I have just finished reading the astonishing book by Daniel Kahneman ‘Thinking, Fast and Slow’ – it is a book that takes you on a journey of thirty years of discovery in psychological science. Once you read it you will never ‘think’ about yourself the same way again. The central tenet of the book is particularly salient to the conversation in the health service about mortality and the statistics relating to it following the recent publication of the findings of the second Francis report.

Judgements, Biases and Heuristics

Kahneman describes three dichotomous concepts – Firstly two types of thinking ‘System 1’ (Fast, intuitive, associative, innate and effortless) and ‘System 2’ (Slow, analytical, calculating, learning and effortful); Secondly two types of people ‘Econs’ (rational, consistent, logical, ideal economic agents that always make the ‘right’ choice) and ‘Humans’ (reasonable but subject to biases of their thinking such as priming, framing, narrative fallacy, imabalanced attitudes towards risk of loss and gain, excessive weighting to ‘available’ evidence, relatively blind to statistics and the ‘external’ view); Thirdly two ‘Selves’ the experiencing self (the person reading this blog here and now) and the remembered self (the person your mind has created through the narrative stitching of remembered events and experiences). For more details – go and read the book…

What is particularly interesting about his research is that he has demonstrated unequivocally time and again that being an ‘expert’ in any field, be it healthcare, economics or even psychology itself, does not protect you from these innate biases of human thinking – even when you know they exist they still influence you, and in fact being an expert simply puts you in a position where these biases are more consequential (your biases harm other people as well as yourself). He does, however, describe a number of strategies that organisations can adopt that defend against the consequences of individual judgment bias, strategies that need to be adopted systematically and deliberately. He gives examples of spectacular corporate failure, through group think, where these strategies had not been adopted.

The Statistics of Death

Why is this all relevant to us following the Mid-Staffs crisis, Francis report and the renewed scrutiny of hospitals with ‘outlying’ mortality figures? In the pantheon of spectacular corporate failure the events in 2007 at the Mid-Staffordshire NHS Foundation Trust must rank prettily highly, and of course the principle theme of the second Francis report is that this was an NHS corporate failure, not just a hospital failure. One of the central themes of the crisis centres on the role, meaning and response to mortality statistics for the hospital at the time. It is worth, therefore, taking a little time to understand how mortality statistics are generated.

At the time there was a single statistical measure routinely used to compare mortality in hospitals across the NHS – Hospital Standardised Mortality Ratio (HSMR). HSMR is calculated by taking the observed death rate and dividing it by a calculated figure for an ‘expected’ death rate. The expected death rate is essentially the death rate in hospitals for the whole of the UK with a number of adjustments made in order to compensate for differences in case mix (the diagnoses patients are admitted with), age, co-morbidity and social deprivation. The ratio is multiplied by 100, so if your observed death rate is the same as the expected then the ratio is 1.0 and the HSMR would be 100. When observing mortality in a population it is important to recognise that over time mortality will always increase (we all have to die eventually) – therefore when comparing mortality in different populations we have to know over what time period mortality has been counted (usually 30 days, 90 days, 1 year or 5 years). One of the weaknesses of HSMR is that it does not specify the time period – it is simply the time spent in hospital – therefore a hospital with a longer than average length of stay will tend to have a higher mortality. Another weakness of HSMR is that it does not have a diagnostic category code for palliative care. The provision of out of hospital end of life services across the UK is at best patchy, where provision is poor patients are admitted to hospital to die, HSMR does not adjust for these expected deaths and so hospitals in this situation will have a higher than ‘expected’ HSMR. As a result of these statistical biases, HSMR is being replaced by a newer indicator – Standardised Hospital Mortality Indicator (SHMI). SHMI is very similar to HSMR but differs in two important aspects. Firstly it expands the number of diagnostic codes against which case mix adjustment takes place from 56 to 140, including one for palliative care. Secondly it fixes the number of days over which mortality is measured to 30 days after discharge.

The other important thing to recognise about mortality statistics – is that they are just that; statistics. As such reliability depends on sample size and confidence intervals. As a rule of thumb a condition with an expected mortality rate of 10% needs a sample size of about 200 cases before the confidence interval falls to a point where a doubling (or halving) of the observed rate can be explained by anything more than random chance. This is best illustrated graphically by the ‘funnel plot’ an example of which is below – and explained simply in this article here.


Two Stories About Mortality

Hospital A is a medium size district general hospital in a provincial town of the midlands. It is more than 30 miles from the nearest city and serves a relatively fixed population, bounded by open countryside, which is below the threshold for sustaining a comprehensive range of hospital services. It has recently successfully achieved foundation trust status by importing a new board that have railroaded a controversial savings program through that has helped make the long term finances appear sustainable. Many staff have been made redundant and staffing ratios on the wards have been reduced. Morale is low and sickness rates are high, the wards are busy with large numbers of elderly dependent patients. The hospital has always struggled with attracting high quality medical staff because of its geographical location, tenuous affiliation with a university hospital, low numbers of doctors in training and an unexciting specialty portfolio. There have been a number of recent complaints from relatives unhappy about basic standards of care on the wards – two of these have been reported in the local newspaper, with the suggestion that neglect of care was a contributing factor in the deaths of patients. The HSMR for this hospital is 127, the second highest in the country.

Hospital B is a large university trust in a major city in England. It has a number of highly specialised tertiary services for which it has a national and international profile. One of these is complex paediatric congenital heart surgery, for which it is one of only a dozen centres in the country. The unit is celebrated locally and has a loyal following of patients and their parents who have received treatment there. The surgeons often having taken on cases others have refused and in doing so averting what would have otherwise been certain death. The unit has been threatened with closure as a result of a national consultation on re-configuration of paediatric cardiac surgery – aiming to concentrate services from eleven to seven centres. The local newspaper is outraged and has rallied support from local and national celebrities and politicians to keep the unit open. The staff are highly motivated and capable and the surgeons have published acclaimed original research in international journals. The standardised mortality ratio for paediatric heart surgery at the hospital is 200, the second highest in the country.

