Mea Culpa training course

If you would like to receive a free copy of introductory material of my 5-session training course (“Mea Culpa”) addressed for both frontline staff as well as senior managers, please feel free to contact me by email (azharalani@gmail.com), twitter (@azharalani), LinkedIn or directly on mobile +447842322021. We can also discuss how to deliver the training to your organisation.

Mea Culpa course helps staff at various levels own up to their mistakes and build an organisational trust-based culture of candour. Errors are not only one of the main types of process waste in Lean; they can be fatal as in health care, aviation and energy industries. Admitting to minor mistakes is one approach to avoid having major ones.

Mea Culpa 5-session training course can be delivered to an audience of up to 30 people, either as one-week module or scheduled over a course of up to five weeks as suits the workforce/organisation. Course introductory material (available free upon request) is PowerPoint slides in PDF format of 42 slides, file size 1.84MB. Training materials content can be customised to fit your organisation’s industry.

If doubt begets belief, then vulnerability is essential for trust.

We build on strengths, but beliefs start with doubts. For teams to perform at higher levels, members need to have the courage to take risks, safe in the knowledge of their own vulnerability – in other words, to build trust from the ground up.

In his famous book “The Five Dysfunctions of a Team” Patrick Lencioni outlines the root causes of teams’ inability to realise their optimum potential, and he puts absence of trust at the base of the pyramid:
  

1.       Absence of trust

2.       Fear of conflict

3.       Lack of commitment

4.       Avoidance of team accountability

5.       Inattention to team objectives

As for Descartes, he doubted all his beliefs to see which ones he could be certain were true, or to trust his beliefs if you like. We need to apply this method when building teams to help members realise their full potential. It has been argued that what Descartes really meant by “I think therefore I am” was “I doubt therefore I exist.” The very act of doubting one's own existence serves as a proof of the reality of it, or at least of one's thought. Some say this argument has become the foundation for all knowledge. We can apply Descartes “discourse of the method” to the exercise of building trust among team members by starting with, what I would like to call:

The Declaration of Team Trust.

You see, the beauty of Descartes model is that it starts from scratch, from the ground up, and deconstructs every belief to sort out what’s true and what’s not. Similarly, with Lencioni’s model, trust, being the base of the pyramid and the foundation of a high-performing team, to build it out we need to recognise team members’ vulnerability. We also need to ensure that we will have safety net(s) in place to try out new things and fail-safe when things don’t work out as planned.

As a suggestion for the Declaration, we can ask team members to sign a sort of a social contract for the newly formed team (or newcomer members) using the opening lines in Descartes’ “Meditations” - with some adaptations:

“We might have in the past accepted many false opinions about other team members as being true. Consequently, what we afterward based on such principles was highly doubtful. Going forward, we commit to getting rid of all the opinions we had adopted, and of commencing anew the work of building our team trust from the foundation.”

A new type of “flow” in Lean: know-how vs know-why

Having worked in and led many kaizens, and by coaching executives and managers about the principles of Lean, I have always asked the question: why do we focus only on the process “flow”, how about workers’ flow?

I once came across a business book that had more (positive) psychology than numbers! Fascinated by the title “Good Business,” the book talked about “flow” from the operator/worker perspective. I thought that is a good source to tap in while attempting to extend the concept of “flow” in Lean. The book author, Mihaly Csikszentmihalyi, argues that the quality of experience is a function of the relationship between skills (x) and challenges (y). Optimal Experience, or “flow”, occurs when both variables (x, y) are high.

“We have to grasp not only the Know-How but also ‘Know-Why’” -Shingo

It is fundamental in Lean to implement process flow, as it is a pre-requisite to have “pull” if a process is to be optimised. However, that is all true from the process perspective. In many industries, especially process-intensive ones like energy, healthcare and retail, the flow of the product and the work of the operator are on two different planes, as Shingo showed us in his network of processes vs operations model. Hence, what is needed here is to think of “flow” in Lean down two dimensions: process flow and operator flow. The former is a very well documented in Lean literature. I think we need to shed some light on the latter, let’s call it operator flow.

