Thursday, May 5, 2016
Errors in Any System and Channels of Information Flow
Errors in any complicated process system are almost always a matter of the efficacy of how that system collects information on what it does, how it does it and what the results are, compared to what was actually intended; after which, once the information is collected, how it then flows into a dynamic feedback process to make appropriate adjustments.
This endeavor to actually understand what you do, and then react to changing circumstances, in itself, is almost as complicated as the original process system that it is supposed to monitor. And certainly subject to its own deficiencies and errors.
With healthcare as a systematic process, combined with the fact that it must operate as a commercial enterprise, whether for, or non profit, and that we also have the identification of liability, and the handling of how that is determined as its own, quite large, commercial enterprise; all combined with the fact that information itself is inherently a commodity, you end up getting what is all too often a perfect storm of incentive, and/or opportunity, to mess with the flow of this information from start to finish.
The wonder is not that we have errors in the application of healthcare, but that they they are not actually orders of magnitude worse.
If you consider it at all you quickly come to the conclusion that it is an ungodly tangle of contradictions wrapped within competing priorities. Lets begin.
Outcomes have to matter to some degree, of course, because, at the very least it is a product. But because of that there must also be the constant drum beat of cost reduction, and obviously, everything you do, and somethings that you don't do, have a cost. That cost, though, is both institutional, and personal, as to whom it directly affects, and nowhere is this more deeply woven into the fabric of all of the players involved, as well as the institutional structures, than in healthcare; the patients, the doctors, the nurses, technicians and administrators all have skin in the game to either win or lose with big time. Everybody has an interest in not only the outcomes, but every aspect of what information is collected, how its collected, and then what is ultimately done with. And the really interesting thing here is that they all have a certain love-hate, benefit-risk, in creating the information accurately, and seeing to it that it gets transmitted as it should
Patients are not always truthful, or objectively accurate. The participants in providing the care are both pushed hard to do the right thing at the right time, but also to input what is done accurately all along the way, and the fact of the matter is that both sides of that get more and more complicated as more and more aspects of what is required on both sides are identified. More things that the patients bring into the situation that are ancillary to the primary issue at at hand; as in the bacteria on their skin, their sexual life style, or even emotional issues that could go off in any number of ways, to just name a few. Then, on the participant's side, the ever changing dictates of what payers will allow as appropriate for what may, or may not be, the actual condition, or complex of conditions, that the patient is certainly not always clear on. This, in addition to whatever physiological imperatives that might be immediately be presented, and for which, direct action may, or may not, need to be taken.
I don't think you could possibly think of a more fertile ground for the making of mistakes than that, save, perhaps, in the planning and conducting of war.
And all along the way the information has to be moved, or not moved, because it is not only private, on the one hand, it is also potentially essential for finding mistakes at all, but it is also a potential gold mine for those who would seek to profit from it in a number of other ways (as in payers avoiding bad risks before coverage can even purchased in the first place). Then, when mistakes are made, their are the outside interests whose livelihood depends on getting the most out of the assignment of liability.
The most damnable thing of all, for me, however, in this cluster fuck of conflicting priorities, is that money is made regardless of whether mistakes are made or not, or even if the patient outcome is positive or not; regardless whether good people, as providers in the trenches, work their butts off doing what they feel in their heats is healing, or just come in to punch a time clock or not. And all too often it is the good people who, being human, and pressed so hard that mistakes will happen from time to time, who suffer almost as much as the patients who didn't get the outcome they needed.
I have worked with these people and I know for a fact that most of them do it despite the money, the pressure, and the horrible hours. They do it because being part of a healing process that does manage to work is something special. And it is truly a wonder to me that as many of them that are still in it remain there. Much like the teaching profession these days I think.
It is just another reminder that a cost, money based way of doing things, in an age where the free flow of information is imperative, but all the more restricted, precisely because it;s property, or potential gold in somebody's pocket, is simply no longer viable. We can't know what we need to do, and when we need to do if we first have to worry about how we will be able to purchase the facts to base decisions on. Too much gets lost between the cracks in that kind of market mediated truth.