Beside ourselves jumping to conclusions

Death is a powerful word – just reading it on the page is likely to result in both a physiological response (increased heart rate, blood pressure and dilated pupils) and an emotional one (fear, disgust and aversion). These responses are usually rapidly attenuated by the rational part of the brain (system 2), however the alertness brought on by the physiological and emotional response will have activated system 1 – your innate, intuitive, fast thinking brain will be in overdrive (primed to deal with the ‘threat’) as will all of its biases.

So what are you thinking about the two (completely fictional) hospitals above? At whom is your outrage directed in each of the stories? Would you allow your grandmother to have her fractured hip treated at hospital A? Would you recommend a friend have their child with VSD be operated on at hospital B? Are you angry with the hospital or the system that is trying to close it down?

Before you answer those questions it is worth taking some time to reflect on how your thinking may be being manipulated:

  • First of all – Priming – the stories I have written have a ring of familiarity to them, you have made an association with a previous experience for which you know the outcome, however hard you try to avoid it, this will be influencing your thinking in both situations.
  • Secondly – Framing – I have (rather clumsily from a literary perspective) set the scene in both stories in a way that influences your thinking, I have told you what some other people think about those hospitals and I have given you some limited facts that probably make you like or dislike each of them.
  • Thirdly – Narrative Fallacy – I have told a compelling story that ‘explains’ the numbers. We all like stories and are primed to discern patterns in randomness – there is a multi-billion pound industry built on this tendency, its called professional sport and is hilariously exposed on a regular basis by Daniel Finkelstein
  • Fourthly – Availability Bias – this is also variously known as positive reporting bias and / or economy with the truth. It is ruthlessly exploited by the pharmaceutical industry through the suppression of non-supportive evidence for the efficacy of drugs. They are by no means the only culprits though, most published academic research is subject to this bias as well. Even though you ‘know’ I haven’t told the whole story in both cases and can easily entertain the idea that there may be other facts, unreported, that could change your view of the situation – your view is firmly anchored by what I have told you so far and new evidence can only move you from this position.
  • Finally – Statistical Blindness – the fact is that whilst system 1 thinking is life saving, allowing you to act quickly, decisively and intuitively in almost all everyday situations – and many non-everyday situations – it is designed to jump to conclusions, to abide by rules of thumb, accept evidence, particularly statistical evidence, at face value. As much psychological weight is given to a statistic based on a handful of cases as many thousands even when there is no mathematical justification for doing so.
  • This last point is particularly pertinent to my two stories, because they both have one thing in common – they are both ‘small’ – one is a small district general hospital, the other is a small highly specialised unit. Their outlier status is almost certainly more to do with their smallness than their quality of care, although this should not be ruled out of hand either.

    A Prejudice Fuelled by a Bias

    Buried within the shrill, insistent and pervasive criticism of the Mid-Staffordshire Hospital Trust is a deeply held prejudice amongst leaders and policy makers within the health service; big is good small is bad. This prejudice is affirmed and re-affirmed on a regular basis by the apparent evidence of poor performance and outcomes – the smaller you are the more likely you are to find yourself at the top or bottom of a league table. The fact that this phenomenon is a mathematical inevitability is either not recognised or overlooked because it suits ‘the system’, it provides supporting ‘evidence’ that not only are small services expensive they offer poor value as well.

    Big of course is not inevitably good either – one of the advantages of being a large institution is that you experience the converse of the ‘small outlier’ phenomenon in your outcome statistics, you are generally a ‘large average’ institution, you routinely find yourself (reassuringly) ‘in the pack’. Reassured you shouldn’t be though – hiding in every large institution’s aggregated outcome statistics will be some great performance and some dreadful. Some of the shrillness of the commentary will be disguising the fear that every leader holds – that within their own institutions are lurking little bits of Mid-Staffs.

    The mortality figures at Mid-Staffs were probably the least surprising and least relevant part of the story. A great deal did go wrong at the hospital – particularly at board level where there is much evidence that it was the victim of ‘group think’ – almost all of the pre-requisites and risks were present and it would appear none of the defences. A topic I think I will come back to in a future blog.

    Outcome Statistics – A Health Warning

    As an intensivist I have lived and breathed outcome statistics (I’ve even written a book chapter on that subject as well). They are incredibly useful tools, but they take time to become useful, it took the intensive care community a good decade to start to understand the meaning and utility of the statistics produced by ICNARC. What is absolutely certain is that they can never tell the whole story, and in fact when constructing a story about the quality and safety of a service they should simply act as pointers for further and deeper investigation. There are many nuances even to the apparently binomial outcome of mortality that have to be unpicked and understood before coming to any meaningful conclusion. I thoroughly welcome the fact that mortality as an outcome has found the spotlight – it used to frustrate me immensely as a clinical director that I was held to account more for my financial balance than the number of deaths on my unit. But in finding the spotlight it has been picked up, sensationalised and put to political use – not just by the press but by people within the health service that should know better.

    The conversation about mortality in hospitals needs to be held in an intelligent, un-frenzied, non-political and unprejudiced environment – we risk doing immense harm to fragile services if we don’t.

    When thinking about mortality it is vital that we think slow.

    As a medical director I am routinely required to assess, grade and act on the results of serious adverse events that have occurred in hospital. Often these events have resulted from failures of care through lapses, oversights, errors or neglect. This is often accompanied by a clarion call for some form of disciplinary action and or restitution – usually most insistently from within the organisation rather than by those directly affected, either carers or the patients themselves.