Operator experience is optimal when the job at hand present the worker with challenges that match their skills, as Csikszentmihalyi eloquently demonstrated in his aforementioned book. This calls for the whole discipline of organisation design to be employed for this discussion – and rightly so. As part of my experience working within huge business transformation programmes, I learned first-hand the importance of sequencing the steps of implementing change: first, design processes to ensure Lean flow/pull: simple, streamlined, standard processes, then and only then, design roles to operate the processes. Bundle related roles together logically and hey presto; you will have job descriptions ready to be published to hire the right people for the right job. If all goes to plan, workers will be able to do the right thing, the right way first time and every time, that was the inspiration.

Csikszentmihalyi neatly summarized the steps required to achieve flow:

• The task at hand is challenging enough – “just right” neither boring nor frustrating
• Focus: you will need to concentrate without interruptions and/or noise
• Crystal-clear goals: if you aim at nothing you will achieve it all the time
• Immediate feedback provided
• Task at hand is meaningful enough to be front and centre and absorb you into it so that everyday life recedes into the background. In other words: know-why not only know-how.
• Sense of self disappears for a while (loss of ego) and when it comes back, you are refreshed. Sense of inspiration and harmony
• You are in control over your actions – autonomy

While Maslow professed “self-actualisation” as the ultimate human achievement, Csikszentmihalyi goes further to say that we need to contribute beyond one’s self as integrated individuals – every worker is unique in their own right but can achieve much more when part of a team – the whole is greater than the sum of its parts. Some ideas have energy of their own, but we need to harness that energy. Most people think Edison and Ford where geniuses who worked alone. Wrong! They were supported by their team and networks and that’s why they were able to turn vision into reality on a continuous basis. They created industries on the back of their innovation. Therefore, in process design, we need to create workplace to be amenable for operator flow to occur.  Letting creativity juice flow is one way of creating such workplaces. By enticing operators to work better together and together better, and encouraging them, especially front-line staff, to come up with new ideas to make their job more efficient and more effective, ie to process-innovate not just product-innovate, we will have a more conducive atmosphere for flow to happen in (at least) two dimensions.

Innovation success factors

• Quality of business ideas – rigorous selection
• Education program – unique, tailored
• Delivery – state of the art- excellence
• Mentors – strong network, wide, world-class
• Inspiring role models

This is one of the risks process standardisation presents to any organisation-redesign programme. Where do you draw the line between locked-down “gold standard” processes and the provision of “sandbox” for workers to innovate? Well, one answer is in the organisation’s vision statement that Csikszentmihalyi wants us to call it the “soul” of the organisation: “if a vision is genuine and is carried into action, it becomes a powerful attractor for members of the organisation. It provides a goal that is worth pursuing over and above the extrinsic rewards that can be provided by the job.” 

I tried discussing Csikszentmihalyi flow when I worked at one of companies in the Middle East. The aim was to increase KPIs to new unprecedented levels – stretch goals if you like. During the session where I was announcing the new targets, I told my team that we need to have jobs to be challenging enough to match your skills, which, after working with my team for several months I was convinced they were to ready to shift gears upwards. And I recall the message worked very well. However, this was also coupled with launching “team collaboration” and “process innovation” awards, which got everyone buzzed, and all wanted to achieve more by working/innovating together.

My article about and Q&A with Shurooq Amin

Exhibition: “Shot! – The Untold Truth of Society Girls” by Shurooq Amin

Words: Azhar Alani - Paintings: Shurooq Amin - Venue: Lahd Gallery, Hampstead, London

Plato once said something to the effect that physical lust involves the eclipse of the soul by the body. When I saw “Take Me to Heaven” painting for the first time, I thought of it as the exact opposite: the soul has triumphed and eclipsed the body in total submission. The half-naked woman in the picture is kneeling totally, where the front of her face is touching a prayer mat or a small carpet she is using for, eh, meditating? Perhaps!Among Amin’s other paintings on display at the Lahd Gallery, this one stopped me, full stop. Amin, a multi-talented artist, presents local cultural dilemmas using traditional devices in an uncanny way - an art form that is hard to describe as just painting. The woman’s wild hairstyle in the “Take Me to Heaven” masterpiece connects it to another striking painting labelled “Medusas Resting”. Go figure!

The two asymmetrical wing-shaped tattoos in blue and red are not only located at the summit of the woman’s body as it’s kneeling, but it’s also the place where Amin shot this painting with a rifle using Hornet cartridge. She said in an interview that she felt, after having done the paintings, that “there was something missing.” That’s when Amin pointed at either the heart or the “summit” of the main character(s) in the pictures and shot them with a rifle to finish off the artworks. Hence the name of this exhibition: “Shot!” as all paintings on display have been actually shot at by the artist. It’s quite a scene when the paintings are viewed in the Gallery where the telltales of the passing bullets are staring at you when you look closer.

