Views

Education must be not only a transmission of culture, but also a provider of alternative views of the world and a strengthener of the will to explore them.

Jerome Bruner

This is the view across the Dublin skyline from my office window. Dublin is a low-rise city.
Describe to me what you see.

I asked a number of my staff to do this and no two descriptions were the same…in fact no two descriptions were remotely alike. What we see when we look at a view is a product of many things including:

• What we are doing at the time;
• How much time we have to dwell on the view;
• What’s on our mind;
• How we woke up that morning;
• Our upbringing;
• Our education; and 
• What we are looking for.

In the case of one of my staff it was a case of ‘What’s he on about now!?’ When I explained it was an exercise in preparing me for my BLOG all was forgiven (maybe not!).

In this view I see history; values; economics; political impulses; imperatives; restraints; constraints; hope and hopelessness. I also see beauty and ugliness.

The humble community housing in the foreground, named in honour of one of the heroines of the 1916 Easter Rising, Countess Markievicz, is overshadowed just a few blocks beyond by the glass edifices of the Ulster Bank HQ – a legacy of the Celtic Tiger years of excess. Just out of shot to the left is one of the world’s most prestigious universities, Trinity College and in the shadow of Trinity is the house in which Oscar Wilde was born. Just out of shot to the right is the Sean O’Casey Bridge over the River Liffey, which is a fitting tribute to the writer who had his own take on life:

I have found life an enjoyable, enchanting, active, and sometime terrifying experience, and I've enjoyed it completely. A lament in one ear, maybe, but always a song in the other.

And then, not such a fitting tribute to another great Irish writer is the building from which this photograph was taken, which houses the ISQua Offices, Joyce House, which would be an appropriate honour for the great man if the building had any prepossessing or redeeming features which, alas, it does not. Then Joyce himself had quite a different view on life:

“All Moanday, Tearday, Wailsday, Thumpsday, Frightday, Shatterday.” 


I could understand Joyce feeling this way if he ever had to live in Joyce House.

So, where is this all leading?
I think it is celebrating diversity. The Irish have become good at that in recent times having been not so good at in the past – witness a plebiscite on Gay Marriage a few weeks ago that was carried by a majority of over 62%. Yet, even when divorce and contraception was illegal in Ireland, not so long ago, Ireland, as always, was producing permissive writers such as the aforementioned Wilde, Casey and Joyce.

This BLOG is getting away from me a little and I am finding it difficult now to link it to what I want to talk to you about, being the new ISQua Vision, Mission and Values.

But, perhaps not.

Take the word ‘transformation’ in the Vision, and the Values of Transparency, Integrity and Ethical behaviour and……..wait for it……DIVERSITY.
These are nothing if not permissive values.

And why should not healthcare embody and encourage such important values. In fact, when one considers the challenges that are bearing down on healthcare now, and particularly those that will do so in the future, how can we continue to deliver high quality healthcare if we do not embody such values?

Now, what I really wanted to do with this BLOG was to issue an invitation to you. The ISQua Board needs to know what you think about the new Vision, Mission and Values before we lock them in as our guiding principles for the next three years.
I have reproduced them below in case you can’t read what is written on the staff kitchen white Board (or in case you mix them up with the Plant Watering Roster which is scribbled right next to them).

Vision
Be the leader of transformation in healthcare quality and safety globally.

Mission 
To inspire and drive improvement in the quality and safety of healthcare worldwide through education and knowledge sharing, external evaluation, supporting health systems and connecting people through global networks.

TAG Line
Inspiring and driving improvement in the quality and safety of healthcare worldwide.

Priorities 2016 – 2018
External Evaluation, Events, Education & Knowledge Sharing, Person Centred Care, Innovation, Global Regions.

Values
Transparency, Integrity, Diversity, Ethical, Excellence, Evidence Based

So please, be in touch to tell us whether you think your Society is on the right track

And the last word to Mr Wilde……
Questions are never indiscreet, answers sometimes are.

