2 March 2010

Am I a Killer?

Filed under: Culture, Ktismata, Psychology — ktismatics @ 9:43 pm

I’ve not read Mark Fisher’s book, but apparently he’s incensed about workplace management audits. I’ve read his latest post, which also links to the podcast of a talk he gave recently about the book. Keeping track your own performance is worse than a waste of time, says Mark, because it prevents you from doing more useful work. Of course no one really believes that these audits help improve performance, he asserts; they’re only representations of performance staged for the Big Other. It’s “nuBureaucracy” — an absurd simulation of market forces perpetrated by government as a means of perpetuating the class distinction between workers and managers.

The k-punk post cites Michelle on healthcare auditing:

getting “good” results from audits is probably a lot worse on the whole than getting “poor” ratings… nuBureaucracy is not only psychologically destructive, it can actually kill people.”

Does anybody besides me find this line of argumentation offensive? Why shouldn’t the government be concerned about the quality of healthcare its citizens receive? Isn’t it possible to identify specific standards of adequate care? Isn’t it in the public’s best interest to evaluate the extent to which these standards are being met? If the standards are wrong or the measures inappropriate, change them. But to claim that the measurement apparatus itself is killing people, rather than the faulty processes of care which the measures are trying to identify — that’s just fucked up.

Mark argues that nuBureaucracy constitutes a simulation of market forces in an environment of heavy government regulation. Twice in his  podcast he says that allowing the free market to operate, where maximizing profits is the explicit objective, might be better than the “market Stalinism” of nuBureaucracy. It seems that Mark’s biggest objection to performance auditing is that it stifles workers’ freedom, choice, and flexibility. This sounds a lot like a libertarian argument. Industry has made similar objections to governmental auditing of environmental pollutants, pharmaceutical side effects, and risky lending practices.

I don’t understand why work audits should be dismissed as a spectacle staged for the Big Other. I thought we were talking about systematic empirical evaluations conducted on behalf of the public, which pays for the work being evaluated and which suffers the consequences of poor performance. The public is the Big Other now? That sounds like a good thing.

I understand that audits are often used to punish individuals for systemic failures and to justify getting rid of workers when money is being squandered on bailing out big financial institutions and so on. I also agree that some measures really are worthless indicators, and that collecting some kinds of data isn’t worth the time and effort. But tell me this: if the workers actually controlled the means of production, would they no longer regard it as important to evaluate whether they’re doing a good job or not? Should workers’ freedom really take precedent over those for whose benefit they’re doing the work? Is it really that much to ask of hospital workers that they keep the nosocomial infection rates down, or of doctors that they adequately manage their diabetic patients’ blood sugar levels? Should the citizenry simply take the healthcare workers’ word for it that they’re doing a good job?

Mark contends that work audits serve as a mere substitute for real marketplace forces. But how is someone undergoing bypass surgery to evaluate whether this doctor or that hospital is better than any other? It’s not like you buy bypass procedures every couple of months: hopefully it’s a one-time-only purchase. Readily accessible market indicators like price or the hospital’s location or the shininess of the doctor’s shoes aren’t of much use in being an informed healthcare consumer. What you really want to know is whether this doctor and this hospital are demonstrably good at what you need done. The relevant information can be obtained only by compiling and analyzing aggregated data — that is, via performance audit. Otherwise you have to rely on marketing and hearsay.

I’m familiar with the contention that standardizing work processes stifles innovation, and this may be true. But shouldn’t the innovative worker be able to handle the routine stuff as well? It’s like arguing that students shouldn’t have to be able to do algebra because it gets in the way of their learning calculus. In most fields of endeavor progress is incremental, built on a foundation of lower-level skills. Most of the time people who can’t do the basics well aren’t very good at the advanced stuff either.

If you’re a professor with a Ph.D. you almost surely think you’re smarter, more creative, etc. than the people who think up the measurements schemes by which you’re evaluated. It’s possible, of course, that the measurement types might be just as smart and creative as you are, but their jobs don’t provide them with as much opportunity to express their brilliance as your faculty position does. Besides, how much does brilliance really factor in to how good you are as a teacher? Do students pay tuition, do citizens pay taxes, in order to subsidize your brilliance, or to educate people? If existing measurement systems don’t accurately distinguish between good and bad teaching, maybe there’s not really much of a distinction to be made.

Maybe I’m just sensitive to this shit because I have measured healthcare work processes and outcomes as a job. Maybe it bugs me when somebody claims that, while I thought I was contributing to systemic improvements in quality of care, I was actually killing people. Or maybe I think it’s disingenuous when somebody claims that getting “good” (note the irony quotes) ratings on, say, keeping people alive post-surgery is probably worse than getting “poor” ratings.



