Healthcare has no Red Teams - we need them

NHS has no red teams - we need them

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

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

What is Red Team?

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

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

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

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

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

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

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

Red Teaming

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

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

Healthcare needs Red Teams

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

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

© HEMADRI

Follow me on twitter @HemadriTweets

Further reading

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

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

Subjectivity is the curse on examinations for UK doctors - get rid of it

Subjectivity is the curse on examinations for UK doctors - get rid of it

There is currently a controversy raging in UK healthcare about doctors. For many years it was known and was passively accepted that if you were of Black or Minority Ethnic origins more so if you were an International Medical Graduate (IMG - a doctor with a primary medical qualification outside the UK or European Union) facing a Royal College examination you would have a much lesser chance of passing the examination. If you were of BME or IMG origins and were of a generous persuasion you would call this sub-conscious bias but most called this racism, whether it was racism or not. If you were representing the establishment you put out phrases that are superficial gibberish, such as 'reasons are multi-factorial and complex' but certainly not racism.

The issue came to a head with the MRCGP examination where in the new version of the examination the differences between white and non-white candidates were so gross that you would notice it even if you were colour blind.

The medical post graduate examinations conducted by the Royal Colleges are essentially about medical knowledge both theoretical and applied. Given that these are knowledge tests, why did the results show racial differences? We will not discuss racial supremist reasoning here.  Many of us will remember the days before the MCQs - the essay answers were often a demonstration of your wizardry in medical English. Apparently even in the MCQ based knowledge tests we can use linguistic jugglery so that a non-native English speaker comes out as having poor medical knowledge - we are not discussing that further here.

The curse of subjectivity

Applied knowledge in medicine is tested in vivas, OSCEs, with patients and simulated patients. Here the marking is done by examiners, that is where subjectivity comes in despite current best efforts, subjectivity is ruining careers.

The rest of this blog post is about subjectivity (the collection of the perceptions, experiences, expectations, personal or cultural understanding, and beliefs specific to a person - Wikipedia)

The sad paradox is knowledge especially in medicine is objective but part of the testing process of this knowledge is subjective. The tension that results from an objective topic tested subjectively is where the fundamental flaw lies. Where subjectivity exists, there bias exists and hence unethicality at the best and fraud at the worst exists.

Subjective assessments must not have a place in career make or break decisions such as exit examinations or in any arena where career progress or ability to practice the chosen profession can be stopped. Subjective assessments do have a place and can be used for progressing in learning and development - some of which are known as formative assessments. Must not be used for stop-go decisions where only objective assessments should be used.

Reducing or Eliminating subjectivity

Examiners in vivas, OSCEs, patient encounters, interview and other areas currently suffering due to subjectivity, are generally given questions - they should also be given answers and as long as the candidates answers fit in with the recognised accepted answers the candidate passes, when the answers fit in with recognised unacceptable answers the candidate fails and where the answers fit in with recognised borderline, a published formula for accepted number of borderline for a pass or fail should be defined (no, this is not the 'borderline method' that is used in standard setting).

This may beg the question whether vivas are needed at all - verbal communication is essential in all walks of life and especially so in healthcare; a candidate should be able to answer effectively and accurately under stressful verbal conditions and hence vivas are needed but the subjectivity of the vivas must be eliminated.

Subjectivity cannot be sometimes avoided but when forced to use it the answers should be 'force fit' in a pre-defined uniform manner and the candidates be assessed against that uniform force fit. The candidate does not have to know what the defined force-fit answer is but all candidates would be marked against the same answer.  

Lets look at an example: Let us assume that in a scenario where there is a certain level of oxygen desaturation which does not impact on life or limb but where a candidate has to act - say an peripheral oxygen saturation that has fallen from 98 to 89 but where the patient is otherwise very stable. The candidate has to make preparations for an adverse eventuality but there was no need to act immediately. Let us also assume that currently this is subjective and hence an assessor would mark someone and this would be variable (depending on the other skills of the candidate). Let us try a force-fit answer for this scenario - the examiner would be given a set of answers and would give the candidate a mark for each correct answer, for instance, a) the patient if conscious was asked if she was okay within two seconds 1 mark

b) the pulse oximeter probe was checked and re-applied within 4 seconds

c) capnograph reading checked within 6 seconds

d) the oxygen flow and any gas mix ups were checked within 8 seconds

d) airway tube position checked within 10 seconds

e) airway change kit and reversal drugs asked to be brought in and kept ready with 12 seconds

etc. You get the picture.

