Archive for February, 2008

The horse was unharmed

Friday, February 29th, 2008

This report from the New Zealand Herald of a road fatality is sombre reading - apart from the curious detail about the state and location of the horse. What about the driver of the four-wheel drive?

Protecting “our back yard” from aliens

Tuesday, February 26th, 2008

Artists attempted to take photographs of their works on the steps of Parliament. Fortunately, vigilant officials prevented this from happening without first obtaining appropriate permission from the speaker.

Aliens at the Beehive
Image courtesy of Scoop.

There’s a WOMBAT in there somewhere. Thanks to Scoop for bringing us the full story.

Accidental hospital deaths plummet from estimated 750 to 40 actual

Monday, February 25th, 2008

This is either a remarkable improvement or the figures are understated. To say they are understated is itself an understatement: we’re talking about more than a tenfold understatement. National party health spokesman Tony Ryall said “the committee’s figures vastly understated the size of the problem”. He’s not wrong.
The NZ Herald article states,

“Committee member Dr Mary Seddon, the clinical director of the Counties Manukau board’s quality improvement unit, said there were more preventable incidents than had been included in the report.”

I’d expect that “more” to be maybe 10-20% more. What was the real number? Will we ever find out?

A May 2007 report into accidental hospital death (The Press, Christchurch) put the figure at an estimated 750 each year (see our original blog post) but the recent report released stated only 40 deaths in the past financial year.

40 preventable deaths from 834,000 admissions is a fantastically good result - a pity it’s not the real number.

How about we take a look at the report? Where do we start - Ministry of Health or the Health and Disability Commissioner?

Let’s try the HDC first - go to Publications - then Other Reports where we find the Safety of Patients in New Zealand Hospitals: A Progress Report known here as the “plethora of policies” report. OK - that was October 2007 - nothing since then.

Must be on the Ministry of Health website - go to Publications and Resources and Find by Date. Not there! OK - so since we’re there let’s have a look at Quality Improvement since it’s a hot topic. Quality Improvement - Publications - nothing since 2004 (could this have anything to do with “slow and patchy” progress?) However, under Toward Clinical Excellence is a page Toward Clinical Excellence: Learning from Experience. This page tells us that in September 2001 -

“The Sentinel Events Project Working Party members have been brought together from throughout the health sector to make recommendations to the Director-General of Health on the feasibility of implementing a mandatory event reporting system for health and disability services and related matters.”

The page links to their report that includes a number of recommendations. Here is Recommendation 3:

“Implement a national system (to be called the Sentinel Events Reporting System) that requires health and disability services to report a defined list of events (to be called Sentinel Events) to the Ministry of Health for review.”

The recommendation was made in September 2001. The initial report was published in February 2008. The data it published is neither accurate nor standard. Meantime, preventable death and harm occur. That’s a WOMBAT.

Seven years to get an incomplete report - how long to get some effective interventions?

And where do you find the Commentary On Sentinel & Serious Events Reported By District Health Boards - 2006/07 report? On the site of the Quality Improvement Committee - a sub-site within the Ministry of Health. Don’t bother trying to find it easily from the Ministry of Health website (it’s buried in there somewhere) - it also needs some quality improvement.

“The reality is”: harbinger of dogmatic opinion

Monday, February 25th, 2008

The reality is that the phrase “the reality is” prepended to a statement has to be taken as a warning of an impending dogmatic statement. That statement is potentially highly suspect but lives in the opinion of the utterer as an incontrovertible truth.

Personally, when I hear those words an air-raid siren goes off in my head and I speed to my mental underground bunker to defend myself from an incoming “reality attack”.

Quote me a study, give me fact, bring data - or just give me your opinion unencumbered by false authority.

Your opinion is all that is required: prepending “the reality is” doesn’t add anything. I think it takes away.

Spam from Remove Spy and Adware dot com

Friday, February 22nd, 2008

Is there something incongruous about getting spammed from a spy and adware removal site? Especially annoying when you’ve already railed against this kind of practice.

The spammer has a bot that regularly sends comments to my post “Protection Rackets on your desktop“. Sample:

Hi there Expert, what made you want to write on Protection Rackets on your desktop? I was wondering, because I have been thinking about this since last Monday.

