The Pretence of Better Communication

This blog was first published at doc2doc http://doc2doc.bmj.com/blogs/doctorsblog/_pretence-of-better-communication It has been modified, extended and re-posted here.

Discharge Summaries in NHS
10 years ago in the NHS most consultants used to do discharge summary letters for their in-patients. Quite rightly so. The discharge summary was and is the only communication that the hospital provides to primary care on what happened to the patient in the hospital. It is one of the most important pieces communication that the specialist sends to the generalist. It was the knowledge of the expert given as an opinion. It was also an opportunity for the consultant to review and reflect on the care provided, identify errors and recognise the capability/limitations of the team members.

5 years ago the consultants mostly devolved this responsibility to some experienced staff working with them such as Staff Grades or Registrars. The discharge letter became a task that had to be done. Information was passed to the general practitioners.

Now, the discharge letters are electronic and are primarily if not exclusively done by FY1s or FY2s who are the least experienced doctors in the system. Discharge letters are a part of the contractual requirement to be sent within a set time. There is enormous data within those discharge letters which is sent to the GP more or less contemporaneously. The junior doctors do a very good job; of transmitting data; they cannot with their level or training, expertise and experience do anything more.

Anyone who knows a little about this things will recognise that to derive any meaning or learning from what we do on a day to day basis, data has to be processed and assembled to generate information; information has to be analysed and contextualised to create knowledge. In the case of the NHS discharge summaries, knowledge transmission has now deteriorated into data transmission. Transparency and detail which are important have taken the place of trust and succinct senior opinion which are equally important.

The most crucial and often the only piece of communication from hospitals to general practices is now generated by a combination of off the shelf software programmes filled in by the junior most medical staff and usually has no oversight from anyone senior. Of course there are reasons for this, the letters can be generated quicker, can reach general practitioners on time and the current economic climate a consultant who is an expensive human resource is better used doing actual clinical work. Fully understandable. But let us not make the mistake of assuming that this is superior communication.

A friend who works on analysing and reporting risks in financial industry wrote in to say 'in my area of work if I do not provide the final oversight on what gets published on the credit opinions..which can sway bond markets...an error means I can be banned from working in financial services...if related to sovereigns...maybe jailed as well'. Now that's how seriously communication should be taken.

The Abuse of Communication Skills

Now that this blog has a growing readership; friends and acquaintances are writing in with examples from their own places of work. There seems an increasing cultural tendency where people think its okay to abuse communication skills. Righting a wrong not by action but by words. Not fair but read on.....................

Car Parking Vs Patients

Clinician running late, found a parking place and noticed that the parking permit was missing. Dilemma. Go to work and ring security to inform - risk of clamping and £60 fine. Go to security first and late to work - patients waiting.

Decision. Go to security first. Cannot afford £60 fine.

Explanation: 'Oh we can apologise to patients, show them empathy, sympathy, tell them our story, sit by their side rather than opposite them, perhaps even hold their hand and build a better relationship. They will forget the waiting. But security will clamp and will fine £60; my work place will not be supportive'

'We can handle complaints'

Bed manager rings on-call doctor: 'Try and send patients home from A&E, there are no beds in the hospital and we don't want patients to breach in A & E'

On-call doc: 'Well, apart from clinical reasons, there is also patient expectation. We could have serious complaints'

Bed manager: 'Oh don't worry about that. Complaints come only later. We can handle that. We are really good at handling complaints. We can provide them a detailed explanation and an apology if necessary'


Those are classic examples of abuse of a good skill. I have a problem with people using great tools and doing wrong things with it.

Let us get real. Let us not delude ourselves in the NHS by harping on about the primacy of communication.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Servant Leaders in Healthcare - Stand up and make it count

Airline operational performance results for major carries in USA have come out and it shows that in general flying experience parameters are all getting better. The WSJ has a nice tabular column which explains it really well.

Southwest Airlines had the largest number of system wide emplanements (I take this to mean the highest number of passengers took Southwest flights) and they have the lowest rate of complaints per 100000 emplanements. Southwest had about 40% less complaints than the next best complained airline and the highest complained about airline had 14 times (1400%) more complaints than Southwest.

United had the highest complaints. The stats show that United had the highest rate of bumping (passengers denied boarding due to overbooking by airlines) and highest rate of lost baggage and understandably they had the highest complaints.

Then an interesting fact leaps out:

Out of 7 major USA airlines, Southwest had the second highest rate of bumping, third highest rate of late flights and was in the middle of the field for lost baggage but had the lowest rate of complaints. As I explained earlier it was not just lowest it was (at least for the month November 2011) had 14 times lower complaints than United.