These answers may not be based on evidence because there is no evidence to base it on. However, for the purposes of the assessments the answers are defined on the basis of agreement between examiners and are used uniformly with all candidates. Then the chances of the examiner being influenced by mastery of the language, social status of an accent, the image projected by clothes, the false confidence provided by a charming smile or colour of the skin would be less.

Subjective experts are simply socially acceptable influential frauds providing a certain voyeuristic celebrity value when they are reviewing wines, films or restaurants. Techniques similar to those have no place in medical examinations. It is of course a completely different story that the British are not able to trust the training provided to their young doctors for somewhere between a minimum five years (in the case of general practice) or an approximate minimum of twelve years in the case of surgeons that makes an 'exit' exam essential to cross check knowledge (which is then pretty badly due to the subjective components). In the USA exit exams are not mandatory, they are voluntary, the Americans obviously have a great degree of confidence in their trainers, trainees and training system. The British system needs reform and a commitment to eliminate subjectivity when the stakes are high could be core to whether the UK will ever have a equitable outcome in examination results.

 

© HEMADRI

 

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This blog has argued for reducing or eliminating subjectivity from re-validation http://successinhealthcare.blogspot.co.uk/2012/11/revalidation.html

We have discussed differential results in surgical Royal College examinations http://successinhealthcare.blogspot.co.uk/2012/12/exit-exam.html

Warning: Legality could be injurious to health

This particular blog post is fictional. Any resemblances to any person living or dead or incidents current or historical are purely coincidental.

Warning: Legality could be injurious to health

It was the saddest day of his life.

Let us start from the beginning. Bill was a brilliant student at A levels, he was also a stickler for formality, rules and process. This stood him well and he was very highly thought of as a scrupulous, proper, law abiding young man. He went on to study medicine, completed junior general training and got into specialty training – all very smoothly. His specialty also involved working in the operating theatres.

Bill found within a few weeks of into his registrar job that his work never ever finished at 5 pm.  Bill being Bill, thought he will simply leave at 5 pm as long as there was no patient he was directly dealing with was acutely ill. He did that for a week. Bill then found his training was getting adversely affected. Consultant ward rounds continued after 5 pm, if he did not join in he cannot learn. Patients for elective surgery were admitted after 5 pm, if he did not see them he will not be ready for them for the next day. Theatres routinely over ran easily to 7 pm sometimes longer, if he was not there he will lose out on the training.

Bill discussed this with his consultants who looked at him as though he was an alien zombie. When he insisted on resolution they told Bill that he is free to leave at 5 pm if he wished to do so, some of them insisted that he leave at 5 pm so that he did not breach his hours. Bill’s logical argument was very simple, substantial training happened after 5 pm so to take consultants’ advice and leave at 5 pm means that he will never get the training he deserved. So Bill refused to leave on the grounds of training needs and claimed payment for extra time on the basis of actual time spent working at the hospitals. Boy, this was resisted by the management. Bill was born different, his documentation was perfect, they had no choice but to pay him. The managers gave the consultants a hard time because of this issue; the consultants did not take it lightly.

The time came to ‘assess’ and ‘report’ on Bill which were used at annual progress meetings. These used to be called RITAs before now called ARCPs. Bill’s numbers, performance, success rates, patient feedback and anything clinical were spot on average. Bill’s consultant reports were full of masked vitriol on how his attitude, behaviour, cooperation, et al were not compatible with a surgical career. This was pointed out to him and he made tremendous efforts to improve. Every time he was assessed externally he had no issues on any of the ‘soft skills’ assessments. But he would not stop claiming for staying after contracted hours. Every hospital that made him work after 5 pm paid up; the consultants from the hospital wrote badly about his approach to life.

After 6 years of completed training with same average clinical rating as his peer group, Bill was denied his completion of training certificate due to five reports that faulted his attitude. Bill cannot get into the specialist register; Bill cannot be a substantive consultant in the NHS. His colleagues with his level of performance and achievement and some with lesser performance and achievement were signed off.

All because he followed the country’s law and the NHS rules. The message his colleagues got from their seniors was that people who followed the law can be severely, career damagingly punished. The message other trainers and managers got was that they can break the rules and law with impunity and use their power to penalise the person who caught them out. Bill can go to employment tribunals and the like but when he has at least half a dozen consultants who have already written badly and a dozen managers willing to write badly – he faces a lost cause. In a world where the subjective decimates the objective - he is a lost soul.