Why would I approve a generated comment that gives him a link to his website? If he’d bothered to write a considered comment that adds to a discussion I’d approve it. You want the value of a link, you give me a valuable comment - simple - else it’s a WOMBAT.

Make meeting agenda item timings more flexible

Thursday, February 21st, 2008

Conventional wisdom says that to make a meeting run to time we should allocate time to each item and include in the agenda. We think not.

The common process is to examine the agenda and allocate times to each item based on complexity, the result we want achieved and the importance of the item. We have no disagreement about this part of the process. Here is an example of the resulting agenda (PDF 45kB).

What is the problem with timed meeting agendas? It is the influence of Parkinson’s Law i.e. “work expands to fill the time available.” If everyone knows how much time is assigned to each agenda item then discussion (”work”) will expand to fill the available time.

What’s the alternative? Create two copies of the agenda. One copy includes the proposed times and the other doesn’t.  The facilitator (chairperson) and convenor of the meeting have the copies with allocated times and the rest of the participants just have the items without showing the time. This prevents unnecessary time expansion and provides the facilitator/convenor flexibility if items take longer/shorter than expected.

This device is just one incremental change to the traditional meeting model that saves time and boosts productivity. The full Action Meetings process is a reinvention of the traditional meeting model and provides a significant jump in meeting productivity and satisfaction.

“Slow and patchy” progress on the $1.8bn hospital death problem

Tuesday, February 19th, 2008

750 people unnecessarily die each year in New Zealand hospitals - that’s almost twice the annual road toll. Fifteen people per week are dying and using the “statistical value of life” of $2.5m per person that’s a $1.8bn problem - as we noted last May.

The road toll gets huge focus and attention with advertising and drink-drive campaigns to bring this horrendous figure down - but meantime this problem of almost twice the proportion seems to be mired in bureaucracy. The finger is being pointed at regional inconsistency and a lack of information sharing and the notion of safety “league tables” has been mooted.

“League tables” are appealing as they are intended to provide some competition and aspiration to lift levels of performance. However, what often happens is that they lead to divisive competition and “burying” of data that will cast a bad light. There is often an uncomfortable paradox in that we do want to embrace accountability but at the same time be careful not to produce or develop blame cultures as these are ones in which morale degrades and no quality improvement is possible.

The CATS process that we subscribe to and practise is only successful in an open environment where blame is not appointed to individuals and points of failure are assigned to missing or failing processes. A complete repair to a process results in a permanent change that removes that point of failure. Getting rid of an individual just leaves the replacement exposed to the same risk of failure and blame the next time.

Accountability goes to the process owner - it is up to them to be managing robust processes.

We don’t know the real reason why progress is slow and patchy but we do know that each unnecessary death could teach us how to prevent another.

Six-sigma not a guarantor of success

Monday, February 18th, 2008

Motorola, the founding organisation for the “six sigma”  process improvement methodology,  is hitting hard times in the cellphone market.

This should not really be possible for an organisation that has been using and developing the “best” process improvement technology for over 20 years. Skeptics of quality improvement methodologies have produced statistics that show no correlation between improved EVA (economic value added) and adoption of these methodologies.

From my own experience, the RAZR cellphone I own is pretty but fails to “wow” through poor usability and strange rules that leave me annoyed and very unlikely to buy a Motorola cellphone in the future. It’s not as though cellphones are new at Motorola, they have been producing them for at least 15 years now. In that time you’d think that they would have got to grips with the basics of creating phones that are a delight to use - but perhaps in the rush to be cool the basics went out of the window.

Microsoft have embraced the concept of “good enough” software - routinely shipping software with bugs (but knowing these are relatively unimportant) - and it’s hard to argue against their EVA. Why are they successful? Because the value of the software they provide is high as usability is always a priority in their product development.

So, let’s not forget “it’s better to do the right things than to do things right”.

Margaritas are like buttocks

Monday, February 4th, 2008

Having just one is ridiculous.

This deep insight came to me while on the holiday that is now, sadly, over.

So - no more levity - we’re back to the serious business of dealing with WOMBATS - and there are plenty around - for example, yet another rail crossing death.

Maybe I’m grumpy ’cause I’m back from holiday but the TV ads exhorting us to celebrate Waitangi Day by eating pig and dropping in to “get a bargain” cheapen and detract from our national day.