Bah Humbug!

Now, before you get too upset that I am going to go all Ebenezer Scrooge on you, this BLOG has a happy ending.

But around about now one starts to see headlines like the one below:

Dangerous decorations, fairy light injuries and death by snow: Why Christmas is the most perilous time of the year

• One in five risks food poisoning from turkey leftovers
• Falling snow and ice kills 25 people a year
• Of the 350 reported fairy light injuries, most occurred whilst decorating
                                              By SARA MALM
                                              PUBLISHED: 04:48 GMT, 19 December 2012 | UPDATED: 07:31 GMT, 19 December 2012

And warnings about the dangers, not of Christmas itself, but associated with it. And fair enough. Christmas is one of those celebratory times of year when we do things we would not otherwise do, which, by definition suggests these are marginal activities for us; like drinking too much, eating too much, trying to do more than we should in a given period of time aka ‘rushing’, trying too hard to impress or please family and friends. In Australia, where I usually celebrate Christmas, it is common for tourists to drown in the surf, unused as they are to the wonders and whiles of the sea.

So my message to you this Christmas  is to ‘chill’ and enjoy without going ‘extreme’.

Don’t drink too much, don’t eat too much,don’t drive, definitely don’t drink AND drive, don’t go swimming, definitely don’t go swimming after eating/drinking too much, don’t stress out about right present/wrong present/ decorations/ the guest in the corner you don’t recognise (but check to see if he/she does belong to someone in the room you do know, don’t give dangerous presents (to children)……..just ‘chill’ and enjoy.

So from all of us here in the ISQua office, to all our you, who visit our website, wherever you are in the world.

SEASONS GREETINGS!

From little things big things grow.

Systems – can’t live with them; can’t live without them.

“Everything must be made as simple as possible. But not simpler.”
― Albert Einstein


My day is organised and managed in accordance with a careful plan – I have a system. The underpinnings of this system have been more or less the same for a while now.
And in one or more respects this system always fails.

Lord Darzi said in his ISQua Global Leader Lecture in May this year that from the time he awoke on the morning of the Lecture to the time he stood to deliver it he had made perhaps half a dozen errors, no doubt despite the fact he had a plan, a system in mind for the day. All were minor, none was fatal but somehow the plan was imperfect (although it may have been as good as it could have been). We all experience this all the time.

But are these our failures or has ‘the system let us down’?

In thinking about this BLOG I scribbled down the following words late one night….:
‘All systems failure is human failure – why? – because people design the systems’

This seemed so blindingly obvious and simple (simplistic as it turned out) that I immediately assumed it was a well held and oft recited view and that I had read it somewhere and it had just percolated from my sub conscious to my conscious being. But GOOGLE all I like and I could not find a quote along these lines. So, if it is not a universal veritas then perhaps it is not so (mind you, it is well to remember that, in Roman mythology, Veritas, who was the goddess of truth, a daughter of Saturn and the mother of Virtue, hid in the bottom of a holy well because she was so elusive).

So, let’s see what we can find out….

SYSTEM………the word is so widely applied and misapplied it can mean almost anything that has more than one component to it. I have lamented the misuse of words, labels and ideas in my BLOG in the past, for example, ‘tipping point’, and system is one of the most misapplied I can think of.

I considered the definition ‘A group of interacting, interrelated or interdependent elements forming a complex whole’  . This does not convey the dynamism of systems sufficiently for me.

I like even less…….  ‘A condition of harmonious, orderly action’.   Really!? Harmonious and orderly?  Some maybe.

So, I have decided to craft my own definition……….. ‘A collection of stable and dynamic elements, and tools, coordinated and managed by a process, seeking to achieve a predetermined outcome’.

So what might be a ‘health system’? That is how do we APPLY HEALTH? How do we make health happen?

Donabedien talked about ‘structure, process, outcome’.

But you and I have seen the breakdown of systems often enough to recognise their complexity. Elements act independently of the system and the system impinges on the elements within it and those bombarding it from without so the whole thing gets thrown out of whack.
‘Every intervention from the simplest to the most complex has an effect on the overall system and the overall system has an effect on every intervention.’  (de Savigny and Adam eds 2009)

This is where Systems Thinking might play a role.

‘Systems thinking works to reveal the underlying characteristics and relationships of systems’  (idem)          

But sometimes you need a miracle if you are to succeed.