    Bad things happen in hospital all the time. Healthcare is the only industry where for a significant minority of users the outcome is death or injury, either expected or unexpected. The overwhelming priority in this situation for both the recipients and providers of the care is learning: learning the truth of events, learning if it was avoidable, learning how it might be avoided in the future, and sharing that learning so it might be avoided elsewhere.

    Prerequisites for Organisational Learning

    We have, as human beings, an innate gift for learning – it is built into our DNA and, whilst most active in our early years of life, never really leaves us. Individual learning is the most powerful lever of change in human societies, because people love to learn and change as a result. Teams and organisations are made up of people and yet team and organisational learning does not happen by chance as it does for individuals – team learning is an unnatural and deliberate act.

    There are three prerequisites needed within organisations in order to promote learning from error and system failure. It is strangely rare to find them all reliably present in healthcare organisations.

  • A Learning Environment
  • A Team Based Learning Infrastructure
  • A Compelling Vision Delivered Through Leadership
  • I will expand on these three prerequisites, but first I want to explore why they are found rarely in our hospitals and healthcare organisations.

    Two Key Barriers to Organisational Learning in Hospitals

    Hospitals are busy places, this is a universal truth – not unique to the NHS. The work processes of nurses and doctors in hospitals rarely run smoothly – they are by their nature characterised by frequent interruptions, unexpected deviations and minor crises. In order to get the job done a large part of the work involves having to create on-the-hoof workarounds and solutions to problems – giving rise to the familiar sense of almost continuous ‘fire fighting’.
    We are actually incredibly successful at doing this, much of our individual innate learning capacity is consumed developing coping strategies for the chaotic environment we find ourselves in. The problem with this ‘first order problem solving’ for ‘low level failure’ is that the learning it generates is of value only to the individual nurse or doctor – they are simply adapting to the flawed environment they find themselves in – just to get the job done. In doing so they are condemning themselves and and their successors to having to learn the same lessons in perpetuity – this grinds you down and drives talent away from ‘the front line’. How do we break the cycle of low level failure that requires constant first order problem solving making every day work flow inefficient and time consuming? The first step is to recognise the problem and then acknowledge that low level failure, whilst common place, is neither inevitable nor acceptable. The next step is to then deliberately and collectively make the time to move first order problem solving into second order problem solving (of which more later).

    The second key barrier to organisational learning in hospitals is a deeper, more cultural one. This is to do with interpersonal attitudes and responses to error. The shameful truth is that the overwhelmingly pervasive culture is a blaming one that inhibits speaking up with questions, concerns and challenges that might otherwise have caught and corrected human error. Moreover there is a culture in medicine that does not encourage admissions of error. Both ourselves and others have high expectations of success in medicine – when we don’t meet those expectations we are as blaming of ourselves as we might expect others to be. What is interesting is that the direction of blame isn’t just top down – in fact top down blame only really materialises when the failures mount up to catastrophic levels. The vast majority of, and undoubtedly more corrosive, blame is that of our colleagues and peers. What is clear is that whilst blame remains the primary response to failure opportunities for learning will be lost and the quality of the lessons learnt will be poor. Overcoming this barrier is a true challenge of leadership at all levels of an organisation as it requires a change in culture – a clear and sustained statement and restatement of values, unwavering adherence to behaviours that follow from those values, even in the face of challenges from within and without the organisation.

    Leading Learning for Patient Safety

    So where should we start with creating a learning culture in our organisations? The answer has to be with leadership, because without leadership on this issue nothing else can follow. The type of leadership and skills required to lead learning, however, are not what are typically viewed as traditional leadership skills. The leadership model for leading learning differs from the traditional leadership model in several important ways:

  • Whilst a ‘burning platform’ undoubtedly exists, the future state can only be guessed at (in an educated way)
  • This makes it hard to articulate
  • The flaws in the current state are hard to spot – there is a deep seated culture of acceptance of low level failure
  • The way forward is not a clear plan with deadlines and critical paths but a process of experimentation, a gradual reduction of uncertainty and regular revision of interim goals and ultimate vision
  • The leadership task is primarily one of engagement and reduction of fear not a promotion of employee effort
  • The task will never be finished
  • If you have read my previous blogs you might guess that I believe these ‘New Model Leaders’ need to come from the rank and file of doctors, nurses and other healthcare professionals that don’t often put themselves forward for such a role.

    Second Order Problem Solving and A Team Based Learning Infrastructure

    Second order problem solving is about creating long term fixes for recurrent problems, it is about analysing root causes and putting in place solutions with ‘traction’, it is often about changing behaviours in ourselves that have consequences for others. There are several reasons why we don’t stop and take the time and effort required to convert first order to second order problem solving. First of all – it does take both time and effort – neither of which we have much left of after a day / week / month / years of fire fighting. Secondly the problems we need to solve are quite often not even perceived as problems, we have been compensating for so long it has just become part of the job – this is where our new model leader has to be insightful. Thirdly second order problem solving requires some quite specific skills such as root cause analysis, process mapping, and change modelling that are not commonly found in healthcare teams. Fourthly – we are quite proud of our first order problem solving, being a coper and thriver in a stressful front line job is associated with significant kudos, particularly in the hospital environment. Finally it does require us to meet as teams for a significant time on a regular basis – which we are astonishingly bad at doing – and when we do for those team meetings to be led in a way that promotes speaking up, learning from others, admissions of failure and a willingness to innovate (and therefore risk failure). This final requirement leads on to the the final pre-requisite for organisational learning – an environment of psychological safety – A Learning Environment

    Blame Free Culture Vs Accountability – A Balance that Creates ‘Psychological Safety’

    Our new model leaders have their work cut out – not only do they have to create time (in an already overloaded time table) to bring together teams (who are singularly reluctant to gather) to discuss both low level and high level failure (failures that may not even be recognised as such) and defend these notions against pressures to use the time ‘more productively’; but also resist the temptation and pressures from above, inside and out to apportion blame for every failure that comes to light. The prize is great if they achieve it – a learning environment in an organisation that continually improves both itself and the people that move through it, one that delivers both on the economic and quality front. A true value adding organisation.

