Chasing the Rabbit: Official Blog by Author Steven Spear

Complain to some health care professionals about broken processes, ineffective systems, failing through the cracks, and the like, and some will contend that patients have to manage their own care, responsible for interpreting advice, integrating the services of disparate specialists (often without the advantage of an electronic medical record to keep all information in the same place).  

Of course, there are basic problems with this approach.  Patients (and their families) typically lack the training to make decisions that should be made by experts and they can’t recognize that something is wrong  until it is too late.  Magnifying those handicaps, they are emotionally and physically compromised–that is why they are receiving care in the first place.  

Then there is the basic question of challenging authority, the basic intimidation factor that goes with putting someone in a white coat with a stethoscope draped around their neck.  The Yale researcher, Stanley Milgram ran a series of experiments in 1963 in which subjects were mislead to think they were assisting in an experiment.  Their “job” was to ask questions of “subjects” (really actors who were part of the study) and apply what they thought was an electric shock to “punish” a wrong answer.  Most participants “just followed orders,” applying ever larger shocks despite the cries of pain, protests, and pleadings of the actors–connected to fake electrodes–who were part of the charade.  Adam Cohen writes in the NY Times, (”Four Decades After Study, We Are Still Willing to Inflict Pain” NYTimes Dec 30, 2008) that a replication of Milgram’s study, done by Jerry Burger of Santa Clara University duplicated Milgram’s results.

Cohen runs a thread from these results to training for military and police.  There is another thread for training patients and providers.  Situational influences can do an enormous amount to suppress people’s ability to question authority precisely when it should be challenged.  This can be nurse to doctor, patient to provider, and so forth.  It becomes critical that providers be aware of this, and do what they can to reduce the silencing effect of the situation.

Liz Kowalczyk’s article (Hospitals Shorten the Waits in ERs, Boston Globe, December 24, 2008) reveals a deeper truth about health care delivery.  We would get more and much better care at less cost were healthcare delivery managed more sophisticatedly.  Government can prompt this, without more taxing and spending.  

Hospitals were under serving patients by diverting cases elsewhere when emergency departments (EDs) overcrowded.  However, over crowding was not just a demand-capacity imbalance.  There were avoidable delays, inefficiencies, and disconnects in the EDs and other departments.  Investing time (not only money) in smoothing flows and coordinating efforts generated ‘free’ capacity.  The key?  Performance had to be measured, with hospitals held accountable for bad performance.  This unlocked creativity and innovation directed to the betterment of care. 

The same is true across the board, not just with emergency medicine.  As documented in my book, Chasing the Rabbit, and as is proven by the Institute for Healthcare Improvements 100 Thousand Lives Saved and 5 Million Lives Protected from Harm campaigns, providers can eliminate persistent afflictions such as ventilator associated pneumonia, surgical site infections, and patient falls by managing care delivery in other than a haphazard fashion, thereby unlocking previously squandered resources for better access across the range of preventative, primary, chronic, and acute care.  Demanding an end to diversions is a first step as is Medicare/Medicaid’s refusal to pay for ‘never events’—harm done while a patient is being treated.  Next are better measures for more services, and increased circumspection by payers and patients based on those.

Thomas Friedman is absolutely correct (”While Detroit Slept,” December 10, 2008).  The particular issues being addressed in any bailout plan are merely symptoms of a more fundamental problem: an institutionalized inability to improve, innovate, and invent as a core capability.  This is characteristic of Detroit specifically; it is also characteristic more generally of institutional failures.  The flipside is that great success goes to those who learn how to create a dynamic of high speed, relentless, broad based innovation.

I base this assertion on research I did, starting in the mid 1990s.  I was studying Toyota, trying to understand how it was able to widen its lead on its competitors, increasing the number of dimensions on which it was competing even though Toyota had been studying so extensively.  What I discovered is that for all the fervor to copy it in the form of ‘lean manufacturing’ tools–value stream maps, pull systems, standard work, etc.– people had missed the fundamental issue that Toyota had learned how to institutionalize innovation in a large complex organization generating surprising agility and responsiveness relative to its competitors.  Consequently, with much less effort it could generate far greater yield, first outstripping the field on quality and production efficiency, later on product diversity, time to market, regionalization of its business, hybrid drive, and so forth.  

As Friedman has so often pointed out, innovation is what distinguishes success from failure for economies, military campaigns, or corporations.  When I extended my research from Toyota specifically, I found it goes one step beyond that.  Other organizations that were able to institutionalize innovation as well.  

For instance, my book, “Chasing the Rabbit: How Market Leaders Outdistance the Competition” lays out examples as diverse as product and process design, heavy industry and high-tech, products and services, and dot.com. The US Navy’s experience developing nuclear propulsion in the late ’40s and early ’50s

Perhaps the most immediately compelling examples are in health care, where some providers have learned to provide nearly double the care at half the cost as has been accepted as the norm.  Were others to do on a national level what the pioneers have tried and accomplished, health care would disappear as a problem demanding we either spend more or accept less.