There is nothing more that annoys passengers than bumping or flight delays or lost luggage. Why did Southwest have such a low rate of complaints? Why did Southwest customers not complain more? Looking at the data, one would expect many more complaints. How can we explain this?

Southwest Airlines practices Servant Leadership, which is pretty unusual at a whole organisation level. Servant Leadership seems to have led to employee empowerment which then leads to building ground level relationships with customers. All those lovely videos on youtube about Southwest are examples. Customers begin to see Southwest employees as 'friends' who are coping with difficulties that are common and typical of airlines; they do not want to add to the burden of their 'friends' by complaining.

Relationships trumps poor stats and bad stories. This is true of healthcare as well. Patients relationship with their doctors and their local hospitals are the ones that keep our NHS hospitals going; if that was not the case we would see a significant movement of patients away from high mortality hospitals every time the mortality results hit the press or a bad news story hit the press. That is not happening at a perceptible level.

However, some hospitals are finding an increase in complaints every time the mortality results are published and on the occasion when bad news stories are published. Complaints are a useful tool for feedback, problem detection and improvement but when an organisation is already on a well recognised path of validated development complaints on routine operational matters can also be a source of distraction, expense and negative publicity. Problems which were not or could not be prevented, as might happen in healthcare often, if identified, as soon as they happened and customer service methods were used to deal with them, could avoid complaints and its ill effects.

In an organisation that is clinically performing well, to ensure that the doctor-patient relationship and the hospital-patient relationship which clearly exists is translated into a low number of complaints would need empowered employees enabled by an organisation wide servant leadership approach.

Where are the servant leaders in healthcare? Which organisations follow servant leadership approach? I can recognise very few leaders but no organisation practising servant leadership.

The thoughts on servant leadership are quite old, ''Mark 9:35 Sitting down, Jesus called the Twelve and said, "If anyone wants to be first, he must be the very last, and the servant of all''; there are other religious and philosophical variations which are older and younger to that quote. However the management description of it was by Robert Greenleaf who wrote:

"The servant leader is servant first. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead."
"The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priorities are being served. The best test, and difficult to administer is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servant? And what is the effect on the least privileged in society; will they benefit, or at least not be further deprived?"
Robert Greenleaf: The Servant as Leader 1970. (http://www.greenleaf.org.uk/about.php)


One would have thought that the medical profession with its high altruistic calling of serving the ill would abound with servant leaders; it seems that may not be the case. The time has come for any true servant leaders in the NHS to stand up and be counted as this seems a good model for leadership development for our caring and noble profession.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

http://online.wsj.com/article/SB10001424127887324081704578231553159491828.html
http://www.dot.gov/sites/dot.dev/files/docs/2013JanuaryATCR.pdf

This blog was originally written for and posted at Faculty of Medical Leadership and Management  https://www.fmlm.ac.uk/blog/makani-hemadri/servant-leaders-nhs-%E2%80%93-stand-and-be-counted
Re-posted here 

End of management (long version)

A shorter crisp version (about 600 words) is published in the FMLM (blog http://www.fmlm.ac.uk/blog/makani-hemadri/end-management)  for which this topic was originally written. This is the rambling 1500 word extended narcissistic version. You are welcome to it ...  

It is important to read Alan Murray’s ‘The End of Management’ Corporate bureaucracy is becoming obsolete. Why managers should act like venture capitalists; in the WSJ. Here is the link: http://online.wsj.com/article/SB10001424052748704476104575439723695579664.html

Once you have read this blog post gets its context and then you can read this either as a commentary of the WSJ article as relevant to NHS or on its own. This blog is deliberately off-key, the topic is such, bear with me. Compared to many healthcare systems we do quite well in the NHS. Could we do better? Of course yes but how we do that will define our future.

We are the management and we will tell you how to end management!?!?!

At a broader level, in the NHS there are no examples that I can think of where corporate structure or management has been ‘ended’. The previous government did good work with top down waiting times and so on; the present government is attempting top down radical change in organisational structures. The government is trying to get us do differently. When individuals try to do something creative, the organisations and the NHS as a whole tries to look at 'where and how it fits in with the overall plan'. But in the public sector there is the government not just wanting us to do different but also telling us how precisely to do it; with organisations 'encouraging innovation and creativity' only if it fits in with pre-defined policies. But that is what modern business is trying not to do; modern thinking in management is not telling people what to do but to let people to do things first and the management to amplify the good ideas.

