benefit of the juniors’. It is for everyone, specifically for senior post holders. Also, though the specific examples are about anaesthetics, surgery, etc; these cases are not about anaesthetists, surgeons, etc; the lessons are for all of us clinicians and non-clinicians; the generic issues are relevant as lessons for everyone. Techniques are speciality specific and person specific, errors and learning are generic.

Learning

Elaine Bromiley's case is well known and is full of learning which have been described by many before.


In the Ewing case, the Sheriff says:

‘While the lead clinician has the over all responsibility to ensure safe use of equipment, individual clinicians have a professional responsibility to use only equipment with which they are familiar and competent to use. This is particularly so where the piece of equipment is rarely used.’

There are many gems in the Gordon Ewing report.

In the gall bladder surgery cases, the report speaks about:

Tunnel vision

Damaged confidence from an incident preventing speaking up at a subsequent incident, potentially causing harm.

Poor notes, missing notes

Breast surgeon doing cholecystectomy

Consultant surgeon not attending

Consultant radiologist refusing to do scans at night

Consultant surgeon who does not do lap cholecystectomy dealing with complications of cholecystectomy

The repeated failure that patients post operative problems could result from the surgical procedure

The report is very recent. The incidents happened not too long ago either. They are from a normal hospital with normal people like you and me working in it and dealing with typical/usual patients.


The learning is profound, not new - many of us would have faced these situations a number of times; errors are recurrent. The impact of errors are horrendous for the people involved in it especially for patients and families (see previous blog on impact of complications http://successinhealthcare.blogspot.co.uk/2012/02/complications-or-harm-and-their-impacts.html)


Fundamental issues

It is very heartening to note that courts and authorities who write the reports use a very respectful language towards doctors. They limit themselves to investigating and reporting event, post-event and agree with the given wisdom in practise as acceptable standards. I wonder whether this prevents an exploration of some fundamental issues.


Let me ask an awkward question. Why is a general anaesthetic even an option to deal with the terminal phalanx of the little finger? The report says that there was no record of non-GA options. My point is not that, my question is why was GA ever an option. Some of you are going to leap up and say 'patient choice' meaning that patients have to be offered a choice or patient choice to have a GA must be agreed with. Patients choices are mainly guided by their clinicians views, supplier induced demand, often felt to be well meaning, is alive and well in healthcare.


I know a general anaesthetic is routinely one of the anaesthetic options for any surgical procedure; but so was Halstead's mastectomy for any breast cancer in the past. Would we offer it as a choice now? Hypothetically if a patient wanted a Halstead when a local excision would suffice, would we do it? When an easier, safer, quicker, better, cheaper method is available is it still valid to offer potentially high risk complex procedure as an option?


Here is another awkward question. Why are breast surgeons, colo-rectal surgeons and all surgeons doing gall bladders and hernias when hernia surgeons do not do breast or colo-rectal surgery? I do not mind good old style of general surgery where everyone did everything - at least that is what they were supposed to do.  But that is not the world we live in these days (even in 2006) at least in the western world in the era of sub-specialisation. The situation of anyone doing the so called 'simple' things, still persists in many hospitals. Toe nail problems are as profound as any other 'major' medical problems for that given day for that given patient; it is not a matter of scale or judgement.

I wish the various authorities recognise the need to ask very deep and fundamental questions. Such as was this really indicated in the first place? Were the right people dealing with issues to begin with? I wish they would not accept given wisdom based on pacts of convenience as acceptable. Not with a view to punishing but with a view to improving clinical quality.

I wish they recognise and point out that these are massive system and leadership failures.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Fearless Healthcare is what we want

Recently read a book called 'Driving Fear Out Of The Workplace' by Kathleen D Ryan and Daniel K Oestreich. It was published in 1991 so obviously you can see that my wisdom is only now dawning. It is based on the 8th principle of Deming which is 'Drive fear out: employees must not be afraid to ask questions or take a position'. The book is written in an easy language and narrative style with enormous number of quotes gathered from their work with a variety of organisations but when read reflectively it can have profound impact on us and others.

The book wants us to
- be able to discuss the undiscussables
- realise behaviours that create fear
- understand the cycle of mistrust and break it
- acknowledge the presence of fear
- value criticism & reward the messenger
- reduce ambiguous behaviour
- move from participation to collaboration
- challenge worst-case thinking

The authors believe that driving fear out will overcome the invisible barriers to quality, productivity and innovation. The book is nothing to do directly with healthcare and has no direct examples but at a human level the threads are common. I recommend the book.




