14 Jul We Designed An Industrialized Healthcare
Blog post written by Andy DeLao
Process improvement. The 80 / 20 rule. 6 Sigma. Lean. Defects. Waste. Efficiency. Output. Production. Value added. Automation. Productivity. Workflow. Capacity Management. Quality. Access. Costs. Scale.
I have noticed over the past few years that as I travel and speak to patients, physicians, ministry of health officials, CEO/COO/CFO, and various hospital administrators that the above words often come up in the midst of our conversations.
What surprises me the most is the above words originate from manufacturing, not healthcare. As we identify opportunities to improve quality and access while reducing costs in healthcare, many leadership teams have looked to hire the best minds from Toyota, Kimberly Clark, and Boeing.
Do not get me wrong; I believe there is richness in building a diverse cross functional team, borrowing from other businesses, and finding news ways of connecting the dots to drive innovation.
However, I am not convinced we have historically done this well in healthcare. I believe the only thing we have accomplished is the design of an industrialized healthcare system.
We collectively managed to mass produce average care, scale it, and make everyone mediocre.
The industrial revolution is that period of time that brought innovation which allowed us to move from making goods by hand to being able to make goods with machines. As time moved on, technology began to evolve, and we continued to improve our ability to produce more goods. Technology such as the power loom and the cotton gin improved the output of a worker by 40 to 50 times. The steam engine gained in efficiency and was able to go further, do more work, and use less fuel.
Moving from charcoal to the use of coke in iron making allowed us to drive the cost of iron down, produce more, and achieve economies of scale.
Creating goods cheaply, while increasing revenues and allowing more people the ability to purchase more goods enabled the emergence of the middle class. For the first time in history, there was an economic advantage that was widespread across the population. The standards of living increased with the ability to provide adequate housing, acquire proper nutrition, and allow life expectancy to increase.
The middle class meant that there was more people able, willing, and wanting to be employed to provide for themselves as well as their family.
Increase the middle class and you develop a need for more goods.
Then came along a man named Henry Ford. He developed the assembly line and the ability to mass-produce a product. Henry's assembly line principles were simple:
- Place the tools and the men in the sequence of the operation so that each component part shall travel the least possible distance while in the process of finishing.
- Use work slides or some other form of carrier so that when a workman completes his operation, he drops the part always in the same place—which place must always be the most convenient place to his hand—and if possible have gravity carry the part to the next workman for his own.
- Use sliding assembling lines by which the parts to be assembled are delivered at convenient distances.
As time progressed, technology improved, and capitalism grew. We continued to see more and more ways to mass-produce goods. We realized that if you can develop a process that is well documented that you could begin to automate it. The more automated a job, the less defects, the more cheaply you can produce a good, and the more profits our capitalist can reap. (Could there also be a tie into the less failures of a product, or defects?)
Remove the people, remove the connections, remove the art, and you increase quality, access, and lower costs.
Looking to the once shining example of industrial might, Detroit, the assembly lines are now empty; and the few remaining are filled with workers: robot workers. Fewer men, more machines.
We scaled mediocrity to the point of making the extraordinary truly extra ordinary.
In a June 15, 2012 article published in HBR called, “Five Keys To Prepare For The Business of Aging” written by Marta Elvira, Carlos Rodriguez Lluesma, and Nuria Mas, they outlined one of the major global problems healthcare had to face- an increase in the aging population.
In the article, they clearly stated that there are two ways in which healthcare will need to tackle the topic. The first is to moderate consumption of healthcare by introducing copayments to certain services. The second recommendation is borrow from manufacturing, and focus on the reduction of “waste” in the production of healthcare, or to focus on the efficiency. (same answer, just different framing)
Is designing a mass production system to manufacture care for people the right answer?
Is healthcare moving towards the same demise as the world of manufacturing? Are we designing a system that takes all of the art, all of the humanity, all of the connections between patients and their care team out?
Did we design a system that was initially all about people, care, healing, and moved it into an automation assembly line? Have we mass-produced care inside of a factory that we call a hospital? If we can adopt processes, repeat them, and apply them to all cars, I mean patients, we can then build more factories, oops, I mean hospitals.
Are we “leaning” the care out of our hospitals and clinics? Have we “6 Sigma-d” ourselves into a false reality that being human and making mistakes will never happen?
We have adopted the 80-20 rule. We believe that for 80% of the patients that the same care is going to work, most of the time. We believe that for the ‘outliers’ or the 20% of patients diagnosed with a chronic disease, comorbidities, or extenuating circumstances that our process do NOT work well; Or ever. We do a subpar job managing those patients, caring for them, or meeting their needs. Our factories, I mean hospitals, can’t handle producing care for those patients. So our costs have skyrocketed.
