Carl Horsley
@carlhorsley.bsky.social
Intensivist at Middlemore; Resilient Healthcare + Te Ao Māori; Clinical lead for System Safety @HQSCNZ ; MSc HF & System Safety, Lund. All musings my own
#medsky #safetysky #icu
#medsky #safetysky #icu
October 3, 2025 at 7:38 PM
A story in two parts:
1) A proud announcement from the Minister of Health about the new ICU and HDU at Tauranga Hospital
2) A comment from the Clinical lead for Tauranga ICU
1) A proud announcement from the Minister of Health about the new ICU and HDU at Tauranga Hospital
2) A comment from the Clinical lead for Tauranga ICU
September 6, 2025 at 6:33 AM
A story in two parts:
1) A proud announcement from the Minister of Health about the new ICU and HDU at Tauranga Hospital
2) A comment from the Clinical lead for Tauranga ICU
1) A proud announcement from the Minister of Health about the new ICU and HDU at Tauranga Hospital
2) A comment from the Clinical lead for Tauranga ICU
"Managing costs causes costs"
Seems relevant to healthcare currently. When we focus on cost control, we risk mistaking efficiency for effectiveness.
Effectiveness can only be judged against the purpose of the system: To support a state of health or Hauora
Seems relevant to healthcare currently. When we focus on cost control, we risk mistaking efficiency for effectiveness.
Effectiveness can only be judged against the purpose of the system: To support a state of health or Hauora
July 27, 2025 at 8:39 AM
"Managing costs causes costs"
Seems relevant to healthcare currently. When we focus on cost control, we risk mistaking efficiency for effectiveness.
Effectiveness can only be judged against the purpose of the system: To support a state of health or Hauora
Seems relevant to healthcare currently. When we focus on cost control, we risk mistaking efficiency for effectiveness.
Effectiveness can only be judged against the purpose of the system: To support a state of health or Hauora
You don't "secure organs", you give every family the choice to donate.
That's just crazy as an incentive.
That's just crazy as an incentive.
July 23, 2025 at 4:53 AM
You don't "secure organs", you give every family the choice to donate.
That's just crazy as an incentive.
That's just crazy as an incentive.
Also clear in his talks. Safety II is about all outcomes. There is also a lot of discussion on resonance ie the interplay of variability of performance and variability of conditions
July 11, 2025 at 10:19 AM
Also clear in his talks. Safety II is about all outcomes. There is also a lot of discussion on resonance ie the interplay of variability of performance and variability of conditions
"A hospital may still deliver surgeries, but patients feel unseen."
An interesting article to reflect on.
open.substack.com/pub/freshthi...
An interesting article to reflect on.
open.substack.com/pub/freshthi...
June 27, 2025 at 7:52 PM
"A hospital may still deliver surgeries, but patients feel unseen."
An interesting article to reflect on.
open.substack.com/pub/freshthi...
An interesting article to reflect on.
open.substack.com/pub/freshthi...
June 24, 2025 at 5:18 AM
What you measure is what you value. Everything else is rendered invisible, even as risks increase and the system becomes more brittle.
June 15, 2025 at 8:05 PM
What you measure is what you value. Everything else is rendered invisible, even as risks increase and the system becomes more brittle.
"It is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail."
- Maslow
Simple answers for complex times...
- Maslow
Simple answers for complex times...
June 15, 2025 at 9:35 AM
"It is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail."
- Maslow
Simple answers for complex times...
- Maslow
Simple answers for complex times...
LLM is a bullshit machine.
link.springer.com/article/10.1...
link.springer.com/article/10.1...
June 3, 2025 at 6:47 PM
LLM is a bullshit machine.
link.springer.com/article/10.1...
link.springer.com/article/10.1...
We are looking for Clinical Fellows for 2026.
A fantastic unit culture and a fascinating case mix. A real chance to explore what it means to be a specialist and develop your interests.
Come see what all the fuss is about.
tas-adhbrac.taleo.net/careersectio...
A fantastic unit culture and a fascinating case mix. A real chance to explore what it means to be a specialist and develop your interests.
Come see what all the fuss is about.
tas-adhbrac.taleo.net/careersectio...
May 31, 2025 at 5:36 AM
We are looking for Clinical Fellows for 2026.
A fantastic unit culture and a fascinating case mix. A real chance to explore what it means to be a specialist and develop your interests.
Come see what all the fuss is about.
tas-adhbrac.taleo.net/careersectio...