Healthcare & Fear

There are many reasons that driving out fear is even more important in healthcare. The very strong hierarchical structures in healthcare is an ideal culture medium for fear to thrive especially amongst the medical and nursing colleagues. The mostly pick and mix nature of evidence in healthcare delivery makes these hierarchical voices even more powerful. The difficulty with evidence generally creates poor systems, people who work within poor systems understandably do not do well and the culture of defensiveness and fear becomes greater.

Establishment is very strong in healthcare, in the UK clinical practice context you must submit to the clinical establishment (royal colleges, specialist bodies, et al) or to the research establishment (universities, funders) or face difficult consequences. Clinicians have a legal obligation to provide care recommended by NICE 'guidelines', there are armies of back office people who audit compliance to NICE guidelines which everyone fears of falling short. Providing the treatment recommended by NICE is a statutory duty i.e. law, I wonder why it is not called law and then define some exclusions. Why the euphemism? Now, would you have a fear of falling foul of a law?

The current economy does not help with many reduction in posts and changes in roles. It is also well known that in the context of the NHS the reorganisations are almost continuous and many non-doctor staff do live in fear of the next change that may adversely affect their role, skill and income.

Generally high anxiety and stress is understandably common for clinical professionals when dealing with patients given the very high emotional component involved in any healthcare advice or treatment especially acute care. The stress levels are even higher for patients and that is projected on to clinicians and reflects. This puts pressure to get it right every time, there is a fear amongst clinicians about getting it wrong; get it wrong in high finance and few points might drop of the footsie index, getting it wrong in healthcare could cost people a hand or a foot literally. But working with fear does not help the cause.

Constant comparisons with other industries (aviation, manufacturing, etc) while is very important for healthcare professionals who can understand the principles behind these comparisons and use them for improvement, is often taken out of context and has created an atmosphere where some of the public begin to have very high expectations that are difficult to service and some of the pubic fears healthcare. When let down, these lead to potential litigation which is a common fear amongst clinicians.

I could go on, but you get the idea. I do believe that fear should be driven out of the work place and especially so in healthcare; it would liberate the true power and potential of clinical professionals.

Fear could result in some of the effects discussed earlier in the blog, such as branding people as bad apples (http://successinhealthcare.blogspot.in/2012/07/bad-apple-theory-in-healthcare.html) or agreeing with persons so as to please them as in the Abilene Paradox and other not so helpful behaviours. In healthcare, these combined with the issues around evidence and process efficiency leads to the phenomenon of Clinical Wrongology.

What are your fears at work? What are its effects? How do you and your workplace deal with it?

©M HEMADRI 

Follow me on twitter @HemadriTweets

CLINICAL WRONGOLOGY

CLINICAL WRONGOLOGY©

M. HEMADRI

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence

Substantial activity in clinical medicine cannot after care delivery find evidence to back it

Substantial clinical care is delivered incompletely

Substantial amount of errors are found in the delivery of care

Substantial numbers of clinicians are either unable or unwilling to accept the above

In effect there is plenty or wrongness in theory, plenty of wrongness in practice and blindness to wrongness in clinical medicine. The wrongness is affecting patients by causing poor experience of healthcare, avoidable complications and avoidable deaths. Clinical wrongness is also affecting doctors and other clinicians causing variations in practice, restriction in the ability to practice appropriately and punishments for poor clinical performance.

There will be a day in the future when clinical medicine will practiced on the basis of proven science. We will truly rejoice on that day. Till that day arrives clinicians will need an approach that will help in appreciating, understanding and coping with the wrongness that is prevalent. The study of that approach is Clinical Wrongology.

Clinical Wrongology will remove the blindness to wrongness. It will make clinicians appreciate that there is wrong, wrongness and errors everywhere and these are normal to general life and clinicians are not exempt from this. Clinical wrongology will then encourage clinicians to cope with the wrongness around them and will show some methods to practice within the wrongness atmosphere with a view to increasing safety, quality and decreasing cost.
  
Clinical  Wrongology, the new specialty in healthcare is now declared open.

Watch this blog as there will be more on this subject.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: While there are philosophers who are masters on the subject of wrongness and great experts in the study of error, my inspiration for thinking about wrongology and clinical wrongology was from 'Being Wrong', Kathryn Schulz's brilliant book. Kathryn if you are reading this blog I hope you do not mind me calling myself a Clinical Wrongologist, (perhaps the worlds first and only one till date); having vainly given myself that title I could be motivated to live up to it; unless I am totally wrong on that!

