Blame game versus root cause analysis

The blame game is what we play. Root cause analysis is what we need. The latter gets at the primary reason for a problem: why some process fails to achieve its intended outcome or it produces a surprise result. No value judgment - good or bad - is made.

Blaming involves finding some person or group to label as the "bad guy." Jeffrey Skilling, CEO of Enron, was a "bad guy." He was a culprit and a symptom, but not a cause of the problem. The Enron disaster was caused by its corporate culture and loopholes in finance/SEC regulations. Together, these two root causes allowed a massive fraud to occur.

Punishing Skilling may satisfy our need for vengeance and even justice. Punishing him was appropriate: he broke the law. However, punishing him will not fix the problem. Without addressing root causes, problems always recur.

A recent Commenter asked a very, very important series of questions related to blaming and solving problems. [A] "Can you tell me who benefits from the [system] status quo? [B] Why is so hard to change the system? [C] If everyone thinks it [our healthcare system] sucks, why does it continue to get worse? [D] If you can't identify who or what is responsible for 'the system,' how do we fix it?"

The simple answer to [A] is all those who are doing well under the status quo: insurance companies; bureaucrats and politicians who keep their jobs; inefficient hospitals, who survive when they would go under in a free market; rules and regulations that are frankly contradictory; and all those to whom change is threatening (the majority).

The system is hard to change - question [B] - because the system is just like a human body: it exhibits homeostasis, which means it defends itself against any change. It wants to stay just the way it is right now.

The healthcare system keeps getting worse - question [C] - because there is only one group with the power and the need for change - us - but we do not agree on what changes we want nor have we demanded system change. That is the reason why I blog here and on www.thesystemmd.com: to get us to talk, achieve a consensus, and demand change.

Question [D] is critical. No one controls or even "is responsible" for the system. You don't fix the system by punishing or changing the people. You fix the system by changing the processes within the system. For instance, incentives affect behavior (child-rearing 101). If you want time with the doctor, do NOT pay her or him based on so-called efficiency, which is measured as patients per hour. That is what we do now, so are you surprised that the doctor has very little time for you? We need incentives that encourage the behaviors we desire.

Management 101 teaches that you get whatever you measure carefully. Do we really want deaths, costs, complications and lawsuits? Because those are the things most consistently measured in health care. We say that we want to retain our nurses but measure only how many leave (turnover). We should measure and follow the outcomes we want.

You require the doctor to make recommendations based on good hard scientific evidence. Why do you not expect the same from the managers and regulators of healthcare?

"How do we fix the healthcare system?" Find the root causes of problems and fix them. This translates to: incentives that are linked to behaviors we desire; measuring outcomes that we want; and requiring ALL decisions, not just strictly medical ones, to be evidence-based with proper feedback. Blaming plays no role in fixing healthcare (or anything else).