The adoption of EMR/EHR, clinic decision support, computer assisted detection (CAD), Watson Health, and pathways are all technologies that allow us to automate the care we deliver.
We schedule patients early in the morning so that we can fill our surgical suites. We have developed a 10-minute time slot to get cancer patients in and out of radiation oncology. I have seen Radiology departments that can see as many as 20-25 patients in an hour on a single scanner.
All in the promise of caring for more people, reducing the costs to the healthcare system, and improving outcomes for patients. Yet the price that we pay continues to grow.
As prices continue to rise, so does the mediocrity.
Healthcare isn’t producing Lamborghini’s or even Toyota’s. Our hospitals are producing Geo’s (yes, I specifically picked an old unreliable unprofitable production of cars that is now obsolete).
There is not a lot of difference between Hospital A and Hospital B. They each are a big box, with 4 walls, and technology. Both hospitals produce care that lives and breathes by the same metrics all in hopes of being paid and reimbursed in the same manner.
Both hospitals are filled with people.
When physicians and other members of the care team are subjected to being measured and paid on productivity, process improvement, and other manufacturing measures they are encouraged to become a cog in the factory of healthcare. They are essentially “incentivized,,” or paid, to increase the production of extra ordinary care.
Our greatest resource, people, are being encouraged to forget their art, and their passion to become a cog in the process of producing average care. (read: How Might Crushes Right In Healthcare)
In the beginning physicians used to make house calls. Physicians had a personal relationship with the people living in their communities. People paid with cash, chickens, bread, and other goods.
We moved into hospitals as technology evolved because it was easier to have a centralized location, usually in the center of the community, where physicians could convene, share, connect, and leverage the consolidated resources of technology and expertise. It made sense for patients to go where all the expertise was managed and the care was being produced.
Care used to be extraordinary.
Today care is extra ordinary.
The relationship, the bond, the link, the connection between a patient and their physician(s) and care team(s) would last for 25 years. They would grow old together; they could share in the successes and tragedies of life together.
Here we are in the year 2015. In a world where connection is everything, and anyone has the ability to be extraordinary; healthcare seems to be moving more and more towards a system of sameness. Creating care for the lowest common denominator.
We are scaling the mediocrity. (I deleted the following couple of paragraphs to get to this point sooner.)
In all of my meetings, lectures, and discussions with patients, physicians, nurses, leadership, the C-Suite, and care teams I have never once heard anyone ask the question, “How can we become more average? How do we accelerate mediocrity?”
That is exactly what we are being asked to do on a daily basis. We concede our decision to make art and instead agree to mass-produce average care.
We do not place physicians, care teams, or the information in a proper sequence of operation when we produce care. All of our information, technology, and “healthcare networks” are fragmented. Our people are scattered.
We do not place replacement hips, regions of interest on an axial image, planning target volumes, intake forms, or labs in the same place. They are all varied because we are not producing work for an inanimate object. We produce care for living organisms. We care for humans. Humans are our patients.
We do not place our care areas in convenient locations and seldom are they in the sequence in which a patient experiences or needs the services. Primary care is not located next to radiology and pathology. Pathology is not next to radiology. Women’s Services is not adjacent to outpatient surgery. Surgery is not located within Oncology. We make our patients, those that we produce care for, maneuver the complexity and fragmentation of our production lines, our factories, our hospital networks.
We forgot Ford’s manufacturing principles.
At one point in time the workers in Detroit took great pride in meeting and/or exceeding all of their production targets, quality metrics, and process improvement goals….before they were replaced with fewer people and eventually machines.
If you do not take the time to connect with the care team or patients, a robot can replace you.
A robot will replace you.
I believe there is a Shangri-La, that combines both technology and people that allows us to make new art. Better art, Innovative art in healthcare. An art that combines the best of patients and their care teams, leverages technology, and actually delivers on a new set of metrics that matter, that differentiate. Whether it’s the new Minute Clinic by CVS, Medisafe, Ginger.IO, Medical Tourism, Telehealth, or Care Trucks, art can still be created. We haven’t lost the ability to create. Yet.
I choose to design a healthcare that defines and answers patient problems.
I choose to create art.
I choose to scale the art in caring for people.
I choose to connect.
Together we can, and will, bring back the extraordinary in healthcare.
One patient, one physician, and one care team at a time.
So to make this a reality that I believe in, here's my offer: the first 3 healthcare leaders (patients, physicians, management, executives, care teams, professional organizations, or hospital networks) that comment (or email me) on this post with a defined healthcare challenge they are focusing on, I will donate my time to collaborate and work with your team to design an extraordinary outcome.
If you are looking for a community who is looking to change health care in the same way as this article, check out the HCLDR Twitter Chat and blog to be part of something great!