    But – it can’t all be so idyllic surely? People do also make mistakes borne out of stupidity, brazen over confidence, ignorance, stubbornness, laziness, jealousy and – yes – even malice. There is a level of human behaviour for which we all need to be held account. There is also a performance imperative, we all have to be helped to raise our game. Where is the place for accountability in a blame free culture? The diagram below will perhaps help you decide…

    This is the essential difference between ‘blame free’ and ‘psychologically safe’ for the latter comes not just from creating an environment where people feel able to speak up and admit failure but also feel assured that when boundaries are truly crossed that individuals will be held to account. This is the real test of leadership – knowing and communicating expectations and boundaries as well.

    Blameworthy Acts – the Boundaries of a Blame Free Culture

    Where do you draw the boundaries? There are no text books, there are no rules – there is intuition and there are inspirational leaders we can follow. Here is my starter for ten of blameworthy acts:

  • Reckless behaviour
  • Disruptive behaviour
  • Working significantly outside your capability
  • Disrespectful behaviour
  • Knowingly violating standards
  • Failure to learn over time
  • Failure to work as a team
  • Covering up
  • No doubt there are more. Clear boundaries around a learning zone create an environment in which organisations can thrive and patients can feel and be safe.

    I have to acknowledge the source of the ideas for this article. Amy C Edmonson – a truly inspirational teacher at HBS who not only articulates this message with conviction but backs it up with the irrefutable results of research both in healthcare and other settings.

    There is a solution to all the problems in healthcare – it is a simple one, it has a successful track record in many high risk industries and it is one that is acceptable to all stakeholders in the health transaction – Professionals, Patients, Payers, Politicians and Managers. It also saves money – lots of it…

    The solution has been called different things in different industries, it has been adopted in various styles at different points in history by these different industries – but is essentially the same thing. Health is probably the last high risk industry to adopt this solution and is doing so rather slowly, grudgingly if at all – for one simple reason: The harm that healthcare causes does not affect either the payers or the providers of the service.

    The airline industry was an early adopter – because it discovered pretty quickly that not adopting it would be fatal to themselves and their customers. There was also pretty effective self selection of non-adopters as heroic, buccaneering individuals and organisations literally crashed and burned. The oil and gas industry followed somewhat later when they discovered that adopting it made them money – lots and lots of it – with safety being a welcome side effect.

    The solution has created a world where it is safer to fly than it is to drive to the airport. Where more people are killed by petrol in their own garages than in the entire global petrochemical processing industry. Where we enjoy astonishing improvements in quality, safety and utility of the products we consume at either the same or diminishing cost (think of the mobile phone you use now compared to ten years ago).

    The solution is a culture, a state of mind and a way of doing things – it is a committed, system wide and systematic approach to reliability.

    The commonest argument used against the proposal to adopt a reliable approach to delivering healthcare goes along the lines of – ‘Patients are not widgets’; ‘Jumbo jets are more reliable than patients’; ‘There is so much uncertainty in medicine’; ‘This constrains my freedom of practice’ etc. Blaming patients for unreliable healthcare is, however, a highly disingenuous argument. Patients are unreliable, they do present us with enormous problems of variance and deviance from the expected, medicine is difficult – but that is their nature, that is their right. Putting them into an unreliable healthcare system produces variance on variance – which, I have said before, is the definition of chaos. Unreliable healthcare results in unsafe medicine, uncertain and poor outcomes, errors that are destined to be repeated (like history) all of which, not withstanding the human misery, costs. It has been estimated that nearly half of all health care costs are related to failures in the delivery of care.

    What is Reliable Healthcare Delivery?

    The trite (and not very helpful) answer to this question is the familiar ‘Doing the right thing and doing things right’. This particular definition ignores the rather large zone of uncertainty that exists between what we know is the right thing and what we know is the wrong thing. If we were to pause and reflect on the state of medical knowledge and draw a diagram representing each of these three zones – what we know is right (white), what we know is wrong (black), where there is room for argument (grey) – how big would we draw each of the zones? What strategies would a reliable healthcare delivery system adopt in the three different knowledge zones?


    The White Zone – Doing the right thing the right way

    The truth of the matter is we have a huge amount of medical knowledge – there are very many areas of medicine where we know what the right thing to do is and how best to do it. The medical knowledge base is vast and increasing exponentially (see graph below) and there are swathes of medicine where the important unanswered question is not ‘What is the right thing to do?’ but ‘Why (IGN) are we not doing it?’. One of the main barriers to deploying medical knowledge appears to be the shear volume of new information – over 1 million original medical papers were published in 2010 alone. However we have allies to help us – there are expert groups, royal colleges, specialist societies, NICE, Map of Medicine, Bandolier, national and international consensus bodies who are systematically collecting, sifting and grading the evidence for us and telling us what we should do.


    Yet as McGlynn et al. discovered we still don’t do it nearly 50% of the time (see table below). Why? There are healthcare organisations that do take a systematic approach to doing the right thing – Intermountain Health in Utah USA is one of the most outstanding high performing healthcare organisations in the world. Their outcomes for most common medical and surgical diagnoses are way above their peers – their mortality from sepsis is 9.3% compared to a US average of 25% – 40%. They are one of the few organisations in the US that makes a return on Medicare and Medicaid reimbursements. They invented the care process model – of which more later.