Peter Carter
June  2015

Message from the Cheap Seats

Margaret Thatcher did not leave us too many quotable quotes over which to marvel down the years but there is one that is particularly memorable.

When asked about being powerful, Baroness Thatcher said:
‘Being powerful is like being a lady; if you have to tell people you are, you’re not’.

It is the same for those who tell people they are ‘a visionary’, ‘a supermodel’, ‘a leader’, ‘a thinker’.

Believe me, if you are these things we (in the cheap seats) will know. If you feel a need to tell us you are something special, it is almost certain you are not.

The Beatles never described themselves as a ‘supergroup’, others did that. But when hit with a UK Supertax on their earnings George wryly observed, ‘since we have been told we must pay a supertax then maybe we are a supergroup!’ Then he went off to write arguably his best song, ‘Taxman’ which further cemented the Beatles supergroup status.

In a classic experiment conducted in the mid-eighties, 100 undergraduates, divided into same-sex pairs, participated in two unstructured conversations spaced one week apart. In the second session, one subject of the pair was asked to participate either as an ingratiator or as a self-promoter. After the second conversation, ingratiators were rated as more likable but no more competent, and self-promoters were rated as less likable but also no more competent than in first conversation. Naive target subjects clearly recognised presenters attempting to appear competent and reacted negatively to them.

Confirmation that self-promotion doesn’t work. And what’s worse, it’s even less effective than ingratiation, and everyone hates ingratiation!

From time to time I will have a staff member who has produced an elegant piece of work complain to me that a colleague or a superior has taken credit for it. My response is: ‘Those who matter know, and those who don’t know don’t matter’ (and if this doesn’t happen through ‘Karma’, then we make sure it happens through other means!). One cannot pass oneself off as something one is not for very long and get away with it, nor can one claim someone else’s work as one’s own and get away with it. We who have been around for a while, or even if we have just arrived on the scene, know what’s what and who’s who.

A frequent question from the mentees I attempt to help with their development is ‘how do I get on’. This often includes asking me how to promote themselves. My advice is, be measured. Present yourself honestly and openly through your genuine achievements and impress people with your energy and ambition and excitement in what you are doing and what you are hoping to achieve; get out there and build a network, learn from it and give back to it. We in the cheap seats can immediately see an overstated CV or bio for what it is – inflated; the self-promotion is blindingly obvious, and CVs and bios that are written that way are quickly consigned to the waste paper basket. Similarly on websites, in blogs, on Facebook, LinkedIn and wherever, those who are trying to make a silk purse out of a sow’s ear, or to portray achievements as more than they are stand out like the ribcage of a racing Greyhound.

Maggie Thatcher did not have to tell people she was powerful, we all got that as we get that the Beatles were a supergroup; her mere presence and their wonderful music did all the talking for them.

So, relax, do your good work, we in the cheap seats will notice you and we will promote you.

Peter Carter
March 2015


Self-promotion is not ingratiating.
Godfrey, Debra K.; Jones, Edward E.; Lord, Charles G.
Journal of Personality and Social Psychology, Vol 50(1), Jan 1986, 106-115.http://dx.doi.org/10.1037/0022-3514.50.1.106

PAPERWORK: the enemy of the Good.

The sweetest joy, the wildest woe is love. What the world really needs is more love and less paperwork.
Pearl Bailey

SO, HERE WE ARE, 2015.

I have 40,726 emails in my in-box of which 1,982 are marked as ‘unread’. I say ‘marked as unread’ because I have read them, and acted on them (I believe) but I have flagged them as unread to remind me to go back and think about them some more. In reality the likelihood that I will reread 1,982 emails and refine the action taken on at least some of them is remote to say the least. If I were to do that, by the time I finished I would have accumulated 1,982 new emails that would need to be dealt with de novo.

A British MP, desperately seeking re-election this year and trying to impress his constituents, when interviewed for a newspaper article said that each night when he got home after a long day at work, he personally answered over 400 emails. I strongly doubt that is possible, unless the MP in question suffers from Fatal Familial Insomnia. FFI is code for ‘seriously can’t sleep’. It manifests itself in hallucinations, delirium, and confusional states like that of dementia. This might explain the behaviour of more politicians than just this one. The average survival span for patients diagnosed with FFI after the onset of symptoms is 18 months. Having this condition would certainly take the worry out of contesting the next election.