Thinking of me vs thinking of you

At the narrower level, trainees (I am talking about all trainees in the clinical areas- not just doctors) are taught to think of how they are learning and improving themselves; never to explicitly think about their contribution to the organisation. In fact, often people think that their contribution to healthcare as such starts only when they stop becoming trainees. By that time the mind set becomes so fixed in thinking inwardly about the self and not outwardly about others that it becomes very difficult for the rest of their lives. Careerism becomes the mantra for many people in healthcare; we always thought this was the case in the private sector - true but that trend is changing in some areas. 

Best with limits

This leads to people taking very defensive attitudes. Most people in healthcare management are either numerically shy or numerically illiterate. They are unwilling to make a personal numerical prediction on their or their department/division/directorate’s improvement based on a measurable internal parameter due to the fear that they may be unable to stand by it. In any case most of the numbers are geared towards predefined reporting parameters. People who work in the NHS also seem to think that they are somehow very altruistic and have a high sense of entitlement. That attitude is even more profound in the clinicians with clinicians tending to believe that they express their altruism by their very individualistic approaches to healthcare. It is also possible that there are certain kind of people who are drawn to public services (possibly risk averse, change shy, rule-bound, authority loving, service minded and so on) and it would be difficult to use the same methods as for instance in Google to achieve a new management approach.

At both the above levels, healthcare and NHS is thought to be too important and too costly to be creative or innovative; the phrase used is 'risk'. Healthcare especially in Europe and even more so in UK has innumerable external controllers and bodies telling people what to do and how to do it that it simply chokes off creativity even before it begins. In other industries there is an obligation to do some degree of statutory reporting with no real controls on how they do their business.

So, it seems like what the above WSJ article is saying is not possible in UK healthcare at all. There seems no space that is available or can be created for those concepts to happen without falling foul of something or someone. But there lies the opportunity as well to ‘end management’ and create self-sustaining systems.

Blue skies

Hence, I can now boldly enter the imaginary world to explore how the 'wisdom of the crowds' can be harnessed. I think the way to do it is to disengage from current conventions and demonstrate its success. That does not mean rebelling, non-cooperating, behaving illegally, not concentrating, becoming disenchanted or any such thing. It is using our own methods to satisfy our requirements and our clients’ requirement rather than using a method or doing a thing to satisfy an external definition. 

For instance when the roads around Birmingham were choking instead of building a new road, they opened the hard shoulder to traffic which in other roads is actually illegal; peak time traffic situation has improved since in that area. Compare that with an example of the situation in some hospitals where they buy yet another business intelligence interface/data-mining tool to provide information at service line specialty level when the managers and clinicians often feel that human connectivity was the issue that needed resolving to enable their older software to be used effectively. Often the tool is not really the problem, our thinking is.

Let us assume for example that one of our services is not accredited by some specialty society because we did not meet one or more of their requirements in the way they wanted. Normally the tendency would be either to stop that service or to work very hard to meet that accreditation standard. However, if our results in that particular specialty or aspect is better than anywhere else, would we as an organisation, anyone in the specialty society or the general society as a whole be unhappy? Certainly not. In this scenario the badge of not being accredited becomes a badge of honour. The problem is we do not think like that in the NHS. We probably should.

Like the Birmingham roads, what 'illegal' things could we do to make ourselves better?

Obviously we should disengage and develop only if it is beneficial to our hospital and patients and we are able to track it and prove it contemporaneously.

Is this an example of wisdom of the crowds in the real world of healthcare?

     Finally let me try a hypothetical yet hopefully practical proposition to disengage and demonstrate. There is a focus on Unplanned emergency re-admissions and we may not get paid for such re-admissions. I am aware of some of the things that we have started doing to tackle this issue. Let me put to you a potentially disruptive solution in the 'end of management' mode 

     

      a) not offering routine follow-ups for any patient who is discharged from the ward (medical, surgical, post-operative) 

and instead

b) Guaranteeing a clinic slot within a defined time (48 hours to one week as agreed) should the patient choose to contact us.

My hypothesis is, this approach will reduce unplanned emergency readmissions as the issue is often/mostly to with patient concerns on access (rather than real life-threatening matters); the 'routine' follow up itself is mostly to satisfy clinicians habit rather than a scientific finding that all complications in all patients happens precisely 3 months after seeing the doctor and hence patients need a 3 months appointment. This will also clear up the 'congestion' we have in our clinics. 