    There will be doctors reading this (most of them) that are convinced that they are practicing to the highest and most up to date standards, and able account for that standard of care they provide. Yet the outcome from their institutions will come nowhere near those of Intermountain. Whilst they may account for their own practice they will undoubtedly be a little more taciturn on their colleague’s practice, and perhaps a little more vocal about what they perceive the standard of care provided to patients before they arrived in their care and maybe after they left as well. And there is the rub – for to deliver outstanding outcomes we have to do the right thing every step of the way on the patient’s journey – for every patient.

    A good outcome is the aggregated marginal gains of multiple inputs by many professionals. Reliable healthcare is a team sport and as Atul Gawande put it in his tour-de-force ‘The Checklist Manifesto’ we are still practicing the medicine of the heroic individual – we are only just emerging from the buccaneering age of medicine, equivalent in the airline industry of when aircraft routinely fell out of the sky. Unlike buccaneering pilots though doctors don’t die with their mistakes.

    The problem with doing the right thing is that it is rather mundane. It involves being told what to do, it involves following checklists, care bundles, protocols and pathways. It also involves agreeing with your team ‘how we are going to do things here’; that inevitably involves negotiation and compromise, going along with the consensus because doing so is for the greater good. Heroic doctors are not very good at doing those sorts of things. It also takes a lot of collaborative effort to get there.

    There is still plenty of scope for the heroic doctor though. To paraphrase Atul Gawande again ‘Checklists are there to get the 80% of mundane stuff right so that the mind is freed to do the heroic 20%’. It is vital to get the 80% right – otherwise our heroics become expensive futilities.

    The Black Zone – when it goes wrong

    Understanding and managing medical error is a huge topic in of itself – which I will undoubtedly expand in future posts. I am though in a hurry (for a change) to move on to the bit I am interested today which is the grey zone. Suffice to say for now that you cannot be a highly reliable healthcare organisation if you do not manage medical error well.

    The Grey Zone – Learning from uncertainty

    This is where it starts getting very interesting. In our daily practice as doctors our patients constantly present us with dilemmas. Situations where doing the right thing seems to be the wrong thing, or where doing the right thing for one problem is definitely the wrong thing for another. As our patients get older and compound multiple pathologies these dilemmas increase all the time. Each time we are presented with these situations it feels as though we are solving the problem for the first time over and again for each patient – we are faced with the huge and overwhelming variance in presentation and response to treatment.

    The traditional medical model for dealing with these situations is the ‘iterative care process’ underpinned by the ‘experienced clinician’. This care process involves a combination of medical detective work (history and examination), Diagnostic hypothesis (differential diagnosis), Diagnostic tests or a ‘Diagnostic Therapeutic Trial’ (we’ll give antibiotics and see if they get better…). Experience helps by being able to ask the right questions, come up with a feasible and manageable list of diagnostic hypotheses and also design a diagnostic prescription that does the minimum to confirm or refute the hypothesis. Patients will often go through several cycles of this process (either because it doesn’t solve the problem or because the patient has moved to a different team) – with escalating intensity and invasiveness of investigation – until either a diagnosis is made and correct treatment started or the progress of the condition outpaces the process and the patient succumbs (or they get better despite us).

    There are several reasons why this model is problematic and fails to deliver reliable care. The first is that the operating model of the modern hospital (the process by which patients move through the organisation) is not aligned to the iterative care process. The second is we are not very good at it any more – we don’t have enough experienced clinicians to see and review patients progress through the care process in a timely or frequent enough way. Thirdly it is slow, expensive and unreliable. Finally it does not deliver learning at anything other than an individual level – hence the very real sense in which we feel we are re-solving the same problems day-in day-out without seeming to make much progress.

    The complexity of modern medicine and modern patients, the dissolution of traditional medical teams and their replacement by the transitory, multi-professional, socially complex, modern alternatives – means we need a new model for delivering care.

    This medical model needs to achieve several things:
    1) Reliable delivery of care that we know is right that does not depend on the location of the patient, or the presence or absence of a particular professional.
    2) Keep up-to-date with the ever expanding body of medical knowledge
    3) Generate ‘Team Learning’ from variance in presentation and response
    4) Generate ‘Team Learning’ from medical errors
    5) Use that learning to modify and adapt the care process

    The ‘Care Process Model’ invented by Intermountain achieves all of these things. On first glance it appears to be a set of protocols – and many subsequent implementations have deployed it as such. However seeing it as such is missing the point – the content of the protocol is much less important than the process by which it comes about and the way that it is used.

    The diagram below shows the essence of the care process model development and more to the point continuous improvement through organisational learning.


    The essential components are:
    1) An expert team that crystallise the current state of medical knowledge into detailed guidance
    2) Clinical senate that simplify and standardise to a deployable protocol across the whole system
    3) An operating system that reliably delivers elements of the CPM at all points of the pathway – the protocol is the record
    4) A reporting and monitoring system of deviance from the pathway – an expected deviance of 20% is built in – but all deviance is reported and analysed including medical error
    5) Outcomes are monitored
    6) Information is fed back to the clinical senate that adjust the CPM

    You will see that this generates organisational learning – the system gets smarter – and that it does so using three distinct knowledge types – The global medical knowledge base generated by original research, knowledge of its own patient group through analysis of unexpected response and outcome, knowledge of itself through analysis of medical error and non-compliance.

    In my next post I will discuss the pre-requisites in culture, structure and process that are required to create organisational learning and how rare they are in the NHS.