Surgeon Pauline Chen, writing a piece in the New York Times claims that as much as one third of a doctor’s work day hours are spent on paperwork. How many hours does that leave for seeing patients? Only six if it is nine hour day but more likely eight or nine given the hours doctors work.

Perhaps even more worrying, however is the amount of time paperwork robs Residents of what Residents are supposed to be doing: learning through educational activities and learning by doing.

Electronic medical records and other eMed applications will change all that, right? Sadly no. Not only has the paperless office not cut down on paperwork, it has increased it and confounded it.
Increased – we exchange a staggering 10,000 times more communications than we did pre eWorld (and we print out a hell of a lot of them, despite the plea we see at the end of emails begging us not to). And that is not just because there are more of us.

Confounded – cutting and pasting was virtually impossible pre eWorld, now it is rampant in the professions with law leading the way and medicine catching up. The cutting and pasting of notes by over (paper) worked doctors is a worrying trend. A dear surgical friend of mine who was a trailblazer in eHealth told me, with great prescience in the early eDays, that the claims of a paperless office were about likely as would be claims of a paperless toilet.

Dr Chen writes: ‘Residents may rely on notes written by other doctors instead of talking to the patients themselves. These other notes may have also been pieced together from previous notes rather than from actual interactions with the patient. As a list, a paragraph or whole sections get pasted into progressively more documents, important information, like a reaction to a certain treatment, can be lost in the transfer. Clinicians who rely mostly on computer notes for their information are at risk of inadvertently choosing the wrong therapeutic course of action for a patient.’

So much for patient safety! eHealth becomes ‘eUnhealthy’.

So what can be done? Suggestions include outsourcing some of the paperwork requirements away from doctors, to support staff. This takes money. But wait, isn’t employing support staff to do paperwork at $50 per hour better than having doctors do it at $100 per hour? And, if a doc cannot see all the patients in A and E in the allotted time because of paperwork an extra doc may be put on to clear the waiting area.

Surely I should be able to put this into some type of numeric. Let me try………..

100 patients seen for 30 minutes each by one Doc at $100 an hour = $5,000

PLUS

100 patients’ notes written up at 10 minutes each by one Doc at $100 an hour = $1,667

PLUS

The 33 patients not seen while the Doc was writing up her notes which had to be seen by another Doc at $100 an hour = $1,650

PLUS

33 patients notes written up at 10 minutes each by Doc 2 at $100 an hour = $550

TOTAL $8,867

OR

133 patients seen by a Doc for 30 minutes each at $100 an hour = $6,650

PLUS

Support staff writing up notes for 133 patients for 10 minutes each at $50 an hour = $1,100

TOTAL $7,750

An add to that the fact that in the second scenario seeing the patients and note writing are taking place concurrently rather than serially so the total time taken to see 133 patients is less by about 20% which makes the patients happier and everyone can switch off the lights and go home early, thereby saving even more money.

I have simplified this for the purposes of illustration realising full well it is more complex than this. But it suggests a modus operandi that could be massaged into place with some lateral thinking and number crunching.

The other perhaps less measurable effect of paperwork on doctors, and even more so, Residents, is how demoralising paperwork can be.

I accept that Doctors need to know how to record what they see and the treatments they recommend, but today’s paperwork is way more than this. I call it ‘defensive’ paperwork. It is a bit like defensive prescribing (of medications and tests). Let’s prescribe the medication or order the test, however remote the likelihood that we are treating something you have or trying to find something you might have, in case you have it and I get sued for not finding it. All this defensive prescribing and defensive ordering of tests has to be entered in the record………..more paperwork!