  1. I think Mark and Michelle might be referring to the horrific case of Stafford Hospital and Mid-Staffordshire NHS Trust.

    See if you can find “The Lonely Robot”, episode two of Adam Curtis’ documentary The Trap on YouTube — it explains the paradoxes of NHS health care target culture (wherein medics and their bureaucratic superiors frantically “game” the system) better than k-punk ever could.

    Comment by Harold Shipman — 3 March 2010 @ 6:41 am

  2. Thanks for the clarification, Harold. Was measurement killing people at that hospital? There were 3 links to this story on the k-punk post but 2 didn’t work (thus ends my audit). Through other sources it appears that the problem was systemically bad care exacerbated by understaffing. Michelle contends that the ongoing auditing is what did those patients in, and that the nurses would have done a better job if management didn’t require them to do all that paperwork. But then she also says that the nurses lied on the audits. The inquiry after the fact was deemed useless because it was… after the fact.

    So what lessons can be drawn? Management games the audit in order to make itself look good: we can get the work done even without necessary staffing, etc. The workers game the audit in order to keep their jobs, even when the jobs are shitty and they acknowledge they’re doing the job shittily. Post-facto auditing of individual failures will always find plenty of blame to pass around, blame that could just as easily be found at other facilities which haven’t (yet) experienced catastrophic fail. And inquiries in which the results are kept from the public does the public no good at all, serving instead to cover up bureaucratic failure rather than revealing it.

    So what solutions suggest themselves? Less game-able measures. More transparency of findings. Less use of audits as marketing aids to attract patients or to justify budgetary moves, more use of audits to evaluate actual quality of care. But to say that measurement itself is at fault, as if we’d all be better off if the measurement stopped altogether? That’s kind of like saying we shouldn’t bother to evaluate compliance with Geneva Conventions because the Abu-Ghraib audit wasn’t conducted until after the abuses already occurred, and because it targeted individual abusers for punishment when the pattern of abuse pointed to more widespread systemic abuse, implicating the higher-ups in the chain of command. Or maybe polluters would release fewer toxins into the groundwater if they didn’t have to bother with those tedious EPA compliance reports. Or investigating child abuse in Irish orphanages was just making the priests look bad for things that happened so long ago…

    I expected to hear more about managerial abuses of audits in Mark’s podcast, which is a legitimate concern. But he seemed more concerned about how standardization stifles individual freedom and innovation, not how measurement can be used either to expose or to conceal systemic failure. Hence the focus of my post.

    By the way, Dr. Shipman, I understand that you are the man to thank for some of the more effective safety mechanisms incorporated into the British healthcare system. Good work!

    Comment by john doyle — 3 March 2010 @ 7:22 am

  3. I understand that you are the man to thank for some of the more effective safety mechanisms incorporated into the British healthcare system.

    Well I slaughtered most of Hyde, but I think you’ll find that my patient approval ratings were the envy of the whole of Cheshire.

    Comment by Harold Shipman — 3 March 2010 @ 7:42 am

  4. Good bedside manner does the trick every time.

    “The techniques, approved by Defense Secretary Donald H. Rumsfeld for use in interrogating Mohamed Qahtani — the alleged “20th hijacker” in the Sept. 11, 2001, terrorist attacks — were used at Guantanamo Bay in late 2002 as part of a special interrogation plan aimed at breaking down the silent detainee. Military investigators who briefed the Senate Armed Services Committee yesterday on the three-month probe, called the tactics “creative” and “aggressive” but said they did not cross the line into torture.” — from this WashPost article

    Comment by john doyle — 3 March 2010 @ 7:57 am

  5. You’re not a killer, John. As usual, ker-plunk is keen on making a PUNK* AGAINST THE MAN STATEMENT, soundbiting it in the awful phrase “NuBureaucracy”TM, and any subtlety gets lost. So you end up with the kind of BS that Michelle comes out with. Man, all this bureaucratic stuff about whether I have been killing my patients or not is getting me down!

    Ker-plunk has thrown the baby out with the bathwater – but I do have some sympathies. There is an awful lot of auditing and bureaucracy in UK institutions public, private and “third sector” (the new name for giving!). Much of this is poorly done and most definitely weighted in management or the company’s favour. Last week, my department learned the results of our yearly questionnaire on what we thought about the company. We had to do it even though we are very busy and I thought most of the questions were loaded in favour of a positive outcome for management. And the ones that weren’t, you didn’t want to put a negative answer for because they directly affected your line manager, who you get on with. Anyway, in the results presented by our department director everything was fine until our department responses for pay and conditions seemed to come in way below the company averages. Then we were made to feel like it was our fault, that we should be grateful to have a job etc etc.