    The sea reflected the almost unblemished sky with a dark, angry meridian blue. Only the slate-grey streak above the horizon belied the otherwise benevolent August day. The rocky outcrops, punctuated by deep black caves and lightly rusted with seaweed and lichen, glistened like tarnished silver in the midday sun. The mineral white surf thrashed with frenzied futility against the oblique buttresses of rock, throwing up foamy spray that blew about like a midsummer blizzard. Occasionally it would drift up over the cliff edge to the vivid green fields capping the headland, dotted with sheep chewing with bucolic nonchalance, oblivious to the seething battle only feet beneath them.

    The Atlantic rollers were splendid, coming with just the right periodic regularity, energised by the residuum of a distant hurricane reverberating it’s destructive existence from across the ocean three days before. Standing with my surfboard each wave announced it’s arrival at first with a powerful sucking force, dragging sand, seaweed and debris painfully around my legs. It would then rear up, a sandy turquoise colour latticed with submerged foam, darkening suddenly as it tipped into a breaking roller. If I timed it right it would pick me up and accelerate me forwards dangerously, exhilaratingly, thrilling in a way no cosseted roller coaster ride could possibly ever achieve.

    They just kept coming and I couldn’t drag myself away – addicted to the reliable adrenaline rush with each wave I caught. I must have not stopped to look around for some time because all of a sudden the sun winked out, engulfed by the dark grey blanket that had scudded in from the horizon. The mood of the waves turned from playful energy to menacing power and my anticipation became tainted with anxiety.

    I staggered with the drag as the water level dropped from mid chest to below my knees. This wave really towered, it was clouded with the churned sand in it’s turbulent core and seemed to suspend itself above me whilst I decided whether to dive through or try and catch it. Of course it was playing with me, laughing at me, as I decided a fraction of a second too late to try and catch it. I felt the weight of the water first – it crushed the air out of my lungs – before picking me up and turning me over feet first, tearing the surfboard from under me and snapping the wrist tie. I was submerged and tumbling, the force of the water pushing me face first into the gritty sand, before changing direction and picking me up again. I couldn’t breath and sandy salt water was forced into my nose and throat. It kept me under, shaking with contempt my rag doll attempts at swimming, long enough for the panic of imminent drowning to start rising from my solar plexus. Just as I began to think I couldn’t get out of this it dragged me front first into the shallow shore, sand filling the front of my wetsuit. The water hissed as it retreated away from me over the rippled sand, as if to dare me to try this again.

    I limped up the beach with my broken surfboard flapping forlornly, bruised, grazed and my head spinning slightly. I lowered myself on to the picnic blanket to a welcoming sweet biscuit and strong coffee as the light summer drizzle began to fall.
    “How is the surfing today darling?”
    “Brilliant – absolutely brilliant…”


    In a book chapter I wrote on the subject of information management in critical care, I concluded that one of the most important challenges for this generation of doctors is the transfer of clinical information management from paper to electronic systems. So far we have failed that challenge, the vast majority of clinical information is still being recorded and managed (rather poorly) on paper. Those parts that are managed electronically are, in general, still cumbersome, bespoke systems that serve functions other than the delivery of clinical care far better than the needs of doctors, nurses or even patients. As a result a lot of these systems are at best grudgingly tolerated, often despised and sometimes even avoided altogether. The majority of doctors, with the exception of the minority enthusiasts, have withdrawn from the conversation on development of information management systems (or even been left out altogether) because it has been seen as a technological challenge rather than a clinical one. This is wrong and has to change because the way we manage clinical information is a crucial enabler for radical change in health care delivery. If doctors fail in this challenge we will find ourselves marginalised and obsolete in an ‘innovatively disrupted’ health economy.

    Early Adopters

    There is, of course, some history here which partly explains our current situation. Electronic clinical information systems have been in existence for over twenty years. The early years of the development of these systems was dominated by the technological challenges. The sheer volume and complexity of information that is collected in the course of delivering clinical care was a challenge when the cost of electronic storage was high and networking infrastructure not well developed. Taming the complexity of the information – codifying it and structuring it so that it could ‘fit’ in a conventional database – was not only difficult but also met with resistance of professionals as it constrained practice and the PC / workstation became a barrier between doctor and patient. Despite these challenges there are examples of hospitals and hospital systems that showed the world how it could be done (Burton Hospital being a notable example in the NHS) and also how it could go wrong.

    The Lost Decade

    If the nineties was the pioneering decade for clinical information systems then the first decade of this century can only be characterised as the ‘lost decade’ – whilst the Internet flourished and the age of distributed, personalised, world-in-your-pocket computing dawned – hospital IT systems remained desk-bound, cumbersome, inflexible, centralised systems. The need for information sharing was misinterpreted as a need to provide a single solution for all. A strategy that has cost billions, failed to deliver and diverted funding and more importantly the engagement of the medical profession (it was often doctors with IT skills that where the pioneers of the early adoption period) away from user and patient centred solutions.

    A Tablet Ushers in a New Era of Medicine

    Technology is no longer the problem – storage is cheap and abundant, networks are reliable and fast and devices are powerful, intuitive and mobile. Data management has transformed as well. XML allied to sophisticated search algorithms means less taming of information is required, the structure of the ‘database’ need not trouble the user any longer. Cloud technology means that information can be kept absolutely secure whilst not compromising the freedom of permitted users. The technology really has come of age and has surpassed the specification required to deliver clinical information management that truly serves the needs of patients, doctors and managers. Mobile devices like the iPad can give doctors both tools for information gathering and the tools to access it when it is needed without the technology getting in the way of the transaction with the patient.

    Paper, Paper Everywhere!