Systems thinking can ‘…accelerate the strengthening of systems’  (idem) but only if it is applied with liberal doses of leadership, conviction and commitment. When used properly it can find where the blockages are and give us ideas on how to clear those blockages.

Is systems failure all down to human error at the coalface? In some cases it clearly is. The workers at the Bhopal chemical plant pumped Methyl-isocyanate into a leaking tank; the officers and crew of the Herald of Free Enterprise set to sea with their bow doors open; the Costa Concordia was deliberately diverted from her planned course at the Isola del Giglio; Night Nurse Marie misread the medication chart on the ward because she had left her reading glasses at the nurses’ station. In other cases, not so much and systems failure can be more down to managerial or organisational factors that create the pre-conditions for things to go wrong. But then I ask myself, are not deficient managerial and organisational factors man made problems?

Chris Johnson talks about management’s role as organising and managing work practices; and managerial failure being when they do this badly. He identifies another culprit though, which I think is important, and which is often overlooked; this is regulatory failure. Regulatory failure refers to the ways in which governments and other statutory bodies govern and monitor the work practices of companies and industry.

Johnson argues that the role of managerial and regulatory practices as preconditions for human error has been particularly neglected. He says most human factors and systems engineering has focussed on the immediate causes of human error and systems failure and has not looked at the organisational and regulatory context of that error, in other words, step back look at the forest as well as the trees.

‘Given the complexity of healthcare work systems and processes’……there is a need to…. ‘emphasise the need for increasing partnerships between health sciences and human factors and systems engineering to improve patient safety’ (Carayon 2010).

Transitions of care are increasing – this is a high risk process. A transition may occur within a ‘system’ or between ‘systems’. Either way they are plagued by poor communication and inconsistency in care and adverse events are a common outcome (Beach et al 2003).

Returning to Lord Darzi’s Global Leader Lecture; I was interested to hear him talk about the high correlation between one factor, being patient satisfaction/feedback, and most if not all other commonly used measures of patient safety/quality. He suggested a quick and accurate way of determining if you are doing it right is to ask the patient if you are doing it well in her or his eyes.
This is patient centered care, and it’s good because not only is it safer care but it is ‘…. care that is respectful of and responsive to individual and patient preferences, needs, values …’   and ensures ‘…patient values guide all clinical decisions’. (Institute of Medicine Committee on Quality of Health Care in America 2001).

Donabedian may have characterised health systems as structure – process – outcomes but he also referred to another important, and for him the most important ingredient. So I will let Donabedien have the last word:

“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love.”

Peter Carter
Chief Executive Officer
October 2014

Professor the Lord Darzi of Denham
http://www.isqua.org/education/resource-centre/lord-darzi's-global-leader-lecture

Don de Savigny; Taghreed Adam eds: Systems Think in for Health Systems Strengthening. WHO, Alliance for Health Policy and Systems Research: 2009.

C.W. Johnson, Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting, University of Glasgow Press, Glasgow, Scotland, October 2003.


Pascale Carayon et al:  Patient Safety: The Role of Human Factors and Systems Engineering. Stud Health Technol Inform. 2010 153: 23 – 46. 

Beach C.  et al: Profiles in Patient Safety: emergency care transitions. Academic Emergency medicine. 2003; 10(4): 364-367.

‘A CHAMPION TEAM WILL ALWAYS BEAT A TEAM OF CHAMPIONS’

“Teamwork: Easier Said than Done” 
― Nauman Faridi

A team is not necessarily a group.

And a group is not necessarily a team.

GROUP:- any collection or assemblage of persons or things.

TEAM:- a number of individuals undertaking different tasks with a view to achieving a pre-determined goal.

TEAM

 Groups have to exist in the same time and usually in the same place. The key characteristic of a group is that of being a collection of individuals who are designated as a ‘group’, that’s it.

The individuals who make up teams on the other hand can exist in the same place or different places; in the same time or in different times.

A group can have no purpose, one purpose or many purposes. A no purpose group: a number of individuals who share a geographical proximity ie they just happen to be standing together for the moment. A one purpose group: the protest march. The many purpose group: the crowd at a U2 concert.

A team can have only one purpose.

If an organisation has one purpose (goal) it has one team and if it doesn’t it will be dysfunctional. It will also be one group. If an organisation has a number of purposes (goals) it will have a corresponding number of teams; BUT it will be, at the same time, one group.