Okay, where is the 'wisdom of the crowd' here? The crowd in our example is the patient; and the wisdom is the patients’ knowledge about their own health on what is wrong with them and they should be able to access us when they find something wrong with them. This is of course one step further than the current thinking on 'crowd' which is usually the employees in a large organisation. We even need to change the definition of crowd to suit our requirement. 

Rambling ambiguity and the threads of new systems

We can predict that the conventional management methods will not work in the 21st century. End of management as we know it is not chaos as many would like us to believe. New models are not apparent or clear yet. Perhaps there may not be one new model; possibly there may not be a well defined model at all. There are emerging themes; democratisation of data, data mining, crowd sourcing, coping with anti-knowledge, cloud care and dumb-terminals, many more............ It is not these themes that are important; it is how we implement these themes that are relevant. We can be told how to do it thus not ‘ending management’ or we can show how we do it.

Thank you for getting to this sentence of the blog. If you thought this was rambling ambiguity, I am grateful for your attention and will do better next time. If there are some threads that we can build on then I have achieved my aim.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Clinical Practice, Melody and Harmony

Clinical Practice, Melody and Harmony

Music is an art that is given form by its characteristics including melody, harmony, rhythm, texture, dynamics and pitch coming together.

There is evidence both the 7-note diatonic scale (melody) as well as harmony existed 3400 years ago as seen in the Syrian city Ugarit tablets. Though in earlier times there was probably no formatted succession as musical melody of any sort. In musical development, a sense for "melody" would not have occurred overnight as music often was the playing of single notes, assigned to various rituals, such as one gong for moon, another for sun, another for death, birth, etc.

Every piece of music has its own DNA, made up of three elements: melody, harmony and rhythm; present in every popular song from every genre. Melody is defined as the soul of music can stand alone; the addition of harmony gives music its beauty and adds detail thus catching the listeners' attention.

One of the music explorers of the 20th century, Alan Hovhaness, once said that the compose  joins Heaven and Earth with threads of sound which  combine the melodic lines and harmony. They are the two necessary elements to music.

MELODIC SYSTEM

Melody is defined as the primary sequence of notes or successive line of single tones or pitches perceived as a unity forming passages or phrases in various patterns leading to a song with the characteristics such as range, shape, pitch and movement. Movement of a melody or melody line is the direction or shape or the geometric line made when notes are joined together. When the melody moves stepwise and is connected, the movement is termed conjunct. Melody that leaps from pitch to pitch with no natural connection or flow is said to be disjunct.

In melodic music, normally there are one or two 'leads' who sing or play the melody. Music forms such as country, rock, Hindustani and Carnatic are examples of melodic forms of music. Hip-hop, rap, reciting verses, reciting slokas can also be considered a version of melodic music.

In melodic system of music there is a greater freedom to improvise and almost no two artistes are likely to perform the same song/music in a similar manner neither would they wish to do so.

HARMONIC SYSTEM

Harmony is defined as the secondary series of a particular sequence of notes or chords (a group of 3 notes played together or in a separate manner one after another) which occur simultaneously with the melody. Harmony is the relation of notes to notes and chords to chords as they are played simultaneously.

The harmony of a song always has a different series of notes from the melody, although sometimes when the harmony is played simultaneously with the harmony the notes in both may be the same briefly.

In harmonic musical systems very frequently there are 'lead' instruments which play melodies but are at the same time accompanied often by a large group of other instrumental musicians playing something different from the 'lead' at the same time. The relationship between different notes played at the same time is what is called harmony. When two singers or instrumentalists are playing the same notes instead of harmonizing notes, they are no longer harmonizing but instead said to be playing "in unison" or together.

Western classical music is from the same script whenever and where ever it is played. Of course there is improvisation and indeed there are differences between various orchestras and it results in great music but one that matches the script/notes.

Melody and Harmony

Melody and harmony are considered as the body and soul of music. We do not forget the importance of  rhythm and tone that are built into the writing thus making music.

Melody is the linear aspect of music, in contrast to harmony, the chordal aspect, which results from the simultaneous sounding of tones. Harmony's function has evolved mostly to make the notes of melodies "connect" or to make their connection to each other melodically more apparent to the ear. It is a result of the joint contribution of melody and harmony in which the listener is “directed to a single melodic line, but this is conceived in relation to harmony”

While the melodic constraint is nearly universal, the harmonic constraint is more particularly Western.  Many non-Western styles either reject chords altogether, using only one note at a time or build entire pieces around a single unchanging harmony.

