Set Up To Fail
I spend a lot of my time these days thinking about needles and haystacks.
In previous submissions, I have talked about the amount of time being wasted by Family Doctors on frequently redundant paperwork. I realize my presentation of the problem may have focused on the perspective of the overworked Family Doctor. Perhaps this misses the more general point that Family Doctors are being set up to fail and that when a Family Doctor fails, it is a patient that pays the price.
Now, when I say fail, I am not talking about lack of effort, experience or knowledge. I am not talking about professional malfeasance. Nothing resulting from the want of trying or deliberate misconduct. Family Doctors are going to miss important information because it is buried in distraction.
The corollary to the Needle and the Haystack idiom is that the best place to hide a needle is in a haystack. The best way to ensure the needle is not found is to make the haystack as large as possible.
I have challenged the readers of these missives to look back over the last near sixty years of governmental management of the healthcare system and ask themselves if there is any evidence that politicians and bureaucrats can do the job; I contend the evidence says that, if they have been trying, they have failed miserably. With respect to the way information about patients’ health and illness is distributed to the people actually delivering care, I submit the evidence indicates that Family Doctors are being put in a situation where it is inevitable they will miss something important.
Some of you out there may be scratching your head. Doctors see patients, doctors order tests, tests get resulted, the result come back to the doctor. There is a line of thinking that goes, roughly, you ordered it, why are you complaining about dealing with the results of what you ordered?
Valid point, if that was all that is going on here. If one test yielded one result that was presented in a way that allowed for rapid and comprehensive review, there wouldn’t be as much complaining about the volume of results. That scenario is what most Family Doctors are seeking, not complaining about.
In reality, one test can lead to multiple reports delivered via multiple media. I blame the lawyers.
You are the needle, or, at least, your result is. It could be blood work that tells your Family Doctor why you are feeling tired all the time. The x-ray that shows you do have pneumonia and antibiotics are actually indicated. The CT scan report that says whether or not your cancer has progressed. The pathology report that says the mole on your back that was removed was actually just a mole (you have to supply your own sigh of relief for that one). The specialist’s opinion that clarifies what you have going on and that outlines a treatment approach to be followed.
Your needle exists in a stack of negative results. The normal blood work and diagnostic imaging. Consultants reports that say you are being treated appropriately.
Finding the needles is obviously the job of the Family Doctor. The analogy of email works best here. Every day, you get dozens and dozens of emails. Emails have senders and subjects to help you screen them. If the subject line features “Viagra” or “Hot Tubs,” you don’t even have to open the email to know you can delete it. If an email comes form a sender with whom you aren’t familiar, you may choose to delete it without opening it, especially if the sender and the subject don’t make sense in your context.
With results of tests, they all look alike. Name of patient (you) and basic information with respect to what is resulted (“Lab, CBC”, “Diagnostic Image, CT Scan”). I have been told that there is a marker for results that are “Urgent” or “Critical”; I have never seen it, though I have received my fair share of both “Urgent” or “Critical” results. Either it doesn’t exist or it is so unnoticeable that it does not serve its purpose. So, instead of running through the hundred or so emails in my in box, deleting most unopened, I have to open and read each one to see what is in it. Who is the patient, what did they have done, what is the result, what does it mean? It is likely I will have to open the electronic chart to put the result in some context for that patient (what was I thinking when I ordered it?). There will probably be some action item resulting that I will have to manage. Mark the result reviewed, rinse, repeat.
That’s enough work if you only get the result once. The lawyers for the RHA, however, really want to make sure that the RHA’s rear end is covered. The result is that any aberration in result reporting will result in the result being rereported. For example, for a period of time measured in years, because there was no simple way of making sure the results were delivered electronically, one RHA insisted on continuing to send out the results on paper as well as electronically, the same paper we were told would no longer be sent out when the electronic system was being brought online. So, Family Doctors were receiving an electronic copy and a paper copy … of everything they ordered. There was some kind of glitch (I never heard an explanation that really made sense) such that Family Doctors would receive multiple copies of consultants’ reports. They all seemed identical. We are talking pages of free text that had to be read and reread in case there was some change form one to the next (spoiler alert, there usually if not always wasn’t any difference). I received five copies of the same blood work report on the same day, in five different formats. I received two copies of the same bone density report, but six weeks apart. I had already discussed it with the patient, but I didn’t remember until I went in to her chart to schedule an appointment to discuss it (again) and saw my note from a month ago, doing that very thing.