Maybe there should be an agreed ‘likelihood percentage’ below which Docs are indemnified against not prescribing/ordering and against not mentioning it in the course of providing ‘informed consent’.
The incidence of hospital acquired infection is around 6% to 10% in developed countries and docs will tell you when you go for surgery that it is a risk with a likelihood of about 10% (to be on the safe side). That is fair enough even though the surgeons I have worked with tell me no patient has decided not to go for surgery because of the risk of contracting HAI. So, could 10% be the threshold above which docs should warn of the risks, order the tests, prescribe the medication and below which they can’t be sued if the risk materialises? What do you think?

That’s it from me for now. Perhaps just a few ideas to stimulate your grey matter as we launch into 2015.

NOW, back to my 1,982 unread emails……Oh Crikey!! While I have been busy writing this BLOG for you that 1,982 is now 2,246 !!

HAVE A GREAT YEAR!

Bah Humbug!

Now, before you get too upset that I am going to go all Ebenezer Scrooge on you, this BLOG has a happy ending.

But around about now one starts to see headlines like the one below:

Dangerous decorations, fairy light injuries and death by snow: Why Christmas is the most perilous time of the year

• One in five risks food poisoning from turkey leftovers
• Falling snow and ice kills 25 people a year
• Of the 350 reported fairy light injuries, most occurred whilst decorating
                                              By SARA MALM
                                              PUBLISHED: 04:48 GMT, 19 December 2012 | UPDATED: 07:31 GMT, 19 December 2012

And warnings about the dangers, not of Christmas itself, but associated with it. And fair enough. Christmas is one of those celebratory times of year when we do things we would not otherwise do, which, by definition suggests these are marginal activities for us; like drinking too much, eating too much, trying to do more than we should in a given period of time aka ‘rushing’, trying too hard to impress or please family and friends. In Australia, where I usually celebrate Christmas, it is common for tourists to drown in the surf, unused as they are to the wonders and whiles of the sea.

So my message to you this Christmas  is to ‘chill’ and enjoy without going ‘extreme’.

Don’t drink too much, don’t eat too much,don’t drive, definitely don’t drink AND drive, don’t go swimming, definitely don’t go swimming after eating/drinking too much, don’t stress out about right present/wrong present/ decorations/ the guest in the corner you don’t recognise (but check to see if he/she does belong to someone in the room you do know, don’t give dangerous presents (to children)……..just ‘chill’ and enjoy.

So from all of us here in the ISQua office, to all our you, who visit our website, wherever you are in the world.

SEASONS GREETINGS!

From little things big things grow.

Systems – can’t live with them; can’t live without them.

“Everything must be made as simple as possible. But not simpler.”
― Albert Einstein


My day is organised and managed in accordance with a careful plan – I have a system. The underpinnings of this system have been more or less the same for a while now.
And in one or more respects this system always fails.

Lord Darzi said in his ISQua Global Leader Lecture in May this year that from the time he awoke on the morning of the Lecture to the time he stood to deliver it he had made perhaps half a dozen errors, no doubt despite the fact he had a plan, a system in mind for the day. All were minor, none was fatal but somehow the plan was imperfect (although it may have been as good as it could have been). We all experience this all the time.

But are these our failures or has ‘the system let us down’?

In thinking about this BLOG I scribbled down the following words late one night….:
‘All systems failure is human failure – why? – because people design the systems’

This seemed so blindingly obvious and simple (simplistic as it turned out) that I immediately assumed it was a well held and oft recited view and that I had read it somewhere and it had just percolated from my sub conscious to my conscious being. But GOOGLE all I like and I could not find a quote along these lines. So, if it is not a universal veritas then perhaps it is not so (mind you, it is well to remember that, in Roman mythology, Veritas, who was the goddess of truth, a daughter of Saturn and the mother of Virtue, hid in the bottom of a holy well because she was so elusive).

So, let’s see what we can find out….

SYSTEM………the word is so widely applied and misapplied it can mean almost anything that has more than one component to it. I have lamented the misuse of words, labels and ideas in my BLOG in the past, for example, ‘tipping point’, and system is one of the most misapplied I can think of.