Doctors  in melodic form

It will be apparent by now that most doctors who are trained as 'individuals' with high knowledge to be able to deliver 'independent' care supported by a few other individuals in small teams (units, firms, etc) are probably in the melodic form. The 'attending' or the 'consultant' is the 'lead' and will deliver care 'tailored' to the patient (improvisation) and often no two individual clinicians would ever do or want to provide the exact same care even when faced with similar situations. They do deliver great care.

This has recognition with rock stars and rock bands. There is usually a lead singer and a lead guitarist often both are the same person, supported by a very small team of rhythm, base, keyboard and drums. They make great music. Those who are familiar with the Indian systems of Carnatic or Hindustani music will easily recognise the similarity with one (rarely two) lead expert singer/musician supported often by just two other musicians (an instrumentalist and a rhythm player). They make great music.

Healthcare delivery systems are harmonic

Most of us will also recognise that the days of individual clinical experts practising independently in their own premises is over in many countries such as UK when the NHS was created and on the way out in many countries such as USA (with HMOs and other attempts) and India (with corporate sector multi-specialty large hospitals). The practise of medicine has become too complex and sadly too costly for the continuation of the purely 'melodic' practice of individuals however brilliant they may be due to the need to avoid disjuncts.

What might be happening now is that we have put 'melodic' practitioners all together on a harmonic platform and expect harmony. What we get is occasional 'unison' and not harmony. The 'unison' can sound good too as when top musicians perform on the same stage as a tribute to someone or on some occasion. South Indians will recognise the Thyagaraja Aradhana where individual melodic monarchs sing in unison but that should not be mistaken or harmony. Similarly, we have individuals with the training and ability to practice independently all under one roof, occasionally there is unison, often there is cacophony. Hopefully this will be a transitional phenomenon.

This is where leadership comes in. Healthcare employers should be explicit in defining that healthcare delivery is now in overall harmonic mode with the melodic element as a vital element. Conductors (Chief Execs, Medical Directors, Nursing Directors, Clinical Directors, et al) should ensure that doctors and other clinicians work in an harmony mode where every individual within the team/orchestra follows a script (evidence, especially operational evidence that has prior local agreement) that is specific for that song/music and though it does not match with other musicians in an exact manner and though there is some degree of improvisation to cater to the situation (variation as a result of patient based differences). The resulting output will be greater care than we are able to offer today.  Hence our belief is that doctors and clinicians may be better working in a harmony mode.

Melody by itself (monophonic music) was the principal form of composition in western cultures before the year 1000. Together these constraints ensure a two-dimensional coherence in Western music analogous to that of a woven cloth. The classical western music has now moved on to harmony. It is time for healthcare to move from the melody of individual brilliance to the harmony of collective success.

Geetha Upadhyaya & M Hemadri

Co-Authors

©M HEMADRI 

Follow me on twitter @HemadriTweets

Geetha Upadhyaya is CEO and Artistic Director at Kala Sangam. She was a Consultant Pathologist, with a particulat interest in the health benefits of practising arts. Having a postgraduate degree in classical Indian dance and music, her main interests are cross art collaborations, choreography and music. Geetha's aim is to establish Kala Sangam at St Peter's House as a national centre for South Asian arts, heritage and culture.

Geetha's thoughts expressed in this blog post are her own personal views and does not represent any organisation.

Links:

Melody with Clapton on vocal and lead guitar with improvisation et al; obviously it is wonderful tonight https://www.youtube.com/watch?v=vUSzL2leaFM

Melodic Carnatic music with Unnikrishnan singing Ramadas' Palukae Bangaramayena https://www.youtube.com/watch?v=N6FIwW-qWGQ  and note how Balamuralikrishna renders the same song so very differently https://www.youtube.com/watch?v=IEHdHRpLywQ

Singing in unison (individual singing in the melodic form but all together) from the famous annual Thyagaraja Aradahana https://www.youtube.com/watch?v=vsTXLjsfLWk

A classic harmony based music (where the melody is part of the harmony) Holst Planets Suite Mars https://www.youtube.com/watch?v=AGGlL1wexQk

Melody leads & harmony blends to create the James Bond theme https://www.youtube.com/watch?v=S_PEnKgB-cE

 

Swadeshi Healthcare

This was originally written for and posted at Healthradii (http://healthradii.com/guest-blog-an-example-of-swadeshi-healthcare/) now reposted here.