A fantastic unit culture and a fascinating case mix. A real chance to explore what it means to be a specialist and develop your interests.
Come see what all the fuss is about.
tas-adhbrac.taleo.net/careersectio...
We have seen these approaches overseas and they are coming (or already here).
The system is going solid.
And it's not a Middlemore thing, or even just a New Zealand thing, it"s a worldwide issue that is just catching up with us.
qualitysafety.bmj.com/content/qhc/...
The system is going solid.
And it's not a Middlemore thing, or even just a New Zealand thing, it"s a worldwide issue that is just catching up with us.
qualitysafety.bmj.com/content/qhc/...
May 25, 2025 at 7:57 PM
We have seen these approaches overseas and they are coming (or already here).
The system is going solid.
And it's not a Middlemore thing, or even just a New Zealand thing, it"s a worldwide issue that is just catching up with us.
qualitysafety.bmj.com/content/qhc/...
The system is going solid.
And it's not a Middlemore thing, or even just a New Zealand thing, it"s a worldwide issue that is just catching up with us.
qualitysafety.bmj.com/content/qhc/...
We are reprising Ryall's earlier approaches without understanding that even in the 2010s, success was often achieved by moving risk around and gaming the numbers, as discussed by Tim Tenbensel.
Early successes due to QI projects, high morale and extra resources.
www.auckland.ac.nz/en/news/2023...
Early successes due to QI projects, high morale and extra resources.
www.auckland.ac.nz/en/news/2023...
May 25, 2025 at 7:27 PM
We are reprising Ryall's earlier approaches without understanding that even in the 2010s, success was often achieved by moving risk around and gaming the numbers, as discussed by Tim Tenbensel.
Early successes due to QI projects, high morale and extra resources.
www.auckland.ac.nz/en/news/2023...
Early successes due to QI projects, high morale and extra resources.
www.auckland.ac.nz/en/news/2023...
These ideas are incredibly relevant now in the health system space as well. What is the appropriate balance between centralized control and the adaptive needs required for local context?
What heuristics should shape the local dynamic changes and yet still maintain overall system coherence?
What heuristics should shape the local dynamic changes and yet still maintain overall system coherence?
May 1, 2025 at 7:56 PM
These ideas are incredibly relevant now in the health system space as well. What is the appropriate balance between centralized control and the adaptive needs required for local context?
What heuristics should shape the local dynamic changes and yet still maintain overall system coherence?
What heuristics should shape the local dynamic changes and yet still maintain overall system coherence?
ED wait times are not a “whole of hospital” measure. They are now a “whole of system” measure ie impacted by primary care and community access.
The system “going solid” is not about flow of patients from ED to ward. That was the early 2000s, it’s not the issue now.
newsroom.co.nz/2025/04/29/w...
The system “going solid” is not about flow of patients from ED to ward. That was the early 2000s, it’s not the issue now.
newsroom.co.nz/2025/04/29/w...
April 30, 2025 at 2:42 AM
ED wait times are not a “whole of hospital” measure. They are now a “whole of system” measure ie impacted by primary care and community access.
The system “going solid” is not about flow of patients from ED to ward. That was the early 2000s, it’s not the issue now.
newsroom.co.nz/2025/04/29/w...
The system “going solid” is not about flow of patients from ED to ward. That was the early 2000s, it’s not the issue now.
newsroom.co.nz/2025/04/29/w...
Retrospective reviews in general (I have not seen this particular report) often give an illusion of learning. We feel we would not have made those mistakes.
But hindsight does not equal foresight www.researchgate.net/profile/Baru...
But hindsight does not equal foresight www.researchgate.net/profile/Baru...
April 27, 2025 at 12:34 AM
Retrospective reviews in general (I have not seen this particular report) often give an illusion of learning. We feel we would not have made those mistakes.
But hindsight does not equal foresight www.researchgate.net/profile/Baru...
But hindsight does not equal foresight www.researchgate.net/profile/Baru...
Language in the reported case review is full of counterfactuals. What people could, would or should have done.
But I am less sure about whether there is any explanation there of why those decisions made sense. The local rationality of decision making in complex, uncertain and dynamic conditions.
But I am less sure about whether there is any explanation there of why those decisions made sense. The local rationality of decision making in complex, uncertain and dynamic conditions.
April 27, 2025 at 12:26 AM
Language in the reported case review is full of counterfactuals. What people could, would or should have done.