I considered the definition ‘A group of interacting, interrelated or interdependent elements forming a complex whole’  . This does not convey the dynamism of systems sufficiently for me.

I like even less…….  ‘A condition of harmonious, orderly action’.   Really!? Harmonious and orderly?  Some maybe.

So, I have decided to craft my own definition……….. ‘A collection of stable and dynamic elements, and tools, coordinated and managed by a process, seeking to achieve a predetermined outcome’.

So what might be a ‘health system’? That is how do we APPLY HEALTH? How do we make health happen?

Donabedien talked about ‘structure, process, outcome’.

But you and I have seen the breakdown of systems often enough to recognise their complexity. Elements act independently of the system and the system impinges on the elements within it and those bombarding it from without so the whole thing gets thrown out of whack.
‘Every intervention from the simplest to the most complex has an effect on the overall system and the overall system has an effect on every intervention.’  (de Savigny and Adam eds 2009)

This is where Systems Thinking might play a role.

‘Systems thinking works to reveal the underlying characteristics and relationships of systems’  (idem)          

But sometimes you need a miracle if you are to succeed.

Systems thinking can ‘…accelerate the strengthening of systems’  (idem) but only if it is applied with liberal doses of leadership, conviction and commitment. When used properly it can find where the blockages are and give us ideas on how to clear those blockages.

Is systems failure all down to human error at the coalface? In some cases it clearly is. The workers at the Bhopal chemical plant pumped Methyl-isocyanate into a leaking tank; the officers and crew of the Herald of Free Enterprise set to sea with their bow doors open; the Costa Concordia was deliberately diverted from her planned course at the Isola del Giglio; Night Nurse Marie misread the medication chart on the ward because she had left her reading glasses at the nurses’ station. In other cases, not so much and systems failure can be more down to managerial or organisational factors that create the pre-conditions for things to go wrong. But then I ask myself, are not deficient managerial and organisational factors man made problems?

Chris Johnson talks about management’s role as organising and managing work practices; and managerial failure being when they do this badly. He identifies another culprit though, which I think is important, and which is often overlooked; this is regulatory failure. Regulatory failure refers to the ways in which governments and other statutory bodies govern and monitor the work practices of companies and industry.

Johnson argues that the role of managerial and regulatory practices as preconditions for human error has been particularly neglected. He says most human factors and systems engineering has focussed on the immediate causes of human error and systems failure and has not looked at the organisational and regulatory context of that error, in other words, step back look at the forest as well as the trees.

‘Given the complexity of healthcare work systems and processes’……there is a need to…. ‘emphasise the need for increasing partnerships between health sciences and human factors and systems engineering to improve patient safety’ (Carayon 2010).

Transitions of care are increasing – this is a high risk process. A transition may occur within a ‘system’ or between ‘systems’. Either way they are plagued by poor communication and inconsistency in care and adverse events are a common outcome (Beach et al 2003).

Returning to Lord Darzi’s Global Leader Lecture; I was interested to hear him talk about the high correlation between one factor, being patient satisfaction/feedback, and most if not all other commonly used measures of patient safety/quality. He suggested a quick and accurate way of determining if you are doing it right is to ask the patient if you are doing it well in her or his eyes.
This is patient centered care, and it’s good because not only is it safer care but it is ‘…. care that is respectful of and responsive to individual and patient preferences, needs, values …’   and ensures ‘…patient values guide all clinical decisions’. (Institute of Medicine Committee on Quality of Health Care in America 2001).

Donabedian may have characterised health systems as structure – process – outcomes but he also referred to another important, and for him the most important ingredient. So I will let Donabedien have the last word:

“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love.”

Peter Carter
Chief Executive Officer
October 2014

Professor the Lord Darzi of Denham
http://www.isqua.org/education/resource-centre/lord-darzi's-global-leader-lecture

Don de Savigny; Taghreed Adam eds: Systems Think in for Health Systems Strengthening. WHO, Alliance for Health Policy and Systems Research: 2009.

C.W. Johnson, Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting, University of Glasgow Press, Glasgow, Scotland, October 2003.