Swa =own, self, local
Desh = country/locality/region

Swadeshi = of one's own country/locality/region

Gadchiroli, Bangs and the wonder of low Infant Mortality Rates

Gadchiroli

Gadchiroli is a district in western Maharashtra. It is one of the most backward districts in India with a high level of tribal and deprived population. The terrain is tough with forests and floods; what ever little infrastructure suffers poor upkeep. In addition the area is infected with arms, ammunition, explosives with people willing to use these often; Naxalite related violence is a routine feature in the area. Currently there seems only two positive features to Gadchiroli, one of them is a general literacy rate of 74% which is far higher than the Indian national literacy rate of 59%.

The other is Gadchiroli's low Infant and Neonatal Mortality Rate. Clinicians could describe this as a a unique wonder, the faithful could describe it as a miracle. How is it, in an area with a difficult geography, backward population and extreme violence that the Infant Mortality Rate (IMR) is so low that it beats many 'developed' cities in India?

Come explore with me.

The Numbers

Around the year 2003 the whole of India Infant Mortality Rate was about 60 and India ranked 150 (out of 194 countries), Gadchiroli Infant Mortality Rate was 26.5 (which would equal a world ranking of about 100). That means the whole India IMR was a 100% more than Gadchiroli.

What is really interesting is in 2010 Indian Urban IMR was 31 with Delhi Urban IMR at 29. This means that the remote Gadchiroli had a better IMR in 2003 than Indian cities including India's capital have in 2010.

The neonatal mortality rate (NMR) in Gadchiroli in 2003 was 25. The neonatal mortality rate in 2010 for the whole of India is 33 (for urban India the 2010 NMR is 19).

Those are the basic facts highlighted.

How was this achieved?

Localism and operational research

By long persistent and consistent effort. It may be still be a wonder but it is certainly not a miracle. The research was detailed, hypothesis was based on local data and its analysis. The action that ensued was closely followed by continuous operational research and there was sequential building of hypothesis relevant to the local situation.

This means there was no direct transplantation of clinical pathways, technology or treatment from any so called best practice. Principles of public health research were rigorously followed to create locally optimum methods. The principles are universal but the data, analysis, hypothesis, action, pathways, care delivery methods were all local and specific to Gadchiroli.

Who did it?

Abhay Bang and Rani Bang; a husband and wife team both physicians with public health qualifications from Johns Hopkins decided to test and put theory into practice. Both have long family histories of concerning themselves in the matters of improving the lives of others. Just Google their names and be inspired.

What was the approach?

A holistic bundled approach. It is important to remember that these bundles were created on the basis of local data analysis. To put it precisely the Bangs for example found that local data showed sepsis/pneumonia, prematurity and hypothermia as the top causes of death. After a further analysis found in order of priority dealing with sepsis, asphyxia, hypothermia and feeding problems will reduce mortality with management of sepsis alone is likely to contribute to reduction of neonatal mortality by 50%. Tools for management was created after consulting with local population and delivered by village healthcare workers. The village healthcare workers were local resident literate women who were provided with a total of 12 months on the job training.

A 16 item Home Neonatal Care intervention package including management of asphyxia by bag and mask ventilation, injection of vitamin K, thermal care, early diagnosis and treatment of sepsis with two antibiotics (injected gentamicin and oral co-trimoxazole) were implemented. You can see the mind blowing results in the charts above. Over 15000 injections administered by these village healthcare workers and there have been no complications.

Every shred of evidence was local, every intervention was agreed with and co-designed by the local users, care was delivered by local people. No imported best practices, no national guidelines, no experts, no experienced care providers, no external or governmental monitors, to working to imaginary targets/predictions, no high technology, no huge amounts of money.................

The bundle approach did not stop with care delivery for neonates. Women's health was a closely inter-knit issue with child health and that was part of a bundle. Public education especially on healthcare issues was a part of another wider bundle. There have been equally immense successes in those areas.

A good quality of life is enabled by good personal habits and Gadchiroli happens to be one of the few areas in India where the public have recognised alcohol as not conducive to healthy living and hence demanded prohibition and help to keep the prohibition going. This is part of the public health bundle championed by the Bangs. I am positive if there was any way that they could reduce the violence in the area, if they had any power or influence on it they would have, I suspect they might have already explored it.

The Importance of the Bangs, SEARCH and Gadchiroli to the world of healthcare

When we think of healthcare in India most of us will be aware of Apollo in the corporate sector, Aravind Eye Care for brilliant innovation in ophthalmology, some pharmaceutical companies who produce affordable drugs for India and Africa, recently we think of Dr Devi Shetty's volume based quality improvement models; there are many more commercial names we could think of. We may think of medical tourism, we may even think of some traditional Indian healthcare systems such as Ayurveda and general health system such as yoga. While those are examples at the better end of the spectrum, we would probably avoid thinking of a greater cohort of diverse providers and their dubious ways.

