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Learning a lesson from the Butcher of Bundaberg

By Nicholas Gruen - posted Friday, 6 May 2005

Dr Jayant Patel, Butcher of Bundaberg, was a foreigner. What a relief! It gives us a nice distant target for our horror and outrage. Memo to ourselves: foreigners can be sneaky and we should check their credentials better. Case closed.

But, though we could and should have prevented Dr Patel’s rampage altogether by checking his credentials (like we do with vets!), the bigger scandal is that internal systems didn’t detect his rampage within a few months if not weeks.

Finding and punishing the Dr Patels of this world is just fine with me. But it would be a whole lot better - literally more than ten times better - if we also used their outrages to radically improve hospital quality control.


Better information systems are the start. In the early 1990s experts in the New York State hospital system meticulously built a clinical database of cardiac by-pass surgery. All events were “risk rated” so that outcomes were related to operations’ “degree of difficulty”.

It turned out that 27 surgeons who only occasionally performed cardiac surgery were performing poorly. They were moved out of cardiac heart surgery to specialise and so improve their own performance elsewhere. A win-win.

One well-regarded hospital had mysteriously high mortality rates for emergency heart patients. The data revealed the anomaly and some simple detective work discovered the cause which was remedied with new procedures. The change has saved around 11 lives a year since. The whole system saw a 41 per cent decline in mortality rates over 3 years.

In Australia, a quite different program based on similar principles yielded similar benefits at the Wimmera Base Hospital in Horsham Victoria.

The Royal Commission should not shy away from holding responsible those who might have stopped Dr Patel long before he fled. Yet examples like New York State’s experience shows that this is a side show compared with improving the performance of the systems under which all the well-motivated members of our health professions work.

Some of the most successful initiatives have been surprisingly similar to the techniques the Japanese introduced into manufacturing in the 1970s and 80s. Firms like Toyota dramatically ramped up their productivity around a cluster of simple but subtly revolutionary ideas, based ultimately on the idea that they were not making things so much as structuring a system in which people controlled and constantly revised and optimised the complex system of which they were a part.


Central principles included:

  • When given the choice and appropriate encouragement, people prefer to work well rather than to shirk.
  • Given that complex systems are difficult to manage with surveillance from above, setting people to work and solve problems in teams helps unleash creativity and makes bad behaviour more difficult - because well motivated groups police their own members.
  • In this context, fear and punishment must be driven out of the workplace, so that people can be motivated to identify and fix problems instead of watching their back and passing the buck.
  • Systems - particularly systems of control and information - should be built not so much to assist management direct or maintain surveillance of workers, but to assist teams of workers to improve the quality of their work.

In the American State of Utah similar principles appear to have dramatically improved the clinical quality of their hospital system. They drive out fear by encouraging practitioners to report all adverse incidents within 48 hours in return for immunity from legal liability for negligence.

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First published as 'What a feeling system change evokes' in The Courier-Mail on April 27, 2005.

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About the Author

Dr Nicholas Gruen is CEO of Lateral Economics and Chairman of Peach Refund Mortgage Broker. He is working on a book entitled Reimagining Economic Reform.

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