Pascale Carayon et al:  Patient Safety: The Role of Human Factors and Systems Engineering. Stud Health Technol Inform. 2010 153: 23 – 46. 

Beach C.  et al: Profiles in Patient Safety: emergency care transitions. Academic Emergency medicine. 2003; 10(4): 364-367.

‘A CHAMPION TEAM WILL ALWAYS BEAT A TEAM OF CHAMPIONS’

“Teamwork: Easier Said than Done” 
― Nauman Faridi

A team is not necessarily a group.

And a group is not necessarily a team.

GROUP:- any collection or assemblage of persons or things.

TEAM:- a number of individuals undertaking different tasks with a view to achieving a pre-determined goal.

TEAM

 Groups have to exist in the same time and usually in the same place. The key characteristic of a group is that of being a collection of individuals who are designated as a ‘group’, that’s it.

The individuals who make up teams on the other hand can exist in the same place or different places; in the same time or in different times.

A group can have no purpose, one purpose or many purposes. A no purpose group: a number of individuals who share a geographical proximity ie they just happen to be standing together for the moment. A one purpose group: the protest march. The many purpose group: the crowd at a U2 concert.

A team can have only one purpose.

If an organisation has one purpose (goal) it has one team and if it doesn’t it will be dysfunctional. It will also be one group. If an organisation has a number of purposes (goals) it will have a corresponding number of teams; BUT it will be, at the same time, one group.

Group members’ individual roles/tasks are not specifically defined and many individual members may have the same role/task.

Team members’ individual roles are clearly specifically defined and duplication of roles is avoided. Take the Australian Rugby team, the Wallabies; 15 team members each with a clearly defined and differentiated task BUT each with a common goal, to win by scoring points. This is not a group.

GROUP or TEAM ?

I have been told that it has been ‘agreed’ by these groups of birds in chevron flight that the two birds immediately behind the leader rest in anticipation of their turn as leader. If that is so, this group is starting to look like a team. To confuse things even further one definition of ‘flock’ is: a large group of things

GROUP

Then why is it that in researching for this BLOG I found the terms used interchangeably so often?

Having got that off my chest……….; what I want to just touch on in the space and time I have available is the evolution and current state of play of teamwork in healthcare.

To Err Is Human: Building a Safer Health System ₍₁₎ had a lot to do with generating interest in the creation of teams for the delivery of healthcare by highlighting that preventable medical errors, of which it turned out there were many, were often the result of dysfunctional or non-existent teamwork.

Yet,  ‘… training programs designed to improve team skills are still a new concept for medicine, particularly for physicians who are trained largely to be self-sufficient and individually responsible for their actions. On the other hand, outside of healthcare, research has shown that teams working together in high-risk and high-intensity work environments make fewer mistakes than individuals’ ₍₂₎.

So if we agree that effective teamwork is integral to enhanced clinical outcomes in the provision of healthcare, all we need to do is to introduce teamwork (dare I say in lieu of groupwork). Easy. Not so easy (“Teamwork: Easier Said than Done” ― Nauman Faridi )

Even today there is limited knowledge of what makes health professionals effective team members, and even less information on how to develop skills for teamwork. Often it depends on to whom you talk. Healthcare managers might select leadership, knowledge of organizational goals and strategies and organizational commitment, respect for others, commitment to working collaboratively and to achieving a quality outcome. It does not take much experience, or imagination for that matter, to recognise that clinicians would identify a largely (although, admittedly, not entirely) different skill set. One skill that I would expect to see on the lists of both is communication.

Go to:

Background

Although effective teamwork has been consistently identified as a requirement for enhanced clinical outcomes in the provision of healthcare, there is limited knowledge of what makes health professionals effective team members, and even less information on how to develop skills for teamwork. This study identified critical teamwork competencies for health service managers.

Methods

Members of a state branch of the professional association of Australian health service managers participated in a teamwork survey.

Results

The 37% response rate enabled identification of a management teamwork competency set comprising leadership, knowledge of organizational goals and strategies and organizational commitment, respect for others, commitment to working collaboratively and to achieving a quality outcome.