We never think of Gadchiroli or the Bangs who have taken on a whole district with the poorest population and produced amazing results with meagre resources in an clinical area where everyone else in the whole of India finds it daunting. They are a triumph of public health, they are a victory of scientific principles of operational research, they are a beacon of localism.

Yet when I speak to many doctors in paediatrics, public health and operational management they are blissfully ignorant of this leading example. When I speak to paediatricians in India and paediatricians of Indian origin in UK, most of them are totally unaware of this.

It will be essential for every doctor in India and in every developing country to be fully aware of the Bang's Gadchiroli experience. When we talk of developing or delivering alternative models of successful healthcare that are specific to local needs there is no other learning resource better than Dr Abhay Bang's published material which clearly describes the principles of how to do it. These should be taught very seriously as a part of the public health curriculum in medical schools in India.

Aping the west, urban Indian healthcare providers should eliminate their mental block against anything local; they must develop some discipline in following the scientific principles of improvement and vision to own and deal with population health rather than client/customer health; that might help them improve the quality of healthcare in India. If you are Indian you have certainly heard the Gandhian word called 'swadeshi'; Abhay and Rani Bang are probably the greatest proponents of Swadeshi in healthcare, being Gandhians themselves that is hardly surprising what is relevant is that swadeshi has given India some top class results and lessons worth emulating in every area of Indian healthcare.

This is the Indian rural version of what Intermountain Healthcare does at Utah. I recommend the Bang method for India's healthcare improvement. I also recommend a Bharat Ratna for the Bangs.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

Dr Abhay and Rani Bang's SEARCH website: http://www.searchgadchiroli.org

India Infant Mortality Rate graph generated from the longitudinal data at http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate

India IMR and NMR for 2010 are from www.censusindia.gov.in/vital_statistics/srs/Chap_4_-_2010.pdf

NHS in India - be aware of what it means

This blog post was originally published as a guest editorial at Soumyadeep Bhaumik's Caffeinated Works & Random Musings which is one of the largest healthcare blogs in India

(http://soumyadeepb.wordpress.com/2013/01/04/the-uk-nhs-in-india-be-aware-of-what-it-means/)
Reposted here.

I follow Indian healthcare with some interest.

I have wondered about 'why do doctors who work in India and want to continue to work in India take up exams such as FRCS, MRCS, etc?' Many of these exams are conducted in India. I suppose I should give those doctors the benefit of the doubt and think that they do it as a part of knowledge improvement and knowledge validation with an international perspective. Many though may have commercial marketing motives. I ask myself if the content and the style of these exams are suitable for non-western practice? I think not, but that is purely my view.

Now the news of NHS wanting to go to India. The NHS in UK is a government funded public service healthcare system. Is that the model the NHS will follow in India? The NHS in UK is increasingly outsourcing its activity to the private sector and inviting private sector in to the NHS. However, the NHS in its new wisdom may be choosing to go to India to provide services as a private provider. Which is the exact opposite of what the NHS does here in UK. The policy and strategy confusion seems to be immense and contradictory. The NHS currently does not have any great operational experience of purely private provision.

Why would the Indians allow the NHS to do the exact opposite of what they do in UK in terms of business model, inside India? It is a question that should be asked in the Indian parliament; I am sure it will be asked if and when trouble arose.

More relevantly, why would the NHS itself want to do this? The reasons are not that difficult to fathom. India is a growing market in general, healthcare is a really high growth market, there is a clear need for more high quality providers. The non-commercial UK NHS wants to take commercial advantage of these factors to make money for UK. It is nothing else apart from money making. Money making in itself is not such a bad thing, only to couch it in the language of healthcare improvement, helping populations, transferring expertise, spreading knowledge and other obviously superficial euphemisms reflects poor intentions. I am a believer in the primacy of intentions.

I wonder if the NHS would still go to India if it was required to provide 72% of its Indian services in rural India (that is the percentage of population that lives in rural India) to the same standard and more or less the same price that they provide in urban India? I ask because that is exactly what the NHS prides itself in UK; providing more or less the same standard of service at more or less equivalent costs all over UK. Well, if you want to be an international business thats how you begin to think; Coke and Pepsi do that, produce soft drinks, distribute it to all corners of India at almost the same price; which is exactly what they do anywhere in the world. Will the NHS do in India what their business model does in UK? Would the NHS in India treat the rich and the poor equally as they are required to do in UK?