    But we are still using paper – tons of it. Medical records are stuffed with cardboard folders bursting with, mostly useless, pieces of paper. The information is locked away, unstructured and inaccessible – every request for information (and there are lots) is a mountainous struggle, consuming hundreds of man hours to extract it. The functions of the paper medical record as care coordinator, communicator, clinical process manager, monitor and legal witness are all conflated and result in an extreme precautionary approach to the retention of information which completely subsumes the probably more important function as informant almost as important (and often more informative) as the patient themselves.

    It’s the Information Stupid

    It’s time for the conversation to move from the technology to the information. We must focus on the type of information we gather, how we gather it, what we need and when we need it in order to deliver safe effective care. So much duplication and iteration and re-iteration of clinical information has evolved as a defence against the in-accessibility to information. Most patients I have met are astonished at the number of times they are asked the same questions over and over again even within the same clinical episode – they see the duplication and fragmentation that we as professionals miss.

    The care we give our patients is complicated and messy – partly because our patients are complicated and inflict on us huge variance in presentation, severity, comorbidity and response to treatment. That is the nature of medicine and what makes it so all consumingly interesting. But we make life exponentially more difficult for ourselves by imposing our own variance in practice and reliability on this already unpredictable background. Doing it differently every time, sometimes even changing our mind half way through results in variance on variance which is the definition of chaos. Chaotic medicine results in unpredictable, usually poor, outcome and huge waste – and is bad medicine.

    There is an answer to the information problem which also solves the chaos problem and results in not just better care but dramatically better care. Healthcare organisations that adopt this solution are not only better than their peers they are exponentially better. The solution is the key to delivering reliable care and it is the Clinical Process Model. This will be the subject of my next blog.

    It is interesting to reflect – now that the PFI bonanza has come to an end and we all have to hunker down and work out how to pay for it for the next 30 years – on what we have spent all the money on and consider whether what we have thrown up around the land is actually what we need.

    This paper by the think tank Reform The Hospital is Dead Long Live The Hospital is an eloquent exposition of Clayton Christensen’s ‘Innovator’s Prescription’ within an NHS context. The essential conclusion of both of these is that Hospitals need to move from being ‘A place where sick people go’ to becoming ‘An organisation that keeps people well’. This re-framing of purpose prompts the question – what does a hospital that keeps people well look like? I suspect it is not a large building with lots of beds in it (or clinic rooms for that matter).

    Interestingly the specialty of Intensive Care Medicine underwent a similar re-framing of purpose over ten years ago as a result of the comprehensive critical care program in response to a lack of intensive care beds. The outcome of this process was the introduction of critical care outreach teams (or medical emergency response teams) linked to a system of population surveillance (MEWS track and trigger) and an expansion of lower acuity beds (high dependency). There were almost no additional intensive care beds commissioned or provided. The result has been intensive care units have been able absorb ten years of demand growth, almost eliminate the need for inter hospital transfer for capacity reasons, reduce futile care, contain costs and improve outcome.

    How do we replicate this operating model at the scale of the hospital within a health economy (as opposed to an intensive care unit in a hospital)? The essential elements are:
    1) Knowing the population you are caring for – a disease registry
    2) Knowing how they are – a simple method of measuring disease status
    3) A response team that averts crisis when a trigger threshold is reached – a specialist community team
    4) An escalation pathway that includes rapid access to specialist input – specialty hubs
    5) Lower acuity beds for step up or step down care – intermediate care beds
    6) Alternate pathways for those that acute care is inappropriate – end of life services
    7) Acute beds for those that genuinely need it – closely linked to an intensive care unit!

    This distributed model of care does still need buildings – but what it needs more is intelligent information and communication systems used by a workforce that understands the need to keep patients other than those in genuine need away from hospital. It also needs an operating system that measures its impact, analyses unexpected pathway deviance and learns from system failure.

    Eliminating the huge waste in the system of inappropriate and futile hospital care (both inpatient and outpatient) will not only deliver cost savings it will improve quality of care and outcomes and create the capacity we need for the growth in demand we know is coming.

    The hospital is no longer a building it is a healthcare delivery system. We should be investing in the infrastructure that makes it possible – And that is not bricks and mortar…

    In my last post I described my journey to taking the decision to become a medical director. I know that many of my colleagues, whilst being extremely generous in their congratulations and sincere in their wishes of good luck and fortune – may well be thinking along the lines “why would you do that?”. I know that is what I thought for quite some time, and a bit of me still does…

    The Cost

    The loss of clinical practice is the first barrier – it has direct cost to the individual doctor. Earning opportunities for supplementing ones basic NHS salary as a practicing clinician are legion, waiting list initiatives and private practice if pursued with dedication and vigour can easily surpass even a medical directors salary. As one becomes more and more embroiled in the maelstrom of medical leadership the loss of time (and vigour!) gradually closes off these opportunities – the arcane pay structures of the NHS are peculiarly bad at rewarding those that do choose to take that path; and when they do it results in a wholesale pillaging of ones pension by the tax man (that alone is enough to put many off).

    Most doctors though are not wholly motivated by money (fortunately) – but there is a deeper and more personal cost to moving away from clinical practice and that is the less tangible but very real issue of status. The status of medical practitioner is hard earned but once achieved is gratifyingly well rewarded. Doctors are accorded a great deal of authority and privilege both within and outside the work place – with that comes much expectation and responsibility. One’s status as a trained practitioner in your chosen specialty, the time and effort put in to achieving it and the rewards it brings through the gratitude and respect of patients, colleagues and society results in it becoming an embedded part of one’s identity – giving it up is giving up a part of yourself and replacing it with….management (why would you do that?).