Has he learned his lessons that legal and rule based behaviour does not win and not submitting to the whims of the powerful was harmful? We do not know yet. This sounds like a case of operation successful, patient died; only here it will be training successful, career died. Bill hit the target, its the ricochet and the debris that maimed him.

Bill is at a crossroad waiting to change careers.

Oh by the way he also happens to belong to a minority ethnic group.

I think this quote from John le Carre (in his book The Constant Gardener) will probably be very appropriate here "Nobody in this story, and no outfit or corporation, thank God, is based upon an actual person or outfit in the real world. But I can tell you this; as my journey through the pharmaceutical jungle progressed, I came to realize that, by comparison with the reality, my story was as tame as a holiday postcard."

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: The loose ends such as throwing in the ethnic minority, etc are there to be filled in, if and when I get to write this story in full

Blondes, pilots and doctors. Who should learn from whom?

Blondes, pilots and doctors – who should learn from whom?

The Malaysian Airlines plane disappearance remains a very sad mystery. Our hearts go out to the missing persons and their families/friends, it must be unbearable agony.

Now we hear in the papers that young blonde girls were entertained in the cockpit in 2011 by one of the pilots of missing plane. http://www.dailymail.co.uk/news/article-2578146/Young-blonde-says-missing-Malaysia-Airlines-pilot-invited-friend-ride-cockpit-entire-flight-2011.html

I am not taking any moral stand here, pilots or anyone are welcome to entertain blonde girls or any other type of women or men anywhere. My problem arises when these pilots put passenger safety at risk by such acts.

I heard this news on the morning of 12 March 2014 on my way to the CHFG conference in Birmingham. I would have normally laughed out loud, then stay angered for a while and then move on. But there was something else bothering in my mind. Then at the conference, as in any healthcare conference these days, I heard a number of people repeating what has now become a cliché that healthcare should learn from pilots and airlines. What was bothering me then surfaced to provoke me into writing this blog.

If you thought for a minute that this cockpit privilege is dished out only in Malaysia or in some other distant country, you are probably mistaken and it may be time to change your mind.

A few weeks ago a colleague who is a senior doctor with additional responsibilities in the UK told me about travelling in the cockpit of a major airline on a scheduled short haul international flight in Europe. It was obviously very thrilling for the colleague but as a safety enthusiast it was disturbing me. As a senior doctor it might have been appropriate to decline the offer on the grounds of ensuring safety; that is another debate. If that colleague lied to show off etc that is a personal probity issue.

Then the colleague said that this privilege was also offered to another family member a couple of months earlier, who took a flight in the same sector for stag or a hen night. This is even more unsettling since it seems such behaviour by pilots are not one off or localised but probably frequent and international. Update: Since this blog was originally published about 48 hours ago, I have had a very senior doctor now retired telling me that he sat in the cockpit while flying over the Alps on the way to Italy. Goes to show that it is not only localised and frequent, it is also chronic poor behaviour by pilots.

I think the constant bu*****t about healthcare learning from pilots has to stop. This blog has argued for healthcare to learn from all sorts of good sources. I have previously written about animal air transport. I have written on the pilot error rates not falling since 1950s and the very large variation seen in the 'ultra-safe' airline industry. I still believe that healthcare needs to learn from everyone including airlines. But it should not be one-way traffic. Perhaps pilots can learn from doctors who will not pick out anyone from a waiting room on the basis of hair colour or allow 'friends' to join them in operating theatres as a thrill of the day.

We should not also make the error of mistakenly attributing the improvements allowed by technology as advances in human behaviours and interactions.

©M HEMADRI 

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Scheduled airlines are safe – just like out patient clinics

http://successinhealthcare.blogspot.co.uk/2012/09/scheduled-airlines-are-safe-just-like.html

Healthcare is not similar to aviation but lessons can be learned http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html

Kahneman, Colonoscopy and Goole

The Goole way of improving patient experience of colonoscopy

Colonoscopy and pain

All of us are well aware that despite our collective immense experience, colonoscopy can be a painful procedure for our patients. That is the reason we use analgesics. At this time influencing the experience happens by the sedation (midazolam) we give (influencing the perception, awareness and causing possible amnesia for the duration). Of course, the patient always has a better experience if our technique is good (minimum inflation, not going into loops, undoing loops early, change of position, abdominal pressure, lower total duration of procedure etc). Nevertheless patients can experience pain.