Group members’ individual roles/tasks are not specifically defined and many individual members may have the same role/task.

Team members’ individual roles are clearly specifically defined and duplication of roles is avoided. Take the Australian Rugby team, the Wallabies; 15 team members each with a clearly defined and differentiated task BUT each with a common goal, to win by scoring points. This is not a group.

GROUP or TEAM ?

I have been told that it has been ‘agreed’ by these groups of birds in chevron flight that the two birds immediately behind the leader rest in anticipation of their turn as leader. If that is so, this group is starting to look like a team. To confuse things even further one definition of ‘flock’ is: a large group of things

GROUP

Then why is it that in researching for this BLOG I found the terms used interchangeably so often?

Having got that off my chest……….; what I want to just touch on in the space and time I have available is the evolution and current state of play of teamwork in healthcare.

To Err Is Human: Building a Safer Health System ₍₁₎ had a lot to do with generating interest in the creation of teams for the delivery of healthcare by highlighting that preventable medical errors, of which it turned out there were many, were often the result of dysfunctional or non-existent teamwork.

Yet,  ‘… training programs designed to improve team skills are still a new concept for medicine, particularly for physicians who are trained largely to be self-sufficient and individually responsible for their actions. On the other hand, outside of healthcare, research has shown that teams working together in high-risk and high-intensity work environments make fewer mistakes than individuals’ ₍₂₎.

So if we agree that effective teamwork is integral to enhanced clinical outcomes in the provision of healthcare, all we need to do is to introduce teamwork (dare I say in lieu of groupwork). Easy. Not so easy (“Teamwork: Easier Said than Done” ― Nauman Faridi )

Even today there is limited knowledge of what makes health professionals effective team members, and even less information on how to develop skills for teamwork. Often it depends on to whom you talk. Healthcare managers might select leadership, knowledge of organizational goals and strategies and organizational commitment, respect for others, commitment to working collaboratively and to achieving a quality outcome. It does not take much experience, or imagination for that matter, to recognise that clinicians would identify a largely (although, admittedly, not entirely) different skill set. One skill that I would expect to see on the lists of both is communication.

Go to:

Background

Although effective teamwork has been consistently identified as a requirement for enhanced clinical outcomes in the provision of healthcare, there is limited knowledge of what makes health professionals effective team members, and even less information on how to develop skills for teamwork. This study identified critical teamwork competencies for health service managers.

Methods

Members of a state branch of the professional association of Australian health service managers participated in a teamwork survey.

Results

The 37% response rate enabled identification of a management teamwork competency set comprising leadership, knowledge of organizational goals and strategies and organizational commitment, respect for others, commitment to working collaboratively and to achieving a quality outcome.

Conclusion

Although not part of the research question the data suggested that the competencies for effective teamwork are perceived to be different for management and clinical teams, and there are differences in the perceptions of effective teamwork competencies between male and female health service managers. This study adds to the growing evidence that the focus on individual skill development and individual accountability and achievement that results from existing models of health professional training, and which is continually reinforced by human resource management practices within healthcare systems, is not consistent with the competencies required for effective teamwork.

Inadvertent patient harm is all too often the result of absent or poor communication. Medical care is complex and complete and accurate expression through language is limited. Creating a healthcare environment, clinical or non-clinical, where all those working together feel empowered to speak, is the first step; and the second is to adopt a standardised, common language where what you mean when you express yourself is what I understand when I hear what you say. Mistakes are inevitable if we do not do this.

But back to the teaching of healthcare, right back, to the undergraduate years.

The existing focus is still largely on   ‘.. individual skill development and individual accountability and achievement that results from existing models of health professional training, and which is continually reinforced by human resource management practices within healthcare systems, is not consistent with the competencies required for effective teamwork.’_(6.)

Things are improving, which is something, but ever so slowly………

As they say in rugby……..

‘A CHAMPION TEAM WILL ALWAYS BEAT A TEAM OF CHAMPIONS’

Peter Carter

Chief Executive Officer

August 07 2014

1.         November 1999

        I N S T I T U T E O F M E D I C I N E

       Shaping the Future for Health

       TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM

2.         Mt Sinai J Med. 2009 Aug;76(4):318-29. doi: 10.1002/msj.20129.

        Teaching teamwork in medical education.

        Lerner S1, Magrane D, Friedman E.