And here is another twist: in some countries, like the UK, this particular type of bullet, the Hornet, is prohibited from use on deer for game hunting. Was the aim of shooting then to kill, one wonders - if we use deer as a metaphor for women? And the reason why this type of cartridge is prohibited on deer, you may ask? These bullets are considered “sub-powered.” Now all of a sudden we find ourselves thinking about the suffering of the women portrayed in the pictures. Was Amin trying to show that in the Middle East the “upper crust” has no mercy or bravery to end the suffering of those “society girls," as they are customarily known, who usually fall victim to judgemental labels and misconceptions? Or are we all misled to think this way when those “Medusas” are hiding behind their veils and with that obscuring their true colours?

I wonder if Amin sees herself as an Arab “suffragette” - someone, in her own style, campaigning for the rights of women locally. But where exactly is “locally”? Previous exhibitions by Amin touched upon the identity issue by depicting the polarity of West vs. East and how this contrast plays a huge role in the making of the Arab youth and shaping their aspirations. It’s the inverse of Orientalism if you like: how the West is depicted in the Middle Easterners' mind. 

Like other seminal works of art, Amin’s paintings are loud. They provoke some fundamental questions. I left the gallery with my thoughts already longing to go back and see the paintings afresh. The questions those paintings got me asking started to sound like a true and genuine tone; a voice that I know too well: “I” was asking “myself” about “me.” Amin managed to bring all the three of “us” together right in front of this great painting where the soul was calling: “Take Me to Heaven.”
- Azhar

Q&A with Shurooq Amin

After publishing the article above about Shot! I (AA) asked Amin (SA) few questions about her work.

AA: “Take me to heaven” is a very provocative piece of art; to say the least. Can you tell us a little bit more about it?

SA: “Take Me to Heaven” raises the question of religion vs spirituality. The source of humanity is nakedness; we are born naked. Our connection to God, or to the source, the universe, or whatever you have faith in, is a connection based on purity and intimacy. Whether we pray five times a day or not at all, whether we go to Haj or never set foot near the kabbaa, whether we wear Hijab or a bikini, spirituality comes from within. And a true Muslim should know that God is omnipotent, all-knowing, all-seeing, all-hearing. Hence, this painting is not simply that of a "naked woman praying", and certainly lust was not implicated when it was painted; however, it urges the viewer to open a dialogue and question the validity of religious rituals vs true spirituality.

AA: The UK prohibits the use of Hornet bullets on deer (for game shooting) because it’s “underpowered.” Can you explain your choice of this type of rifle cartridge? (If we can think of deer as a metaphor for women)

SA: I chose the Hornet bullet simply because it was aesthetically the most suitable for my work: it dug through the canvas and the wood in a clean, crisp manner, leaving behind it the right size hole, subtle and understated. I had no idea that it was prohibited in the UK when I decided on using it, nor was I thinking of deer as a metaphor for women. But then again, I find that very interesting indeed. You might get better answers if you hypnotize me, as I've been told my subconscious is far more aware than my conscious [but then again, that applies to everyone, doesn't it :) ].

AA: I found your poem “The Other Wife” a bit out-of-character when viewed against your repertoire. One can sense a deep lsense of oss and longing from a woman who was meant to be up against all what life throws at her.... Was this poem a “one-off”?

SA: No, the poem 'The Other Wife' is not a one-off. In my poems, I frequently take on different personas. Instead of writing about a character, I "become" that character. That poem was triggered by a true story that happened to a friend of a friend. I was instantly disturbed by it. I wanted to be in her shoes and see how it felt, what made a woman reach that level of victimization.

AA: Do you see yourself as an Arab “suffragette” if there is such a movement within the Arab world?

SA: Others see me that way, but I certainly don't. I've done nothing to deserve that title, other than just be really brave (reckless?), and not care at all what critics or fundamentalists say about me. I say things as they are, write without censorship, and paint with integrity. Ultimately, most of my poems, short stories, and paintings are shocking and controversial; but then again, someone's got to do it, say it, paint it. Why not me? When I get a emails or facebook messages or phone calls from fans or clients or other artists saying that I've inspired them, opened up dialogues for them, or just helped them in some way, that's enough for me.

To find out more about Shurooq Amin click here.
For her latest exhibition click here. 