    As far as the public and third sectors are concerned, I hear from friends in health and education that targets often get in the way of actual care. The problem is, Government doesn’t realise that audits and targets have limits on what they can do – like any idea has its limits. New Labour is especially guilty of this as it STILL likes to think that every problem can be managered and databased away. Some problems are problems to be cared for: at expense and man hours, it’s just a fact of life. No Government – including of course the incoming Conservatives – want to hear that.

    In the private sector, it’s a little different. Surveys and audits are sadly often there to back up what the higher tiers of management want to do. My girlfriend’s old subtitling company got some management consultants in to audit both management and employees. When the consultants returned an expensive report to the company saying that things were pretty good and gave some recommendations that the employees should actually have less work to do, the company simply ignored the report.

    It’s not measurement itself that does the harm, but the politics behind it and sadly these things are rarely political. Thinking that auditing everything all the time will solve everything, as New Labour does is a bad mistake.

    The bureaucracy culture is not a pantomime for the big Other. This is just ker-plunk gamely showing what he’s mis-learned of Lacan through demagogues like Zizek. Bureaucracy culture is not a simulation of market forces, it IS market forces. It’s part of the same damn thing. The bureaucracy is there as checks and balances to “market forces” (ie the people who have money and power). It is supposed to check the power, but the mechanisms can be adjusted to serve that power. We don’t have unions anymore, we have human resources, who can’t do a thing for you but are always asking how you feel. A friend at work said to me that HR is like the Catholic church in medieval Europe: you don’t really know why they are there or what they do, but they seem to have entry points into every tier of society, from the boardroom to the boiler room. In a couple of disputes that I have had with management about work levels, I’m asked “Why can’t you manage your time properly?” HR ask “how can we get you managing your time properly?” This isn’t a simulacrum, it’s part of the system.

    Having said all that, I do think there is plenty of room for good, independent audits and good human resources. In fact, I know good HR people. To cast aside the lot seems – even if some of much of it is serving the “system” – seems very, very foolish. But then, it is ker-plunk.

    *The zenith of human achievement, endeavour, striving and freedom which cannot be replicated again so we’re all just going to have to be dysphoric. Or dysmorphic. Or something.

    Comment by NB — 3 March 2010 @ 11:47 am

    • It’s nice to hear that things are so difficult for people with lives, NB. although we’re glad you get on with your line manager. the ‘kerplunk’ thing oughtn’t to be allowed. John doesn’t exercise the blogger-policy things fairly, I’ve noticed. He allowed Dejan to say any number of vile things about me the other day. This is just for the record. I really don’t give a fuck whether you have a life or NOT. It’s you who claimed you did.

      Comment by Quantity of Butchness — 3 March 2010 @ 1:41 pm

      • “You’re not a killer, John.”

        I bet he thought he was before you reassured him, though. I don’t see that k-punk has ever said much that has been gripping or convincing despite his following, but you do take him very seriously for some reason That is the one thing you have offered me, although that is not unusual: There are many fans of k-punk, and I have never known why he is seen as an arresting writer. But then you are not either, it always stinks of your analysis. What is interesting is the way you are always so incensed at k-punk, who is hardly the Shining Star. But i suppose the point does need to be made, despite the emphasis on wrongly held lacan, which is practised on these blogs profligately–all of it meant to de-sex all sex. That is what Dejan’s ‘lacanian therapy’ is about beyond using terms like reverse versions of Lesbian and fag hag. Otherwise, you do not find therapy in assigning fuck-roles to blog personae. even Dominic, with his Castration Complex Advocacy does not do this, but it is the same thing–talking about sex seems like sex for people who cannot do it (or at least not without deep guilt which they do want and think necessary). As in his ‘Those who cannot, make policy’, it is ‘those who cannot fuck, write-fuck’. None of the fuck-fantasies that are created on the internet are anything but forms of dementia, and that includes the worst ones, that pretend that they ‘will meet you in person’.

        Comment by Quantity of Butchness — 3 March 2010 @ 1:54 pm

      • Right: I deleted the offending sentence from Dejan. Sorry for the lapse.

        Comment by john doyle — 3 March 2010 @ 2:48 pm

  6. Thanks for the insights into British workplace, NB. I’m going to follow Dr. Shipman’s recommendation and watch The Trap.

    Yesterday our daughter’s school mailed us a questionnaire asking our opinions about how best to cut costs in the schools. My sense was that the results of this mailing will have little to no effect on management decisions as to eliminating jobs, freezing wages, and so on. Mostly it was a PR move, intended to demonstrate the difficult choices management will need to make in the face of the current economic crisis etc. I believe I’ll put a write-in recommendation: let the teachers decide how to handle it; if they want to axe the bosses, so be it.