3.        Qual Saf Health Care 2004;13:i85-i90 doi:10.1136/qshc.2004.010033

       The human factor: the critical importance of effective teamwork and communication in providing            safe care

       M Leonard₁, S Graham₂, D Bonacum

        4.    Teamwork and patient safety in dynamic domains of healthcare: a review of the literature

       T. MANSER

       Article first published online: 22 OCT 2008

       Acta Anaesthesiologica Scandinavica

       Volume 53, Issue 2, pages 143–151, February 2009

5.         Computational & Mathematical Organization Theory

        December 2000, Volume 6, Issue 4, pp 339-360

        Virtual Teams: What are their Characteristics, and Impact on Team Performance?

          Sze-Sze Wong,  Richard M. Burton

6.          BMC Health Serv Res. 2007; 7: 17.

         Published online Feb 7, 2007. doi:  10.1186/1472-6963-7-17

         Effective healthcare teams require effective team members: defining teamwork competencies

         Sandra G Leggat

I’ll scratch your back..and guess what? You don’t have to scratch mine

“Animals have genes for altruism, and those genes have been selected in the evolution of many creatures because of the advantage they confer for the continuing survival of the species.”  Lewis Thomas

I had not previously been to a ‘coffee tasting’ so was interested to go along when a friend invited me to ‘3FC’ in Grand Canal Street in Dublin to taste the coffees. Fergal’s wife, Siobhán is about to open her third bistro, restaurant, foodstore and Siobhán had given Fergal the task of choosing the coffees for the new Clontarf bistro.

Fergal is Irish (what else!) and as such is bubbling with knowledge, ideas and opinions; some brilliant and some whacky. He is also a lawyer and for a time headed ‘Legal’ in one of the big banks. Between sips of coffee Fergal opined that the misery inflicted on the Irish people during the global financial crisis was a product of stupid government, greedy business and complicit lawyers. Only the teaching and healthcare sectors stood apart and above all that incompetence and skulduggery; all those dreadful sins of omission and commission.

It is certainly true that in public surveys politicians and lawyers (and, since the GFC, bankers!) are consistently listed last on qualities like honesty and integrity and teachers and doctors are consistently listed first. Why is this so? After all, in the case of clinicians, salaries are generally high and physicians lifestyles envied by many. People in other walks of life who make a lot of money are also envied but not so universally admired and respected as are doctors. Much of it has to do with the public perception of why people enter the medical profession. And this perception is that they do so not for material benefit but for altruistic reasons. Is the perception the reality?

The answer that I am going to offer to this question is an answer I always criticise as a ‘cop out’ when others give it in other circumstances – but it is the right answer in this case – and that is…. ‘Yes and No’.

The literature on this suggests that one of the motivating factors is material gain.

But, hang on, material gain? On average, in recent times, medicos salaries have dropped on average by 7% while there has been a rise of 7% across other professions – a net loss to the docs of 14%. And as Erich H. Loewy ¹ , points out, in the former Soviet Union and even today in the newly independent former Russian states, the demand for places in medical schools was astronomical despite the prospect of a meagre salary on graduation.

Loewy goes on to cite examples of the enormous amount of selfless pro-bono work undertaken across the healthcare profession when work is done for no material benefit and often in the most inhospitable of 

Interplast Australia

conditions. I can cite many examples of this too. The Pacific Islands Project of the Royal Australasian College of Surgeons saw teams comprised of surgeons, internists, nurses, anaesthetists and technicians spending time in the most trying of settings delivering life saving and life enhancing medical care without any financial return while still bearing the costs of their practices at home, usually from their savings. Similarly, the training, mentoring, advising and hand holding of the next generation of doctors by the current generation is done for love, not money. I am reminded of a leading Neurosurgeon, who was senior examiner for the College of Surgeons, being reported to the local council for disturbing the amenity of the neighbourhood in which he lived because he was in the habit of attaching a floodlight to the front of his lawnmower and mowing his lawn at 5am. It so happened that this always coincided with the weekends on which he was officiating at the surgical exams where each day started at 7am and finished at 11 pm.  No money changed hands for this.

I like Lowey’s story of a cardiac surgeon who was so busy with his pro-bono work that he could only enjoy his hobby of car restoration vicariously; that’s right, he hired someone to restore his cars for him.

