September 9, 2005
It's the Little Things…They Add Up.
Sometimes the simplest things bring unexpected complications. The laws of randomness and surprises.
A while back I attended a wedding celebration that lasted pretty much all day and well into the evening. While navigating down the freeway late in the evening, I noticed I couldn't see the freeway signs well. Fatigue? Old eyes? Need a new lens prescription?
OK, I don't get my “routine” medical exams as often as the “experts” say I should. So, off I go to the ophthalmologist. First rate people. I'm going through the drill with dilated pupils and anesthetized corneas. Acuity, cornea, refraction. And then, pressure test. These little blue circles lower onto my corneas. All ok. And why not, I have no risk factors for glaucoma and my pressures have always been normal.
Then the doctor examines my eyes. Reminded me of the Bill Cosby routine. The doctor almost said “oops”. I had a corneal abrasion from the pressure test. So, I had a problem I hadn't walked in the door with. No one intended to give me a corneal abrasion. But there it was. They gave me lots of free stuff to take home and lots of apologies. All unnecessary. It was all well by the next day.
But it reminded me of all the treatment we give “at the margin” of benefit. That is, the seeking at all times to deliver maximum utility. And no one asked me if I wanted another glaucoma test.
Should I have one every year? What good is it? How does it benefit me? For a person like me the frequent testing of eye pressures falls into the category of low benefit and low risk. It is clearly at the margin of benefit. And though there is a very low likelihood of happening, once in a while, somebody gets a corneal abrasion. The benefit of discovering glaucoma early gives the chance to prevent loss of vision. That's big. But the likelihood that I will have it is very small.
How does one sort through this?
This week The Center For The Future Of Health has been focused on the work of our colleague Yakov Ben-Haim from our affiliated institution The Technion in Haifa . Dr. Ben-Haim's work in info-gap is being tested now in a prototype model at the Center to see if it can help individuals get the care they want at the level of uncertainty they are willing to tolerate.
Another approach is from the provider side. This is illustrated in the current issue of the Harvard Business Review. In an article by Steven J Spear entitled "Fixing Healthcare from the Inside, Today" he describes the resistance of medical care institutions, hospitals mainly, to the implementation of basic industrial engineering practices to reduce errors.
He asks why hospitals can't be more like Toyota. One way to raise the quality of healthcare is to remove risk from the systematic care of hospital-based care. In a sense this is risk that shouldn't be there because with attention it can be markedly reduced or removed completely.
Here's a question to ponder: How much of the roughly $700 billion in revenue generated by the hospital industry is invested in hospital R&D?
Would it surprise you to know that the number approaches zero? Is it any wonder that at a process level, we continue to take care of patients much as we always have for a hundred years or so? This could never happen in a non-protected industry.
Spear points out a salient truth about hospital care. Every problem is treated as a one off solution. No systematic improvement process exists. No institutional learning exists. He goes on to point out that it is a sequence of little improvements, step by step, that result in big improvements in outcomes of care. And that's what Toyota knows about making cars.
Spear offers a number of examples of lowering infection rates, decreasing errors and the like. Efforts such as those he describes have gone on for many years. For whatever reasons, the improvements or the method to improvement never gets generalized or institutionalized into the culture and behavior of the hospital in this case.
In a sense, he describes the obvious. What he never really addresses are the behavioral and cultural barriers that prevent widespread application of what essentially are industrial engineering methods to large institutional healthcare.
But the point is the little things add up. Scores and scores of details in complex systems. Intuitively, we know this to be true. It can hurt us or help us. Do we have the will to address this? Why don't we? Could it be we lack basic collaboration skills? That we do not know how to productively manage the conflict of competing perspectives for the benefit of patient care? That in healthcare we don't value knowledge that wasn't invented here?
And here's a question: will the investment in healthcare information technology help with this problem? First, we have always under-invested compared to the need to deliver more and more information and knowledge to the point of care. Second, automating flawed systems never fixes them. Attention to making things work right all the time, what is known as system integrity, will be required.
Little things become big things. For sure.