Becoming an Agent of Change

Published in British Medical Journal (BMJ) Learning as a training module with 1hr CME credit.
http://learning.bmj.com/learning/search-result.html?moduleId=5004461

Becoming an agent of change: key principles and practical examples of managing change

 

Learning outcomes:

After completing this module you should know about change management as a discipline as well as your role and contribution to change. You should also know how to start putting what you have learnt into practice. You should:

• Be able to define and recognise change
• Know the difference between change and transition
• Be able to describe the three stages of transition and the four phases of response to change
• Be able to outline the steps for implementing change effectively
• Understand your role and contribution as an agent (or champion) of change.

A Patient Safety Revolution

(This article was published in Arab Health magazine http://content.yudu.com/A1tvqk/ISSUE4/resources/5.htm)

Patient safety is one of the most fundamental principles of medicine as a profession. Hippocrates got it right thousands of years ago when he started his medical oath with “First, do no harm.” Fast-forward to now; while graduating medical students still recite some version of the Oath, the statistics of medical errors are sobering. Management and technology solutions are paving the way for a revolution in patient safety.
I studied and practiced medicine in the Middle East before moving to the UK and witnessed firsthand the importance of patient safety and how the public perception is no different here compared with the West. Until we have clearer statistics on patient safety in the Middle East, let's look at the highest healthcare spending country in the world (14% of GDP). In the US, adverse drug events and patient falls cost hospitals $4.5 billion annually. As many as 780,000 surgical site infections occur each year, up to 60 percent of them preventable. Ventilator-associated pneumonia (VAP) accounts for up to 18 percent of all hospital-acquired infections, affecting some 250,000 patients per year and causing 1.75 million excess hospital days.

Challenges and opportunities

Through the use of advanced event reporting and analyzing systems, every incident (challenge) can be recorded and investigated to understand their root-cause and come up with ways to prevent future ones (opportunity). Frustrations arising from patients as victims of medical errors are also shared by healthcare providers. Patients put their trust in the healthcare systems starting from “doctors know best” to leaving almost all decisions down to their treating clinicians. Healthcare providers also get frustrated when they put all that effort, dedication and commitment into their jobs, only to find out that errors could have been avoided or a better system would have ensured more quality, better reliability and transparent accountability.
 

New era in patient safety

As healthcare systems are being redesigned to focus on measurable outcomes, the delivery system itself is also becoming an increasingly important factor in the provision of safe quality care. Health planners now recognize that healthcare is a function of organization design and not individual effort. We no longer weave our healthcare organizations around surgeons and physicians as the axis of delivery, rather, we are truly moving toward a patient-centric healthcare continuum. However, as a note for caution, methods and tools are not outcomes by themselves; evidence based performance is the ultimate outcome. That’s why GE Healthcare Performance Solutions partners with healthcare organizations to implement transformational change that suits the target organization culture using systems thinking combined with assistive technologies to deliver accessible, high quality safe care for patients.
For example, in the United States, Kent Hospital – along with a number of hospitals in Rhode Island – experienced several serious patient safety events. To improve safety and address these events, Kent implemented GE Healthcare’s Medical Event Reporting System (MERS) to track and analyze safety events and address the root causes of error.  The reporting tool empowered the staff to report not only when events occurred, but also when errors might have occurred. Recognizing that true change was only possible if accepted by the hospital’s staff, Kent also implemented cultural change strategies to ease transition to software reporting and cultivate executive communication. In just 7 months, Kent recorded 1,993 reports – up from 1,356 for the total Fiscal Year 2010. In addition, within 30 to 45 days after the system went live, Kent received enough reports to identify two processes of the hospital where near-miss events were an issue: the laboratory specimens and radiology orders. Measures are now being taken to correct processes and reduce the potential of future errors.

Simple change, big gain

In 2006, I wrote about “back to basics” in the British Medical Journal to emphasize that by applying management concepts, healthcare performance can be enhanced and outcomes improved. All healthcare processes start and end with the patient, and using techniques such as value stream mapping provides the ability to employ system-wide thinking to reorganize the way we deliver healthcare.
From appointment booking, through patient hand-offs and all the way to discharge and beyond, if we start/continue looking at the process through patients’ eyes, not only will we identify opportunities for improving quality and avoiding errors, but we will save time and effort and allow more space to have embedded checks and balances to ensure sustainability in the newly adopted quality measures. Quick-fixes and short-term “bandages” should be avoided; we are aiming at longer term system-wide approach.
 