Conclusion

Although not part of the research question the data suggested that the competencies for effective teamwork are perceived to be different for management and clinical teams, and there are differences in the perceptions of effective teamwork competencies between male and female health service managers. This study adds to the growing evidence that the focus on individual skill development and individual accountability and achievement that results from existing models of health professional training, and which is continually reinforced by human resource management practices within healthcare systems, is not consistent with the competencies required for effective teamwork.

Inadvertent patient harm is all too often the result of absent or poor communication. Medical care is complex and complete and accurate expression through language is limited. Creating a healthcare environment, clinical or non-clinical, where all those working together feel empowered to speak, is the first step; and the second is to adopt a standardised, common language where what you mean when you express yourself is what I understand when I hear what you say. Mistakes are inevitable if we do not do this.

But back to the teaching of healthcare, right back, to the undergraduate years.

The existing focus is still largely on   ‘.. individual skill development and individual accountability and achievement that results from existing models of health professional training, and which is continually reinforced by human resource management practices within healthcare systems, is not consistent with the competencies required for effective teamwork.’_(6.)

Things are improving, which is something, but ever so slowly………

As they say in rugby……..

‘A CHAMPION TEAM WILL ALWAYS BEAT A TEAM OF CHAMPIONS’

Peter Carter

Chief Executive Officer

August 07 2014

1.         November 1999

        I N S T I T U T E O F M E D I C I N E

       Shaping the Future for Health

       TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM

2.         Mt Sinai J Med. 2009 Aug;76(4):318-29. doi: 10.1002/msj.20129.

        Teaching teamwork in medical education.

        Lerner S1, Magrane D, Friedman E.

3.        Qual Saf Health Care 2004;13:i85-i90 doi:10.1136/qshc.2004.010033

       The human factor: the critical importance of effective teamwork and communication in providing            safe care

       M Leonard₁, S Graham₂, D Bonacum

        4.    Teamwork and patient safety in dynamic domains of healthcare: a review of the literature

       T. MANSER

       Article first published online: 22 OCT 2008

       Acta Anaesthesiologica Scandinavica

       Volume 53, Issue 2, pages 143–151, February 2009

5.         Computational & Mathematical Organization Theory

        December 2000, Volume 6, Issue 4, pp 339-360

        Virtual Teams: What are their Characteristics, and Impact on Team Performance?

          Sze-Sze Wong,  Richard M. Burton

6.          BMC Health Serv Res. 2007; 7: 17.

         Published online Feb 7, 2007. doi:  10.1186/1472-6963-7-17

         Effective healthcare teams require effective team members: defining teamwork competencies

         Sandra G Leggat

I’ll scratch your back..and guess what? You don’t have to scratch mine

“Animals have genes for altruism, and those genes have been selected in the evolution of many creatures because of the advantage they confer for the continuing survival of the species.”  Lewis Thomas

I had not previously been to a ‘coffee tasting’ so was interested to go along when a friend invited me to ‘3FC’ in Grand Canal Street in Dublin to taste the coffees. Fergal’s wife, Siobhán is about to open her third bistro, restaurant, foodstore and Siobhán had given Fergal the task of choosing the coffees for the new Clontarf bistro.

Fergal is Irish (what else!) and as such is bubbling with knowledge, ideas and opinions; some brilliant and some whacky. He is also a lawyer and for a time headed ‘Legal’ in one of the big banks. Between sips of coffee Fergal opined that the misery inflicted on the Irish people during the global financial crisis was a product of stupid government, greedy business and complicit lawyers. Only the teaching and healthcare sectors stood apart and above all that incompetence and skulduggery; all those dreadful sins of omission and commission.

It is certainly true that in public surveys politicians and lawyers (and, since the GFC, bankers!) are consistently listed last on qualities like honesty and integrity and teachers and doctors are consistently listed first. Why is this so? After all, in the case of clinicians, salaries are generally high and physicians lifestyles envied by many. People in other walks of life who make a lot of money are also envied but not so universally admired and respected as are doctors. Much of it has to do with the public perception of why people enter the medical profession. And this perception is that they do so not for material benefit but for altruistic reasons. Is the perception the reality?

