Tuesday, July 13, 2010

Loved to Death

There is currently a lot of debate around how or even if manufacturing processes such as LEAN and Six Sigma "have any place in health care." The question seems polarizing, with both opponents and proponents providing more heat than light. As if global warming isn't bad enough already.
The problem isn't so much a particular technique (or dare I say, fashion), it is the managerial propensity for falling in love. It's happened before.
Remember clinical paths (care maps, critical paths)? They were going to be the saviour of health care! For a while, they showed some promising results. Patients got better and more timely care. Outcomes improved. Across-the-board job satisfaction of health care workers improved. The costs of providing care decreased.
So what went wrong?
One of the truths about any tool is that it works well for a specific and proscribed number of tasks. This is as true for clinical paths as it is for screwdrivers. You might be able to adjust a Philips-headed screw with a flat-blade screwdriver, but using a Philips screwdriver would yield better results and be easier.
Similarly, clinical paths worked beautifully for some specific diagnostic or procedural group: open-heart surgery, joint replacement surgery, treatment of community acquired-pneumonia. Steps that improved patient outcomes were identified, and systems were put in place so they weren't missed. Activities that did not improve outcomes were minimized or deleted outright. Costs went down and patients got better faster and everyone was happier.
Then someone decided that if it worked for these groups, we should do it for everyone! My standard screwdriver drives standard screws so well, let's use it to drive other screws! And drive nails! And saw wood! And (this is critical) think of the money we'll save!
That the proposition made no sense whatsoever was somehow overlooked.

You can imagine what happened. Clinical paths work, and work well, for those patients who are likely to have a fairly standard hospital course. If the diagnosis, patient response, or complications make the course in any way non-standard, the patient "falls off the path." This isn't necessarily bad, but the tool is no longer useful, and all the improvisation or wishful thinking or watering down will make it so. When one hospital I worked at announced the goal of having 90% of the patients on clinical paths, I knew they were doomed. Some of the paths became so generic that it met the stated goal, but did nothing to improve patient care. Make that "less than nothing": it diluted the power of a once-useful tool, created a paperwork distraction from the real work of patient care, and created the false dichotomy of "it's either useful for everyone, or it's useless."
No tool is useful for everyone, in all circumstances, ever. So instead of using clinical paths only where they were designed to work, they were used everywhere, then abandoned in frustration when the earlier results weren't replicated.
I don't know much about LEAN or Six Sigma. I've heard accounts of it working well in some aspects of health care delivery, and disastrously in others. Even at Toyota, when LEAN was first popularized, the technique was over-applied with horrendous consequences.
I don't believe these techniques will save health care. I don't believe they will necessarily destroy it, either. They, like other tools, will have their appropriate place where they will produce remarkable improvements in quality, cost control, and value.
Then, if the pattern holds true, someone will fall in love, apply the principles where they don't work, and ruin everything. How do we keep that from happening again?
I'm not sure. I think a reasonable start is to learn these systems for ourselves, so that we fully understand their appropriate uses. We also need a healthy level of skepticism: no bullet is magic. Any approach in current favor should be critically appraised with at least this question: "What circumstances or processes do this technique's developers recommend it not be used for?" That question should have a meaningful answer, and that answer should be believed.
We all need to be willing to try new tools, as there may well be something better out there. We also need to understand those tools, understand their appropriate use, and use them correctly.
It's something we aren't particularly good at.

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