Leaning healthcare: process sapiens

GE helps its clients through the use of lean methods to remove non-value added steps from any given process. The aim is to simplify, streamline and standardize processes to be able to do the right things the right way first and every time. The success of lean thinking is strongly supported by academic research; however there is still a hurdle to be overcome. Maria Rieders, an adjunct professor of operations and information management at Wharton, has observed various lean healthcare initiatives. Over the last few years, she says, hospitals have systematically decreased the number of infections by standardizing their procedures. Healthcare professionals are dedicated and well-educated people who focus on doing the best at all times. However, the challenge they face is that whilst they are very good at coming up with a quick solution when faced with a problem, they are not trained to be “systems thinkers.”
GE Healthcare is committed to helping professionals deliver safer patient care and has set in motion a revolution in how to tackle this issue. GE Healthcare Performance Solutions has established a Patient Safety Organization (PSO) as both a think-tank and a delivery arm to put together concepts and implementable solutions to minimize medical errors. While technology is definitely helpful, like Medical Event Reporting System (MERS), the Performance Solutions team is also adapting methods and tools used in other process-intensive industries (like aviation, energy and retail) to apply best practices and quality systems (like Lean, Six Sigma) into the healthcare sector. Through the unique adoption and use of IT, analytics helps provide new insights uncovering new ways to prevent and address any areas within healthcare processes that are error-prone.
Medicine is both an art and a science; so is lean. True change in patient safety will only come when we think beyond data, methods and techniques, and focus on acceptance, culture and behaviour of all those involved in delivering the change initiative focused on safe quality care to the patient..

Simple Change, Big Gain

The role of managers in the provision of healthcare.

(This article was published in the British Medical Journal http://careers.bmj.com/careers/advice/view-article.html?id=1998)

Do any of these sound familiar: cancelled appointments, delayed or lost results, no access to patient records or history, “same problem, every day, for years,” and a surgeon told to “go slow” because he is too efficient? [1]

 

Imbalance

Often the quality of service provided by healthcare professionals does not match their dedication and aspirations. This imbalance presents a case for review from inside the healthcare system. No single solution will fix all of the above mentioned situations, but small changes can make daily work more efficient. As you have probably guessed, in this article I will be talking about the role of healthcare managers.
I will make one point first: this article is not about the National Programme for Information Technology (NPfIT) and its benefits. NHS Connecting for Health, a relatively new agency of the Department of Health, has a well written website with all the related information. [2] The set of changes that will be introduced to health care in England and Wales by NPfIT will lay the foundation for a more efficient system. However, these changes will have to start from within the community of health professionals. Healthcare managers can help facilitate these changes because they will have a critical role in bringing these modifications successfully to the fore. Of course, we will need an NHS care records service, choose and book, electronic transmission of prescriptions, a national network, contact, picture archiving and communications systems, and IT supporting general practitioners. But as you can see from the NPfIT portfolio (see box for definitions), these are mere systems that will be put in place, and health professionals will be left to work them out. This article is about going back to the basics of management and its timeless principles, and how healthcare managers can facilitate the work of health professionals.

Impact of simple changes

A recent edition of Harvard Business Review gives examples of how simple and relatively easy changes could have a great impact on the daily work of health professionals. [3] Steven Spear, a senior fellow at the Institute for Healthcare Improvement in Cambridge, Massachusetts, argues that in the United States medicine does not deliver on the science it employs. I think we can add technology to this statement as one of the short changed assets. Healthcare safety expert Lucian Leape compares the risk of entering an American hospital to that of parachuting off a building because of the number of people who die each year in US hospitals from medical errors. [4] This is happening in a country that is committing trillions of dollars to its healthcare budget. The UK government has already secured billions of pounds for NPfIT. So the issue is not solely financial. It is not that health professionals don't care either. People working in health care are typically intelligent and well trained and have chosen their careers expressly to cure and comfort. Spear has followed several projects over the past five years. These projects are about opportunities that need little capital, can be started immediately, and in most cases can be realised in the near term. Before I summarise the main points of his work, you need to understand why there is a gap between the skills and intentions of healthcare professionals and the US healthcare system's performance. Spear argues that the problem arises partly from the system's complexity. This inherent complexity creates many opportunities for confusion, especially in a multi-team care setting. On the other hand, healthcare workers contribute to the problem by adapting a “work around” culture. Rather than improving the process of doing their daily jobs, they just adopt a short term measure. The quick fix then becomes an almost permanent solution as the involved team becomes accustomed to it as their daily routine.
Here is a summary of two of Spear's case studies and projects.