The pain obviously causes immense distress to patients, it also causes complaints. More relevantly pain may cause the patient to decline colonoscopy in the future. For some patients due to the nature of their disease repeat colonoscopy becomes essential and pain or unpleasant experiences puts these patients into distress even at the thought of considering colonoscopy. Patients may also colour the expectations of their family and friends regarding colonoscopy.

Kahneman and clinical psychology

The 2002 Nobel prize winner Daniel Kahneman has done important work on patient experience and its relation to the patients' willingness/readiness for further colonoscopy in the future if required. My understanding of what Kahneman says is that the total duration of the procedure, the highest rating of pain during the procedure or the duration of high levels of pain matters much less than the degree of the pain experienced at or towards the end of the procedure. For instance this means a patient with a 10 minute colonoscopy who was relatively comfortable for 9 minutes but had significant pain the in the 10th minute reports a worse experience than a patient who had a 20 minute colonoscopy with relatively severe pain for the first 17 minutes and no pain in the last 3 minutes. In fact in Kahneman's experiments they deliberately kept the colonoscope in place for extra 2 or 3 minutes so that the patient can have a pain free ending.

The lessons to us are of course self-explanatory - irrespective of the duration of the procedure or the degree of pain we should not take out the scope quickly and allow a pain/discomfort free period before the end of the procedure.

Kahneman explains this as the difference between experience and memory - with the message being what happens in the end is remembered more as the memory (rather than the totality of the duration of the experience even if that was painful/unpleasant).

The Goole Translation

We wanted to translate this into an even more tangible improvement of patient experience than just a slow withdrawal.  We wanted to go forward from the described lack of negative experience to the establishment of a positive experience. If Nobel Laureate Kahneman says the end of procedure experience is counted as memory we wanted to try to deliberately aim for and deliver a positive memorable experience.

At colonoscopy one of the main roles of the nurse who supports the patient is the reassurance role. Till the scope reaches the caecum the nurse has a reassurance role (‘you are doing fine’, ‘its nearly done’, ‘take nice and easy deep breaths’, ‘pass some wind out & you might feel better’ etc) - this is the normal role for the nurse in any endoscopy unit anyway and we do it as well. Once the scope reaches the caecum and completes the examination of caecum/terminal ileum, this reassurance role generally diminishes as the patient feels less pain, less anxiety etc. At this point I declare to the patient and the staff 'we have reached the end we should be getting out soon'. In Goole that statement would be the cue for the nurse to reduce the reassurance role and deliberately start a conversation with a high quotient of humour with the patient. The explicit aim is to try and make the patient laugh.

There seems no obvious downside or specific risks noticed yet. Important to remember that it is the nurse who supports the patient who engages in humour. The endoscopist and the nurse who supports the endoscopist remain extremely focussed and serious on completing the procedure safely.

We find that the patients end up in a really good mood when we are able to make them laugh. The trick is for the nurse-patient conversation to elicit a laugh. On the contrary, nurse-nurse or nurse(s)-endoscopist or even endoscopist-patient conversation eliciting the laugh from the patient is in my view is not as effective. The nurse-patient conversation resulting in a laugh is the crucial element; anyone else laughing may not be liked by some patients especially as the patient could be at the end of an unpleasant procedure.

In my conversations with people in the know, I learn that on the way to the caecum when the patient is experiencing distress/pain it could be okay to distract by attempting a social conversation but not with the intention of humour as that could end up as 'the memory' ('they joked while I was in pain'); the intention to humour is only after reaching the end point while making a slow withdrawal provided the patient does not have pain on withdrawal (if there was pain on withdrawal, then the reassurance role becomes important again)

It seems like common sense. Apart from a potentially great patient experience we find that the atmosphere in the procedure room becomes very enjoyable. It develops a good relationship between staff members. We have only just started doing this. I write my initial impressions and not any definite long term observations. This is not based on research, it is a simple description of what we do and what we feel about what we do on the matter of influencing patient's memory of colonoscopy.  I just wanted to share this simple and in my view, elegant humour based intervention to improve patient experience. You may want to try it with your patients, get your nurses to do this. Not every nurse will agree or be willing to go with this. That is okay, best to work with the willing.

Kahneman has proven the science - I have just added humour to it.

©M HEMADRI

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