    I get the sense that anything management does these days meets with considerable resistance from workers. Quality improvement techniques, inspirational speeches, job redesign — all of it just seems like so much overhead when eliminating 1 high-priced boss would save maybe 3 or 4 jobs of people who do the actual work.

    I agree too, NB, that quantitative management isn’t just a simulation of the marketplace; it IS the marketplace. CQI and TQM and so on originated in the private sector, only later migrating to public and NGO contexts. I get the sense that Mark longs for a more freewheeling, entrepreneurial, no-holds-barred version of capitalism in all sectors, where both the internal managers and the external regulators are sent packing, leaving the workers free to create. Being a ktismatics guy myself I like creation as much as the next guy, so I sympathize to an extent.

    Comment by john doyle — 3 March 2010 @ 3:08 pm

  7. Twice in his podcast he says that allowing the free market to operate, where maximizing profits is the explicit objective, might be better than the “market Stalinism” of nuBureaucracy. It seems that Mark’s biggest objection to performance auditing is that it stifles workers’ freedom, choice, and flexibility.

    This, I think, reveals the chief political desire of Fisher and the Zero Books crew (excepting, I think, Dominic Fox): to counter neoliberalism’s deterritorializations with workerist and welfare-statist — and even sometimes, apparently, free market — reterritorializations. The railings against capitalist realism, bureaucracy, contemporary (i.e., “sex-pos”) feminism, postmodern architecture, etc., are all animated by a cri de couer for a revived Fordism. (Hatherly is very explicit about this.) The more visibility they gain, the more this conservative impulse becomes clear. It’s SWP politics, but with cultural sophistication.

    Comment by Eric — 3 March 2010 @ 3:36 pm

  8. Thanks for the clarification, Eric. I think I’ll start following your blog, which I’ve not seen before but which seems to have a long trail of posts behind it. It’s hard for me to discern how similar/different the situation is in the US vis-a-vis the States. Political entities like the SWP seem quite exotic to me.

    Comment by john doyle — 3 March 2010 @ 7:27 pm

  9. John,

    I think your point is a good one. Some people have a hard time distinguishing between functional-bureaucracy and superfluous-bureaucracy (or cumulative-bureaucracy, in the sense of existing for its own sake, or because ‘this is the way it has always been done’). Some anti-capitalist thinkers do indeed “throw out the baby” – as one your readers points out above – because they argue against the very existence of bureaucracy, as opposed to detailing how and why specific forms of superfluous-bureaucracy stifle attempts to increase the effectiveness of specific projects.

    Bureaucracy ‘in general’ is neutral in that it is part of the ‘infrastructure’ of a particular set of activities – much like our central nervous system is part of the ‘infrastructure’ of our functioning body. And just as when our nervous system does things that work against the aims or functionality of our body (say in the case of M.S), bureaucracy becomes “bad” or non-functioning when it works against the aims of a particular set of activities (say in the case of governance, or healthcare).

    I agree with Mark that much bureaucracy existing today is non-functional, that is to say superfluous, and a mash-up of old school thinking and doing. But I also agree with you John that functionally-aligned bureaucracy is necessary in order to increase accountability, track outcomes and trends, or in monitoring certain key activities.

    The problem becomes being able to judge and understand the functionality and effects of the various tracking or ‘feedback’ mechanisms enough to prioritize and eliminate those that are superfluous, ineffective or, as Mark points out, simply just a waste of time and energy.


    Comment by Michael~ — 12 March 2010 @ 5:02 pm

  10. Hello Michael. I’m not persuaded that measures can or should motivate individuals to do a better job, but measures can give people a better idea of what they individually and collectively are aiming toward. To proclaim “better healthcare for all” sounds good in a manifessto, but it has the weakness of most ideological assertions: too utopian, not tangible enough. Doing the right thing isn’t always intuitively obvious, and other things — like bureaucracy — can get in the way. What concretely can/should I be doing in my little job that will contribute incrementally to the grand mandate?

    Even without installing performance-based financial incentives, systems ought to eliminate financial incentives for performing poorly. Consider nosocomial infections, where the patient catches an infection while in the hospital. Sometimes it’s just bad luck, but poor hygiene at the hospital is a significant risk factor. If you get a nosocomial infection you have to stay in the hospital longer, use more drugs, have more doctor visits and tests, etc. — all of which adds to your bill and to the money being made by the health system. I’m not so paranoid as to assert that hospitals purposely maintain unhygienic conditions in order to increase business, but they might be less likely to fix the problem if by doing so they lose money.

    Comment by john doyle — 14 March 2010 @ 9:48 am

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