Theme: ambiguity

Preparing a patient for surgery requires a number of steps, one of which is to take blood samples for investigation. Nurses at Western Pennsylvania Hospital were uncertain whether blood had already been taken from admitted patients or not. So, visual indicators were introduced to identify which patients needed the procedure. The second uncertainty was who should do it. The unit designated a staff member to be the sole person responsible. To be more efficient, they agreed to take samples as soon as the patient was registered. Despite all of these changes, a few patients were still turning up at the operating theatre without blood test results. The process was reviewed further, and it turned out that it was unclear where the procedure should take place. The unit converted a small closet into a room to take blood samples. With this final change, the number of patients without blood tests fell to zero and stayed at that level.
Spear noted that much of the credit for the successes at this hospital could be attributed to the problem solving support provided by the unit's clinical coordinator. In a previous incarnation of the clinical coordinator's role, it was simply about we “need this and that” and “there you have it.” Missing laboratory test results, important paperwork, and so on were on the daily to do list. The newly defined role of this particular clinical coordinator was to investigate and work with key people solving reported problems. Solutions were jointly developed, tested, and validated. Ambiguity was tackled by applying simple management skills and employing an experimenting method.

Theme: work operations excellence

Two dozen hospitals in Pittsburgh have reduced the incidence of central line infections by more than 50%. In one hospital, a team of infection control experts documented every line insertion and identified variations and shortcomings. Measures were developed to improve this procedure. Changes were designed to make it clear:
Who was to get what procedure. For example, a new rule was introduced whereby all new admissions with central lines were to have new ones so that the history of the current line could be verified

Who did which aspect of the procedure

What signals could be used to trigger the work: visual aids to prompt removal sooner rather than later, transparent dressings to give a view of the wound site (to see whether it's infected)

Precisely how each step would be carried out: new types of disinfectant, various sized surgical drapes, and a new arrangement of the kit used in this procedure was devised from controlled trials to identify best practices.

Human error

One study showed that for every death due to drug treatment error there were 10 injuries (non-fatal) and 100 instances where harm was averted. [5] Unfortunately, it is only after a patient dies or suffers serious injury that the type of mistakes and the contributing factors are studied. This is where managers and coordinators have their (other) role. Managers can help to implement a common approach to process design and implementation by encouraging “experiments” in a controlled and safe situation (even if that means a mock set up to witness and learn from daily routines with a fresh pair of eyes without the rush of “just do it now”). Healthcare managers can help turn daily work into continuous learning and learning into a collective asset of best practices. In the two examples, simple practical solutions were introduced. Managers can make sure that problems are revealed as they occur and addressed in a structured manner (where the situation permits—in emergency cases lessons learnt can be deferred). When managers work with their colleagues from other departments they can systematically deploy all these enhancements. It is by switching from “why you didn't do your work” to “why you couldn't do your work” that specifics are picked up and addressed in an organised fashion. It's a change in attitude and sometimes a change in behaviour of teamwork. This is what's needed now.

Finally, there was the story of the NHS surgeon who said he would not be forced to have a waiting list. [1] Mr Alastair Paterson, a consultant at the Royal Cornwall Hospital in Truro, said he ran a diary system, which meant seeing and speaking to patients and making a date for their operation. He has never had a waiting list. He said: “I see this as being efficient and also kind to my patients.”
Back to the examples cited in the first paragraph, can you identify a way to address these situations? And, curiously, for the efficient surgeon who was told to take it easy, I think you can see my point of how these changes can be implemented outside the frame of the NHS, can't you?

 

References

1 BBC News. Surgeon told to make people wait. BBC News  2005, 7 2 December.http://news.bbc.co.uk/1/hi/england/cornwall/4506734.stm
3NHS Connecting for Health agency: www.connectingforhealth.nhs.uk
4 Spear SJ. Fixing healthcare from the inside, today. Harvard Business Review  2005, September.
5 Leape L, Adjunct Professor of Health Policy, Department of Health Policy and 6 Management.www.hsph.harvard.edu/faculty/LucianLeape.html
7 Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group. JAMA  1995;274: 29-34.