    Now I’m not saying that becoming a medical director will result in a wholesale loss of status nor for that matter will I be impoverished by the move. Nevertheless I am giving up part of my identity (in my case I am giving up intensive care medicine), I am stopping doing something that on a good day is actually good fun, I am leaving behind colleagues and friends (who no doubt think me very disloyal) and replacing it all with a new and different status – one with uncertain benefits and certain risks.

    Certain Risks

    There is no doubt the climate is harsher the higher you climb the leadership pyramid (for the record I’m not a fan of hierarchical metaphors for leadership structures with all the value laden implications of rank – common usage though makes them hard to avoid…). Scrutiny is more direct, more personal and less forgiving. Failure is overt, public and consequential to one’s job. The safety net of return to clinical practice gets thinner and the holes bigger the more time you spend away from it. Exit strategies are unclear, career paths poorly defined, training and support hard to find (expensive when you find them). These are realities faced by almost anyone in positions of responsibility both in public and private sector organisations. The wind only feels chillier to a doctor because of the remarkably secure, well rewarded and unassailable position that being a consultant is.

    Uncertain Benefits

    You are paid more – though the pathway through clinical directorship and associate medical directorship on your way there is hardly littered with gold. Most Trusts struggle to release the time let alone the money to encourage doctors down the path – certainly insufficient to compensate for the opportunity costs outlined above. Your salary is a matter of public record and subject to scrutiny in a way no other consultant has to endure. Should this discourage you? – Absolutely not, the money is good enough that for the vast majority of us it is a non-issue, it’s ‘off the table’. The role brings a level of autonomy, self determination, sense of purpose and opportunity for personal development that no other leading to it can – for me this is the motivation.

    So would you do it?

    It doesn’t stack up well – and there are lots of things we could do to make it stack up better. Many outlined in this report. I am certain there are many doctors out there with the leadership skills that are needed that are reluctant to put themselves forward. My advice is take the plunge, change is good.

    On the 1st of August 2012 I will be taking up the post of Medical Director at a large NHS Trust in the Midlands UK.

    This blog is an outline of my journey to this critical juncture of my career and I intend to use it to share my experiences in this role and I hope to help others – either actual or aspiring medical directors – in their journeys too.

    It is my belief that too few doctors put themselves forward for leadership and management positions in healthcare in general and the NHS in particular. Having made the plunge – I understand why and want to use my insight to support others in following me. My motivation is that I genuinely believe that without active engagement of and leadership by doctors the quality and safety of the service we provide is significantly threatened by the current and ongoing funding crisis. Only doctors have the insight and knowledge that equips them with the skills to make the really hard choices involved in balancing cost and benefit. However to put themselves in a position where they can make those choices in a way that makes a significant difference to large numbers of patients at a scale that also makes a significant difference to the cost of delivering healthcare to the economy requires individuals to make real sacrifices.

    My Journey

    I am by training an anaesthetist and intensivist. I became a consultant in 2002 and within 2 years found myself clinical director of critical care services in one the of the largest acute trusts in the NHS – operating out of three acute hospitals. This wasn’t because I was ambitious to do so, or even envisaged myself doing that role when I was appointed, it was simply because no one else wanted or was ready to do it (neither was I). My first year as CD I had no directorate manager, I had no training but I did have a fantastic team of senior nurses and consultant colleagues willing to work together as a team. Over the subsequent 5 years I had 6 different directorate managers working with me, some excellent others less so – and therein lies one reason why we should not leave radical reform of services to non-clinicians; only doctors and nurses are in it for the long haul, managers by their nature move on, and don’t always witness the consequences of their actions.

    I am lucky to have trained and worked in a truly modern specialty – one that recognises the necessity of team working, that sees doctors, nurses and other healthcare professionals as equal partners in that team delivering an outcome for the patient – one that recognises the need to take control of the whole cycle of care including the pathway to the door of the ICU (through MEWS and critical care outreach) – one that recognises the need to codify and simplify the process of care delivery in order to improve reliability (through care bundles – checklists by another name) – one that recognises the need to measure risk adjusted outcome and use it to continuously improve the service (through ICNARC). Ten years or more of this approach has resulted in an un-sung triumph of healthcare – the virtual elimination of central venous catheter related sepsis, the placing of sepsis in general at the top of the emergency medical agenda, year on year reductions in mortality (our SMR has fallen from 1.3 to a low of 0.73 just before ICNARC re-calibrated the risk model). This is not a unique success, it has been replicated in intensive care units across the country and the world.

    I recognised that there are some generalisable principles in the critical care story that if applied across a healthcare economy could bring about radical improvements in the quality of care delivered at the same time as reductions in the cost of care. This belief motivated me to not only learn more about models of healthcare delivery and their practical implementation but also to put myself in a position where I could influence – rather than remain a frustrated observer. It struck me that not only is this an area of fulminant intellectual activity, it is also an area where as an individual one can make more difference to more patients in a shorter space of time than any area of academic medicine (I am after all an archetypal anaesthetist – an impatient physician!).

    These thoughts (not necessarily as well formed at the time) led me to apply for the position of associate medical director at my Trust (in 2009), and also to the hallowed halls of Harvard Business School (in 2010/11) where I was exposed to the global cutting edge of thinking in healthcare delivery. This experience has been transformational for me personally, affirmed my belief that this is the right career path for me, and equipped me with knowledge and insights that I am impatient (again) to see put into practice. Many of the ideas will be themes I will draw out in future posts. The time is right – new ideas are becoming established in the thinking of policy makers – integrated care, outcomes frame works, value based competition, improvement science – and the need has never been more urgent.

    And so here I am in 2012 about to take up MD post at another large trust. In my next post I will talk about why many wouldn’t do what I have done and why I nearly didn’t…