NB: Persons in healthcare who want to be involved and contribute to this effort, please leave a comment with a means of contacting you or send a direct message to me on twitter.

Abilene Paradox: Watch out, it could hurt you

Abilene paradox - the importance of managing agreements and agreeable colleagues

Last month I wrote about the Bad Apple theory and argued for a slightly softer approach in understanding and dealing with clinical 'bad apples' in healthcare. In a subjective sense, bad apples (irrespective of whether they are actually right or wrong) are persons who tend to disagree with their group and use negative behaviors to show their disagreement.

The Abilene paradox is some what the opposite phenomenon. This is when we do not voice our concerns, do not speak up, do not disagree. In fact in this paradox we actively do something that we do not fully believe in or want to do, because we felt that is what our boss, our group, our organisation wanted. We agree with our colleagues and peers to please them, we think our agreement will make them happy, will vindicate their opinion. If you are the leader, manager or proposer of ideas you come up with ideas, projects, activities, etc with the intention to please your team; your team in return go with your idea not because they think it is a good idea or want to agree with you, they simply run with your idea as they do not want to displease you or dampen your enthusiasm.. They might agree due to fear of authority, lack of knowledge, loyalty, the desire to play the part of a cooperative team member or perhaps even with the hope of getting something from you in return in the future. Obviously these are all the wrong reasons to play along with an idea if it was bad in the first place.

Watch out. This is something which has the potential to take you well away from your mission and plunge you into problems despite everyone's support and agreement; well actually because of everyone's support and agreement. Some might consider this a version of what we know as 'group think'; perhaps. In my view, group think is when all members of the group are convinced that it is a good idea, whereas the Abiline paradox is when group members may not believe it is a good idea but push the idea along forward and ahead simply because they think it will please other members of the group. This is something you want to avoid at all costs.

The fairly old but very interesting article called the Abilene paradox can be found at http://www.rmastudies.org.nz/documents/AbileneParadoxJerryHarvey.pdf .

In summary, the author John Harvey says
‘’Organizations frequently take actions in contradiction to what they really want to do and therefore defeat the very purposes they are trying to achieve.’’

‘’.......a major corollary of the paradox, ... is that the inability to manage agreement is a major source of organization dysfunction.’’

This is the opposite of what many of us often assume that managing conflict is the usual big problem that frustrates us.

He suggests

‘’through the process of active confrontation with reality, we may take respite from pushing our rocks on their endless journeys’’

Abilene paradox is very relevant to healthcare. Just think, at your department level in MDT (multi disciplinary team) meetings and at national/international levels the unanimous decisions, at the consensus groups. Could the paradox be in play or could group think be in play? May be yes, may be no. But has the question been asked and answered if these phenomena could be affecting our decision making? I think we do not consciously explore this; we simply assume sometimes rightly, sometimes wrongly, that such ill effects did not afflict our decision making. In highly technical industries, in highly scientific industries and in highly evidence based industries adverse effects of the Abilene paradox will be negated pre-event by knowledge and post-event by data. In healthcare with its relatively poor evidence levels which results either in large variations in clinical practice or practice without improvement, the problems with group think and managing agreements are undoubtedly huge with its negative impact on patients.

Abilene paradox may turn out to be the bigger problem in recognition and management of healthcare's complexities.

You see the bad apples are easy since they are visible, audible and apparent. They make you uncomfortable or annoyed. You will be able to identify them and deal with them as early as you wish. Since we are all trained on how to deal with 'difficult colleagues' we at least imagine we can deal with people who disagree with us. Abilene paradox does not make you uncomfortable or annoyed till it might be really late. Since the intention of the group, who fall prey to the paradox is to cooperate and please, it will be really difficult to identify early and when identified we will be reluctant to deal with persons who have cooperated with us with good intentions. We have no knowledge or training on how to deal with easy colleagues who might pleasantly mislead. In organisations and teams peoples role is to cooperate appropriately and that can only happen when people support their team by critically questioning and vigorously analysing the issues. Only after a robust process should people offer their cooperation or agreement. 'Yes (wo)men' are probably more harmful to teams than bad apples in the longer run.

