Process following getting in the way of outcomes

We now have, in many organisations, a culture where processes take priority over purpose. When the concept of Business Process Re-engineering first began to spread, the promoters and practitioners were clear that it was a technique to revise and re-design work more efficiently, to eliminate unnecessary activities, and ensure the correct steps were taken and nothing overlooked. This involved mapping processes step by step around work flows which took a process, for example creating an invoice, from sale to printing to recording, through the minimum steps, but all the steps, needed to carry out some action. Bearing in mind how work and tasks grow and grow over time, some spectacular improvements were implemented.

Now, there are too many organisations, especially in the public sector, where their natural affinity for bureacracy, form filling, and back covering has interbred with poorly understood management jargon and corner cutting lowest price bid acceptance, to produce a tick box culture. The tragedy of the Baby P death demonstrates many aspects of this.

The management defended themselves by saying that 'correct procedures' were followed, that no mistakes were made, and they have three stars for efficiency. Yet the baby died. Every worker ticked each box at the right time. Every step was completed and form filled. Yet the baby died. The processes, workflows, forms, computer systems, scorecards, traffic light performance management, deadlines and so were followed impeccably. Yet the baby died.

The object of all the processes and procedures was to protect the baby, and that was the one thing that they conspicuously failed to do. The same problem occurs throughout business and government: no one makes any mistakes, but the whole point is forgotten.

There can be no clearer indication of how wrong things have really gone when it becomes apparent that the computer system designed to help staff work more effectively in fact takes up more than half their time.  This is an extremely common outcome for large computer systems across the board, and a future blog will try to explain why this is. The essence though is that the systems are designed by people who do not understand how and why the people who will use the system really work. 

The only practical solution is to revisit these processes and procedures, simplify the checking and form filling, and refocus on the outcomes not how to get to them. A simple tool for doing this is to evaluate each step as to how important it is on a common scale, what are the real risks surrounding it, and what does it contribute to the outcome.

Drugs, risks and bad counting

Last week saw a lot of articles, like this, on the 'wonder drug' rosuvastatin (Crestor), which apparently cuts heart disease risk by 40-50%. 

To emphasise the benefits, the drug companies like to talk about relative risk reduction, rather than the more helpful absolute risk. To illustrate the difference, anyone can improve their chances of winning the lottery by 100%. All they have to do is buy a second ticket. The absolute chance of winning is still rather too high to change your way of life in anticipation of a win - about 1 in 7million.  So to understand real risk to an individual, the figures need to be examined. Ben Goldacre in his Bad Medicine column in the Guardian talks about this.

The details of the research project (Jupiter) show in fact that for the 18000 people in the study, the absolute difference in death rates for ALL causes between those taking the drug and those on a placebo was 49 people (247 to 198). Only 400 heart disease events, such as heart attacks and strokes occurred in total for both groups, about 2.2%., but over half were medical interventions to deal with symptoms rather than sudden illnesses. Only 12 people in each group died from strokes. At the same time, about 100 extra people on the drug developed diabetes. About a quarter of the people dropped out, before the study was stopped after less than two years because of its startling 'success'. If the study had continued for five years there would have been no one left at the end. Coincidentally, although it is not often mentioned, about 25% of people on statins have side effects such as mental impairment, muscle pain, memory loss etc. Other studies (GISSI-HF  and CORONA. for example) have shown that rosuvastatin provides no benefits.

So why are AstraZeneca funding such studies and trumpeting trivial outcomes as huge percentages in relative risk reduction? Could it be that they would like as many people as possible taking an expensive drug every day for 25 years? The current preferred drug, Simvastatin, is now off patent, and therefore cheap. As an illustration, one US commentator pointed out that to save one life using Crestor would cost almost half a million dollars (400 person years of the drug to avoid one death). So, rosuvastatin is a me too drug designed to reinstate an expired patent, rather than produce any other result. 

This is clearly not getting it right. The purpose surely should be to look for cost effective ways of reducing ill health, not selling drug products. Of course, these research studies are expensive to run, and all of them rely on funding from drug companies. None of Big Pharma can or will spend money on comparing their drugs with other solutions. Thus we have extensive testing trying to prove for example that statins reduce coronary heart disease compared with a placebo, but none comparing the drug with normal health improvement measures such as reducing weight, changing diet, exercise. 

There is one interesting fact that has yet to be explained about heart disease. The incidence started to increase noticeably in the 1920s, and peaked at the beginning of the 1970s, since when it has decreased dramatically, by about two thirds in real numbers (from 714 deaths to 194 per 100,000 men aged 55-64 between 1968 and 2005, for example).  Perhaps the right thing to research is what brought about these changes, and how we might extend it.

Things going wrong

The government has spent untold billions on the National Health Service, but there seems to be little improvement in many areas. They have spent more billions on huge IT projects for the Inland Revenue, but they have not worked. The Child Support Agency was a disaster, railways are a mess, education has fallen to pieces. It seems almost all huge projects fail, almost all 'improvements' make things worse. And althought these are public sector examples, the private sector has just as many horror stories (see the banking system), but usually they are kept private.

The question then is why does all this effort to make things better do the opposite. The management guru Charles Handy describes the two error types: type 1 is getting it wrong, that is making mistakes and other types of failure,  type 2 are not getting it right. Almost all of these failed projects and changes are type 2 errors, where avoiding obvious mistakes has taken precedence over achieving the intended outcome, which has dropped from sight.

This blog is a personal view of some of these type 2 errors.