The answer that I am going to offer to this question is an answer I always criticise as a ‘cop out’ when others give it in other circumstances – but it is the right answer in this case – and that is…. ‘Yes and No’.

The literature on this suggests that one of the motivating factors is material gain.

But, hang on, material gain? On average, in recent times, medicos salaries have dropped on average by 7% while there has been a rise of 7% across other professions – a net loss to the docs of 14%. And as Erich H. Loewy ¹ , points out, in the former Soviet Union and even today in the newly independent former Russian states, the demand for places in medical schools was astronomical despite the prospect of a meagre salary on graduation.

Loewy goes on to cite examples of the enormous amount of selfless pro-bono work undertaken across the healthcare profession when work is done for no material benefit and often in the most inhospitable of 

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conditions. I can cite many examples of this too. The Pacific Islands Project of the Royal Australasian College of Surgeons saw teams comprised of surgeons, internists, nurses, anaesthetists and technicians spending time in the most trying of settings delivering life saving and life enhancing medical care without any financial return while still bearing the costs of their practices at home, usually from their savings. Similarly, the training, mentoring, advising and hand holding of the next generation of doctors by the current generation is done for love, not money. I am reminded of a leading Neurosurgeon, who was senior examiner for the College of Surgeons, being reported to the local council for disturbing the amenity of the neighbourhood in which he lived because he was in the habit of attaching a floodlight to the front of his lawnmower and mowing his lawn at 5am. It so happened that this always coincided with the weekends on which he was officiating at the surgical exams where each day started at 7am and finished at 11 pm.  No money changed hands for this.

I like Lowey’s story of a cardiac surgeon who was so busy with his pro-bono work that he could only enjoy his hobby of car restoration vicariously; that’s right, he hired someone to restore his cars for him.

I know there are healthcare workers whose prime motivation in plying their trade is for the material rewards, I know this because I have worked with such people. But I can count them on the fingers of one hand and they are soon forgotten because they are not the healthcare workers that make a difference.

So, to all you altruists out there, well done and thank you, it is you who are shaping the future.

So, back to where all this started, a discussion over coffee. Fergal and I liked the Ethiopian coffee the best so the Bistro in *Clontarf will be the place for you to go for great coffee when next in Dublin.

Footnote* This year celebrates the 1000 anniversary of the Battle of Clontarf.

“Battle of Clontarf” 

oil on canvas painting by Hugh Frazer, 1826

The Battle of Clontarf (Irish: Cath Chluain Tarbh) was a battle that took place on 23 April 1014 at Clontarf, near Dublin, on the east coast of Ireland. It pitted the forces of Brian Boru, High King of Ireland, against a Viking-Irish alliance comprising the forces of Sigtrygg Silkbeard, King of Dublin, Máel Mórda mac Murchada, King of Leinster, and a Viking contingent led by Sigurd of Orkney and Brodir of Mann. 

It lasted from sunrise to sunset, and ended in a rout of the Viking and Leinster forces. It is estimated that between 7,000 and 10,000 men were killed. Although Brian's forces were victorious, Brian himself was killed, as were his son Murchad and his grandson Toirdelbach. Leinster King Máel Mórda and Viking leaders Sigurd and Brodir were also slain. After the battle, the Vikings of Dublin were reduced to a secondary power. Brian's family was temporarily eclipsed, and there was no undisputed High King of Ireland until the late 12th century.

The battle was an important event in Irish history and is recorded in both Irish and Norse chronicles. In Ireland, the battle came to be seen as an event that freed the Irish from foreign domination, and Brian was hailed as a national hero. This view was especially popular during English and British rule in Ireland.

(With thanks to Wikipedia) 

¹ Healthcare Systems and Motivation,  Erich H. Loewy, MD, FACP   Medscape: Thursday, June 19, 2014

Peter Carter

Chief Executive Officer
ISQua
June 2014