Eric Grosch, Letter to Dr. Morgenstern on LOR - Semmelweis ...

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. Carry out the change or test decided upon, preferably on a small scale. c. Observe the effects of the change or test. d. Study the results. What did we learn? What can we predict?...(Deming 1986, 88) 5. A leader will discover who if any of his people is (a) outside the system on the good side, (b) outside on the poor side, (c) belonging <strong>to</strong> the system. The calculations required...are...simple if numbers are used for measures of performance. Ranking of people...that belong <strong>to</strong> the system violates scientific logic and is ruinous as a policy,... In the absence of numerical data, a leader must make subjective judgment. A leader will spend hours with every one of his people. They will know what kind of help they need... People...on the poor side of the system will require individual help....(Deming 1986 117)... 7. Hold a long interview...three or four hours, at least...not for criticism, but for help and...everybody[‘s]...better understanding... 8. Figures on performance should be used not <strong>to</strong> rank the people...that fall within the system, but <strong>to</strong> assist the leader <strong>to</strong> accomplish improvement of the system...(118) ...Running a company on visible figures alone (counting the money). One can not be successful on visible figures alone...he that would run his company on visible figures alone will in time have neither company nor figures. ...the most important figures...are unknown and unknowable..., but successful management must nevertheless take account of them. Examples. Fallacies of reward for winning in a lottery. A man in the personnel department of a large company came forth with an idea, held as brilliant...<strong>to</strong> reward the <strong>to</strong>p (274) man of the month on a certain production line (the man that made the lowest proportion defective over the month) with a citation. There would be a small party on the job in his honor, and he would get half a day off. This might be a great idea if he were indeed an unusual performer for the month. There were 50 men on the production line. Do the results of inspection of their work form a statistical system...? If the work of the group forms a statistical system, then the prize would be merely a lottery...if the <strong>to</strong>p man is a special cause on the side of low proportion defective, then he is indeed outstanding. He would deserve recognition, and he could be a focal point for teaching men how <strong>to</strong> do the job. There is no harm in a lottery...provided it is called a lottery. To call it an award of merit when the selection is merely a lottery...is <strong>to</strong> demoralize the whole force, prize winners included. Everybody will suppose that there are good reasons for the selection and will be trying <strong>to</strong> explain and reduce differences between men. This would be a futile exercise when the only differences are random
deviations, as is the case when the performance of the 50 men form[s] a statistical system. (Deming 1986 275) [5] In a similar vein, Ierodiakonou and Vandenbroucke term medicine a s<strong>to</strong>chastic art: Ancient Greek philosophers thought that medicine was an art with peculiar characteristics, and they called medicine a s<strong>to</strong>chastic art. A doc<strong>to</strong>r might treat a patient conscientiously according <strong>to</strong> all learned precepts; yet the patients' condition might deteriorate. Another patient might be treated rather carelessly by another doc<strong>to</strong>r; yet the patient might regain full health. Thus, in medicine there exists unpredictability between means and ends. By contrast with other arts a diligent execution of the tasks does not guarantee a good outcome, and vice versa... ...we have long witnessed a debate on the right way <strong>to</strong> measure the quality of medical care: should we use outcome or process criteria?...For instance, a few years ago, (542) a series of outcome investigations was started in the USA. Presumably, some administra<strong>to</strong>rs had been convinced that even in health care, quality of performance should be measured according <strong>to</strong> strict outcome criteria, as is practised in the Japanese car industry, for example. The simplest outcome measure was mortality in hospital. Third party payers such as the Health Care Financing Administration, which administrates Medicare, started <strong>to</strong> rank hospitals according <strong>to</strong> mortality rates for specific procedures. The mere idea sent ripples of alarm through the American Medical Association (AMA). Do not we intuitively know that medical centres with the highest reputation attract patients whose illnesses are close <strong>to</strong> being beyond rescue? Advanced epidemiological techniques have proved that differences in hospital mortality can be explained away by adjustment for differences in patient mix. To use outcome as a means <strong>to</strong> moni<strong>to</strong>r quality would necessitate continuous evaluation of all individual patient characteristics. This process would be a gigantic research effort, close <strong>to</strong> the examination of treatments in randomised controlled trials, and would defy all realistic efforts at quality assurance. The whole armamentarium of epidemiology and statistics, such as randomisation, matching, blinding, placebo-procedures, strict selection criteria, and modelling, aims at mastering the s<strong>to</strong>chastic elements that confound our judgment...[6] Why should the performance of trainees be deterministic, not s<strong>to</strong>chastic, inasmuch as the s<strong>to</strong>chastic vagaries of patient-characteristics (case-mix) must influence it, in any individual instance? The difference is that hospital-administra<strong>to</strong>rs have an influential voice in such decision-making. The individual trainee does not. Under pervasive fear of rating, the trainee dares not ask a question that he thinks that the rater might think foolish. He has <strong>to</strong> confine his questions only <strong>to</strong> what he considers “intelligent,” posed with the purpose in mind of impressing the rater with his insight and wisdom, beyond his years. The good regard of the rater is the trainee's life-preserver, on a s<strong>to</strong>rmy sea of insecurity. The trainee walks on eggshells, fearing that his every move, his every word is an element in a cumulative body of chit-marks that may eventually <strong>to</strong>rpedo his reputation. If he should get a black mark against him, for any reason, and the rater learns of it, the trainee shall thereby have lost the rater's support and enter career free-fall. Accordingly, he pre-edits all questions for acceptability before letting them out of his mouth. If he can't think of a zinger of a question, he'll most likely stay mum and live in ignorance about a broad variety of subjects, out of fear of asking a “stupid
Page 1 and 2: DR. ERIC N GROSCH - A new approach
Page 3 and 4: i. distortion from
Page 5 and 6: they were inferior. It is unfair, a
Page 7: Another Irving Langmuir? Can Americ
Page 11 and 12: method[11,12] for “objective” e
Page 13 and 14: than we now possess.[21] The progre
Page 15 and 16: 3. Descriptive, Not Evaluative. Use
Page 17 and 18: University, addressed merit-ratings
Page 19 and 20: etter than any of his contemporarie
Page 21 and 22: In the industrial setting, in which
Page 23 and 24: criteria did the evaluato</
Page 25 and 26: Is it true or false that for every
Page 27 and 28: and the results . . . have been goo
Page 29: home, possibly as a way of accumula

Eric Grosch, Letter to Dr. Morgenstern on LOR - Semmelweis ...

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