But I am less sure about whether there is any explanation there of why those decisions made sense. The local rationality of decision making in complex, uncertain and dynamic conditions.
But I am less sure about whether there is any explanation there of why those decisions made sense. The local rationality of decision making in complex, uncertain and dynamic conditions.
The grief and anger of the family is palpable in the article.
Their relationship with the health system is fundamentally broken. Distrust, a lack of "accountability", and a disbelief that this could happen.
This is why restorative practice matters.
Their relationship with the health system is fundamentally broken. Distrust, a lack of "accountability", and a disbelief that this could happen.
This is why restorative practice matters.
April 27, 2025 at 12:14 AM
The grief and anger of the family is palpable in the article.
Their relationship with the health system is fundamentally broken. Distrust, a lack of "accountability", and a disbelief that this could happen.
This is why restorative practice matters.
Their relationship with the health system is fundamentally broken. Distrust, a lack of "accountability", and a disbelief that this could happen.
This is why restorative practice matters.
The healthcare equivalent of "faster better cheaper" is "more activity, safer care, less cost".
The risks are the same. Short term gains but longer term risks.
The risks are the same. Short term gains but longer term risks.
April 17, 2025 at 3:15 AM
The healthcare equivalent of "faster better cheaper" is "more activity, safer care, less cost".
The risks are the same. Short term gains but longer term risks.
The risks are the same. Short term gains but longer term risks.
Required reading for these times...
Cippola's classic 5"The Basic Laws of Human Stupidity"
ia801609.us.archive.org/29/items/kau...
Cippola's classic 5"The Basic Laws of Human Stupidity"
ia801609.us.archive.org/29/items/kau...
February 6, 2025 at 5:34 AM
Required reading for these times...
Cippola's classic 5"The Basic Laws of Human Stupidity"
ia801609.us.archive.org/29/items/kau...
Cippola's classic 5"The Basic Laws of Human Stupidity"
ia801609.us.archive.org/29/items/kau...
Not sure healthcare needs more "ruthless execution".
January 19, 2025 at 3:59 AM
Not sure healthcare needs more "ruthless execution".
The coming flu season is looking rough for A/NZ.
The question will be whether a focus on optimising efficiency has left the system more brittle in the face of challenge.
The question will be whether a focus on optimising efficiency has left the system more brittle in the face of challenge.
January 14, 2025 at 1:54 AM
The coming flu season is looking rough for A/NZ.
The question will be whether a focus on optimising efficiency has left the system more brittle in the face of challenge.
The question will be whether a focus on optimising efficiency has left the system more brittle in the face of challenge.
The heart of neoliberalism - "There is no such thing as society" (Thatcher)
A focus on individualism, a belief that success is due to talent alone (the deserving rich and therefore the deserving poor) and that markets solve all issues.
www.mcsweeneys.net/articles/i-w...
A focus on individualism, a belief that success is due to talent alone (the deserving rich and therefore the deserving poor) and that markets solve all issues.
www.mcsweeneys.net/articles/i-w...
January 10, 2025 at 8:43 AM
The heart of neoliberalism - "There is no such thing as society" (Thatcher)
A focus on individualism, a belief that success is due to talent alone (the deserving rich and therefore the deserving poor) and that markets solve all issues.
www.mcsweeneys.net/articles/i-w...
A focus on individualism, a belief that success is due to talent alone (the deserving rich and therefore the deserving poor) and that markets solve all issues.
www.mcsweeneys.net/articles/i-w...
Great article from Gigerenzer on the “Rationality Wars”.
I’ve noticed an embrace of heuristics and biases as explanatory mechanisms for “human error”.
Yet, much less knowledge of ecological models of rationality or the field of naturalistic decision making.
www.cambridge.org/core/journal...
I’ve noticed an embrace of heuristics and biases as explanatory mechanisms for “human error”.
Yet, much less knowledge of ecological models of rationality or the field of naturalistic decision making.
www.cambridge.org/core/journal...
November 24, 2024 at 2:40 AM
Great article from Gigerenzer on the “Rationality Wars”.
I’ve noticed an embrace of heuristics and biases as explanatory mechanisms for “human error”.
Yet, much less knowledge of ecological models of rationality or the field of naturalistic decision making.
www.cambridge.org/core/journal...
I’ve noticed an embrace of heuristics and biases as explanatory mechanisms for “human error”.
Yet, much less knowledge of ecological models of rationality or the field of naturalistic decision making.
www.cambridge.org/core/journal...