In old Jewish writings it is said that in a case subject to capital punishment if a guilty verdict was unanimous then the accused would walk free. This was generally thought to prevent group think, I feel their wisdom probably included concepts of the difficulty of managing agreements as in the Abilene paradox. It is said that good effective leaders surround themselves with a good team. Of course that is very important, but good leaders should make sure that the Abilene paradox does not frustrate them. Good leaders should demand that their team provide a genuine expression of opposing or divergent views so that higher quality decisions are made which would enable longer term success.

©M HEMADRI 

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

Bad Apple Theory in healthcare

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We know how bad apples can spoil the barrel, i.e. negative members can cause dysfunctional groups. I came across Will Felps work on it, will be very interesting to check out.

Felps et al say that there are 3 types of ‘bad apples’ (negative member of a group)

- withholders of effort

- being affectively negative,

- interpersonal deviants (violating important interpersonal norms)

They then go on to describe the groups responses to the negative member as

- motivational intervention (changing the negative person’s behaviour)

- rejection (removing the negative person)

- defensiveness (protecting one’s own self)

Felps says that ‘Each of these three responses have a common foundation; the desire to improve an aversive experience, but their intention varies’ as mentioned in parenthesis above. They  say that if motivational intervention or rejection were successful then a negative member never becomes a bad apple.

The work is mainly analytical rather than aiming for any resolution of the issues but they do touch on how the bad apple effects are moderated by determining perceived impact severity –

(1)    intensity of the negative behaviors exhibited

(2)    the group’s interdependence,

(3)    whether outcomes are successes or failures,

(4)    and the team mates’ coping abilities.

They also talk about the group’s ability/inability to cooperate and how low power groups looking to leadership to resolve the issues.

Here is the interesting radio link for an introduction to the work http://www.thisamericanlife.org/radio-archives/episode/370/ruining-it-for-the-rest-of-us

This is the link for the full academic paper http://books.google.co.uk/books?id=RKkxJnn73UoC&pg=PA175&lpg=PA175

My short commentary:

While the bad apple theory is very attractive I would reflect on whether the 'bad apple' behaviour and effect is topic dependent or person dependent. It is possible that a particular topic brings about a genuine principled disagreement from a team member who is so affected by the inability to influence the team hence shows 'negative' behaviours resulting in negative effects. History is equally full of examples where entire groups and even nations have been wrong and at that time any voice of wisdom would have been identified as a classic bad apple. A 'bad apple' in one topic might be the best bet team player on a different topic. However, the negative behaviour may not be topic dependent but entirely person dependent; this brings to fore a new set of issues on why such a person was employed or brought into the group; if the behaviour is recent/new an exploration of the team dynamics that brings forth such behaviour from individuals would be worthwhile.

I also caution that sometimes 'bad apples' can be early lone warriors too. These often tangential maverick thinkers and doers are also important for any societal or organisational progress.

Felps description of the 3 types of bad apples and the 3 ways in which groups respond to negative members are certainly seen in healthcare including amongst clinicians. The peculiarity with healthcare arises from the need to practice evidenced based medicine in the face of lack of good evidence by these precious resources called clinicians. This conundrum is compounded by rigidly hierarchical structures and high regulation in healthcare posing very unique and highly complex leadership challenges. Bad apple behaviours and effects as described by Felps are very naturally observed but allowing it in healthcare or dealing with it by either motivational intervention, rejection or defensiveness as we may be currently doing is likely to have as yet not understood exaggerated negative outcomes. Throw in the highly individualistic style of practice amongst doctors and mix becomes even more unstable. That cannot be good for healthcare.

Felps does not attempt to resolve it, quite rightly so, as this is more complicated than it seems.

There are times when system issues would be exhausted and a purely personal behavorial issue remains. The problem comes when bad apples do not recognise themselves despite well meaning evidence and advice. More worrying is when they recognise it within themselves but fail to acknowledge it - that will be breath taking arrogance usually leading to a big fall.

In democratic groups, due to its political nature the NHS could be called a democratic group, the success of the majority is judged by how well the minority is treated and a quote misattributed to Voltaire is 'I disapprove of what you say, but I will defend to the death your right to say it'. Perhaps these apply to the ‘bad apples’ as well. Real life is full of very mixed people, we could disengage (easy option) and lose valuable opportunities to develop ourselves. We could remain engaged and learn a mature way of thinking. Whichever we chose it will not be easy.

©M HEMADRI 

Follow me on twitter @HemadriTweets

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