I know there are healthcare workers whose prime motivation in plying their trade is for the material rewards, I know this because I have worked with such people. But I can count them on the fingers of one hand and they are soon forgotten because they are not the healthcare workers that make a difference.

So, to all you altruists out there, well done and thank you, it is you who are shaping the future.

So, back to where all this started, a discussion over coffee. Fergal and I liked the Ethiopian coffee the best so the Bistro in *Clontarf will be the place for you to go for great coffee when next in Dublin.

Footnote* This year celebrates the 1000 anniversary of the Battle of Clontarf.

“Battle of Clontarf” 

oil on canvas painting by Hugh Frazer, 1826

The Battle of Clontarf (Irish: Cath Chluain Tarbh) was a battle that took place on 23 April 1014 at Clontarf, near Dublin, on the east coast of Ireland. It pitted the forces of Brian Boru, High King of Ireland, against a Viking-Irish alliance comprising the forces of Sigtrygg Silkbeard, King of Dublin, Máel Mórda mac Murchada, King of Leinster, and a Viking contingent led by Sigurd of Orkney and Brodir of Mann. 

It lasted from sunrise to sunset, and ended in a rout of the Viking and Leinster forces. It is estimated that between 7,000 and 10,000 men were killed. Although Brian's forces were victorious, Brian himself was killed, as were his son Murchad and his grandson Toirdelbach. Leinster King Máel Mórda and Viking leaders Sigurd and Brodir were also slain. After the battle, the Vikings of Dublin were reduced to a secondary power. Brian's family was temporarily eclipsed, and there was no undisputed High King of Ireland until the late 12th century.

The battle was an important event in Irish history and is recorded in both Irish and Norse chronicles. In Ireland, the battle came to be seen as an event that freed the Irish from foreign domination, and Brian was hailed as a national hero. This view was especially popular during English and British rule in Ireland.

(With thanks to Wikipedia) 

¹ Healthcare Systems and Motivation,  Erich H. Loewy, MD, FACP   Medscape: Thursday, June 19, 2014

Peter Carter

Chief Executive Officer
ISQua
June 2014

CHAUNCEY GARDNER

‘A journey is not so much about the destination as it is about the company you keep along the way'   Anon

If I support this notion you will no doubt remind me that in an earlier BLOG I argued that one must know where one is going when setting out on a journey ‘…. lest part way through your journey you find you are travelling in the wrong direction or, worse still, you complete your journey only to find you have arrived at the wrong place.'

Nevertheless, whether you know where you are going or not, the journey is better undertaken in good company.

We are taught, and in turn we teach others, that planning is paramount, that it is everything, that nothing should be left to chance. But is it?

Jack Welch, one of the better known CEOs, has his doubts:

‘Willingness to change is strength, even if it means plunging part of the company into total confusion for a while’

And if you are a Rolling Stones fan you will not be surprised to learn that Mick Jagger would not see planning as essential to success, and successful he has been:

‘Anarchy is the only slight glimmer of hope’

And why is it that surgeons still insist that surgery is both a science and an art?

Where am I going with this? I am arguing that whatever one’s endeavours one must not try to eliminate any possibility of the unexpected completely. Referring again to an earlier BLOG, the one where the composition of Jeffrey Smart’s painting was decided by a wood shaving falling onto and adhering to the canvas; leave room for the intervention of chance; it is a power beyond those one can muster oneself.

You may well ask are these views not an anathema to one who manages an organization that strives to enhance quality? But I am not arguing against seeking to eliminate errors, improve systems, increase knowledge and skills and enhance quality, rather I am saying be aware that on your professional journey your companions from time to time might be the unexpected, the unplanned, and when they join you on your journey, embrace them if they are good and you can learn from them.

The best example in healthcare of the benefits of the unexpected for me is the discovery of Penicillin. Fleming puts the date of his discovery as September 28, 1928. He considered it to be a fortuitous accident: in his laboratory Fleming ‘….noticed a Petri dish containing Staphylococcus plate culture he mistakenly left open, was contaminated by blue-green mould, which formed a visible growth. There was a halo of inhibited bacterial growth around the mould. Fleming concluded the mould released a substance that repressed the growth and lysing the bacteria. He grew a pure culture and discovered it was a Penicillium mould, now known to be Penicillium notatum.’ (1)

Why the BLOG title ‘Chauncey Gardner’? The answer is a movie starring Peter Sellers called Being There. If you haven’t seen it I recommend it to you. It makes my point cleverly.