I suspect that is not what the NHS in India will be about. I sincerely hope the NHS in India will make me eat my words as that will be a win-win for everyone.

The principles of care, content of education, models of care delivery that are needed in India are different. India is perhaps already suffering from a techno-centric, finance driven, western oriented, urban focussed, doctor obsessed healthcare system. As long as we are clear in our minds that whether it is examinations such as MRCP/FRCS/MRCOG/MRCGP which are conducted in India or a possible NHS as a provider in India are simply commercial businesses operating in India for profit making; as long as we recognise and be constantly aware of this its fine. Once we start assigning higher value, philosophical or operational, we will be doing a disservice to the Indian public by deliberately misleading them. Those of you who are highly sensitive amongst the Indians should also reflect on whether this is a form of cultural and knowledge colonialism.

I am British and work in the NHS. I am an admirer of the NHS system and I believe the NHS in UK does a great job in terms of many clinical, operational and cost parameters. It is my vested personal interest that NHS in India is successful commercially. I am of Indian origin and have family in India, hence creating awareness of potential sub-optimisations is probably my broader duty.

M. HEMADRI

Follow me on twitter @HemadriTweets

Human Error: Does not exist

Human Error. Does it really exist?

We have discussed wrong site surgery/procedure (http://successinhealthcare.blogspot.co.uk/2012/10/mark-site-campaign.html)

The equivalent for this in histopathology would probably be labeling errors. Labeling errors could at the best lead to rework/reprocess and at the worst result in wrong report with potentially catastrophic effects on patients which can be as grim as wrong site surgery. In most laboratories there are multiple checking steps within the process to detect errors and prevent them leading to errors in reports that could harm patients. In a busy pathology laboratory in England in 2007 there were 113 slide and block labeling errors. By 2009 after a series of Kaizen events it dropped down to just 2 labeling errors which would be a 98% improvement giving a short term six sigma score of 5.8.

 What is interesting are the results of the root cause analysis of the 113 pre-Kaizen. Most of them showed that human error as one of the root causes. What is remarkable was the post-Kaizen improvement was achieved with the same people. The root cause analysis of the 2 post-Kaizen errors showed further opportunities for system improvement.

If system improvement can reduce or eliminate (well, nearly eliminate in this example) human errors, the immediate logical obvious question to ask is 'Does human error exist?'

Deming says that 80% of quality problems are caused by management and 20% by employees. It is further thought that since the employees are essentially a part of a system for which the management is responsible, almost all quality problems are caused by management. Deming seems to have taken the view that the focus and emphasis on quality has to be top down and the creation and delivery of quality should be bottom up.

There are a number of areas where zero errors or quality problems (or virtually zero errors) are possible. In the same pathology lab the number of endoscopic biopsy request clarifications (which used to happen due to doctors illegible handwriting) are now down to zero since the lab started asking for a copy of the printed endoscopy report to accompany the specimen. Previously it was thought that poor handwriting and not putting enough information was a part of human error due to human fallibility, in practice it caused arguments, distress and wasted time.

We are now beginning to question whether there is anything called human error at all. As realists and practical professionals we realise that there will be some areas where perhaps human error does exist and possibly cannot be avoided but we believe that for people working within well organised systems this should be a rare thing. We wonder if people with poor training and no experience in quality methods who nonetheless think they are capable of understanding quality improvement are unable to analyse with an aim of system improvement and hence blame human error as a reason by default. After all everyone has recognition and sympathy for the phrase 'to err is human'

We are having an emerging view that 'Human Error' as an attribution for quality problems is a cop out clause used by poor managers and weak leadership. It need not be so. However it requires managers and leaders to shoulder the responsibility for building continuous quality improvement into their work and the way their teams function. CQI systems are already available and they have to be applied with patience and persistence - those who do that will find  the path of continuous improvement and will eventually share this view of ours that 'Human Errors does not exist in organised systems' though it may sound very radical right now.

M Hemadri & David Clark

Co-authors

David Clark is a Consultant Pathologist and National Clinical Lead, NHS Improvement. David's thoughts expressed in this blog post are his own personal views.

PS: Regular readers of this blog would have read a previous post about how we find designs which set us up for failure (not deliberately) and we then blame it on 'human error' http://successinhealthcare.blogspot.co.uk/2012/12/blame-it-on-human-error.html

©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 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html