Piling the straw on the haystack. The needle sinking deeper into the distractions. Your results buried in diversion. The Family Doctor may be the one buried under the deluge, but it is your health (as well as the Family Doctor’s) that is at risk.
Family Doctors are being set up to fail. It is not humanly (or humanely) possible for Family Doctors to keep up with the flood. Things are going to get missed. Not overlooked, that implies intent. The face of a bureaucracy is the person sitting across the desk from you when something goes wrong. They, in this case the Family Doctors, are the ones who will wear the brunt of consequence of important patient information being missed. There is an entire system predicated on the principle of sending as much documentation at the Family Doctors as it takes to cover the RHA’s ass.
Sick notes is enterprise outsourcing their Human Resource issues to Family Doctors. The unending supply of redundancy in reportage is the RHA outsourcing Quality Control to the same people. It should matter to you because all this hay obscures your needle.
How does that make you feel?
Thank you for sticking with the series, I appreciate it.
It sounds like you know more about quality control, assurance and management than I do, so please correct me where I have erred. My experience has led me to conclude that Quality only matters when it serves the business purpose. If your clients expect quality, it is worth the business’ while to make sure Quality is delivered. In the case of healthcare, the transactional model the Government/RHA has embraced is about providing a service, not a quality service. The bar has been lowered, deliberately. “The Emergency Room is open,” The Department proclaims, even if it is minimally staffed and more people go home unseen that helped.
I touched, perhaps not enough, on this in today’s piece; doctors are the face of the failings system for most patients, since it is the doctor that has to explain to the patients why they cannot get what they have been promised. Also, the same bureaucracy has learned that, when something does go wrong, the doctor is usually named and blamed first. I don’t hear much media interest in how much Government/RHAs spend on law suits. They have deep pockets, they can handle the cost. Doctors have malpractice insurance too, but the cost of a lawsuit on the doctor involved is measured in more than just dollars and sense.
With respect to the flood of documents, the authorities have been told, we only want to see the last version, the final report. If preliminary reports are available, we can look them up; it sounds like more work, but the act of looking up the preliminary report shows the patient that this is not the final report and that therefore it can change. That is so important if it does change; it isn’t that the doctor changed their minds or misread the preliminary, both participants know that there was a change from a previous version. Patients’ understanding of how the system works improved. The receipt of the final version signifies that this is it, no more changes will be forthcoming. That suggestion was rejected, in favor of flooding the lane.
As regards “arse”, I agree. I don’t know what I was thinking.
I am concerned and angry! I have read your series from the start and I think there is not going to be a change until everyone reads the series or, at least gets a summary delivered by someone who has read and understood your points. We then have to come together as a body to demand a change. For 40 years of my 41 year career after graduation Quality Control, Quality Assurance summed up as Quality Management were at least a significant part if not the entire focus of my job. When I got involved the focus was on QC, turning down defective parts and products usually just before they shipped. QC folks of course took the hit for delaying deliveries and the cost of scrapped materials. Being an engineer I was not satisfied with the process and started to swim upstream like many of my colleagues to find the defective parts before they got to the last step. Still got the blame but it was less expensive! Finally the accounting folks taught us how to talk to management about the Cost of Quality vs the Cost of Bad Quality and we became an asset! we could use the same process analysis to Cost Bad Quality which not only includes defects, it also includes all wasted time and arse covering duplicates. Another example, the document issuer is responsible for the quality level of the document issued and should among other responsibilities be required to identify revisions. Rev 0 is as issued, Rev 1 has a change which should be duly noted as a specific change, like correcting a spelling error through out a document (could be large volume but insignificant impact, or, a single occurrence but high impact). The receiver can then toss, burn, delete any other Rev 0's received with confidence. There have to be consequences for those creating Poor Quality.
Also I do have a trivial comment and am trying to encourage this among all hands and that is the use of Ass vs Arse, we as NLers are entitled to use the term as she is spoke by the Irish, English, Scots and Welch and it is so much more satisfying to write and in particular to say!