Peter Carter

Chief Executive Officer

ISQua

May 2014

1.     1. Wikipedia

A UNIVERSAL PATIENTS’ BILL OF RIGHTS?

The Magna Carta deals with ideals of democracy, limitation of power, equality and freedom under law.

Lord Denning described it as "the greatest constitutional document of all times – the foundation of the freedom of the individual against the arbitrary authority of the despot". Danny Danziger & John Gillingham, "1215: The Year of Magna Carta"(2004 paperback edition) p278

Tim Berners-Lee is the creator of the worldwide web. In celebration of the 25 anniversary of his creation this month, Berners-Lee called for the drawing up of a Magna Carta for the www.

The Magna Carta plan is in effect a ‘digital bill of rights’ – a statement of principles, B-L hopes will be supported by public institutions, government officials and corporations.

"Unless we have an open, neutral internet we can rely on without worrying about what's happening at the back door, we can't have open government, good democracy, good healthcare, connected communities and diversity of culture. It's not naive to think we can have that, but it is naive to think we can just sit back and get it."

So, a call to action!

Tim Berners-Lee

Bills of Rights have been popular ever since 1215 and the Magna Carta.

The best know Bill is the American Bill of Rights. Written in 1789, this is in fact made up of the first 10 amendments to the American Constitution. These amendments guarantee personal freedoms, limit the Federal Government’s powers and reserve some powers to the States and the public. In recent times, the most controversial amongst these freedoms is the freedom to bear arms. Originally this was designed to assuage fears by the States of a Federal takeover by forcer, but in recent times it has been used to justify individuals’ ownership of guns.

There are plenty of other Bills of Rights including Animals Bills of Rights and even a PhD students’ Bill of Rights, the latter talking of a right to a recognised expert and to an ethical role model.

It is however on Patients’ Bills of rights I wish to focus in this BLOG.

One of the fundamental problems with Bills of Rights is what to include and what to leave out. That is the reason so many countries, organisations and activities have failed to achieve what one would consider to be an obvious and good thing.

For example, the US Senate's 2001 attempt at a Bill had just the following eight broad rights for patients with health care plans:

·         have their medical decisions made by a doctor;

·         see a medical specialist;

·         go to the closest emergency room;

·         designate a pediatrician as a primary care doctor for their children;

·         keep the same doctor throughout their medical treatment;

·         obtain the prescription drugs their doctor prescribes;

·         access a fair and independent appeals process if care is denied; and

·         hold their health plan accountable for harm done.

The Bill was passed by the US Senate, amended the House of Representatives and failed when it returned to the Senate.

On the other hand Arizona State’s Scottsdale Healthcare has no fewer than 28 rights (and 16 responsibilities, the argument being that with rights come responsibilities).

The overarching patient Bill of Rights is in fact an oath taken by doctors: the Hippocratic Oath. In this the expectations of how the physician should practise can reasonably be taken to be the expectations of the patient of his or her treatment.

A 12th-century Byzantine manuscript of the Oath

The English translation of the original is:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art; and that by my teaching, I will impart a knowledge of this art to my own sons, and to my teacher's sons, and to disciples bound by an indenture and oath according to the medical laws, and no others.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never harm to anyone.

I will give no deadly medicine to any one if asked, nor suggest any such counsel; and similarly I will not give a woman a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.

This has been modified many times over the centuries but most of the sentiments expressed in the original remain.

There has since 1948 been a Universal Declaration of Human Rights. It comprises 30 Articles based in general around:

-- Human rights are Universal, Indivisible, Interconnected and interrelated

-- With equality and without discrimination for all women and men, youth and children

-- Democracy must be a delivery system of human rights

--All must know, own, organize, plan and act guided by human rights as a way of life

The existence of such a Declaration, while by no means guaranteeing rights for all citizens of the world, allows its invocation in cases where such rights are threatened or subjugated.

Is there then a place for a Universal Bill of Rights or Declaration of Rights for patients as a successor to the Hippocratic Oath which is probably not enough to cover the complexities of a 21^st century society and 21^st century healthcare?

Yes, if the challenge of knowing what to include and what to leave out could be met and if a clear idea of in what circumstances and in what way it could be brought to bear could be decided.

A job for the ISQua Innovation and Systems Change Working Group perhaps?

Peter Carter

Chief Executive Officer

ISQua

March 2014