Sunday, May 22, 2011

There's No Tomorrow

Actually, no today either.  In case you missed it, the world ended last week.  But, if it doesn’t happen as promised, there’s another chance.  This time it’s not the Christian Bible thumpers but the Mayans.  The Mayan calendar will end on 21 Dec 2012. In truth, however, only the Christians have such an apocalyptical view of the world.  The Mayans simply start a new calendar, so perhaps there will be tomorrows.

That ‘s good news, because the ASQ has published their view of what tomorrow will look like.  Others have commented, and, of course, they’re all wrong.  Let’s look at their predictions:
1. Global Responsibility.  ASQ thinks “governments, organizations, and individuals” will act with “a growing awareness of the local imac of local decisions.”  Waste will become socially unacceptable.  Well, they certainly forgot to ask the Tea Party about this, or the Republican party in general.  There are those in Congress who want to remove funding from the EPA, and any thought of a carbon tax brings laughter and derision.  ASQ also talks of waste in the form of “undeveloped minds.”  To turn that around, we would need to strengthen the WIC program and Pre-K enrichment programs for poor kids.  Oh, but we just cancelled those things.  Sorry, despite our fondest hopes in 2008, the U.S. at least, seems headed in the opposite direction. 

2. Consumer Awareness.  They allude to the Internet and social media as providing information to consumers to make purchasing decisions.  Well, yes, some, but that’s here now.  Is there some reason this practice will expand?  Internet shopping is a here and now practice, not a dream for the future.  Even the concept of mass customization is so, well, yesterday.  What about tomorrow?
Globalization.  As they say, globalization of customers and work forces is a factor in most businesses, tho more critical to larger than smaller businesses.  It’s not clear from the discussion what they predict for tomorrow, so hard to argue that they’re wrong unless one could say globalization will become irrelevant.  So OK, I’ll say that.  Globalization will cease to be the boogey-man it once was.  Cheap labor is cheap for a reason, and low wages will no longer be the driving force for location of factories.  Taking healthcare as an example, there will always be a place for medical tourism, but it will never challenge or supplant traditional sources, like your Community Memorial hospital or the Cleveland Clinic.

3. The increasing rate of change.  Change has certainly been dramatic in our lifetimes.  Wow!  I remember dial telephones.  And the first TV in our neighborhood--a 6 inch black and white.  So it’s easy to predict that this will continue.  Easy, at least unless you’re reading the tea leaves.  On a talk show the other nite, someone espoused the radical idea that technology hadn’t really done much in the last ten years or so.  New gadgets, to be sure, but no dramatic improvement in our lives that could be ascribed to technology.  Today’s Washington post carries a column about “life without gadgets.”  So maybe not much will change in the next 5 to 10 years.  Society will take that time to digest what went on in the last.  And we do have a few wars to contend with.  Wars aren’t over when they end.

4. The workforce of the future.  I hope they’re mostly correct here, when they state that unemployment “will become a thing of the past,”  but I suspect this is wishful thinking.  The pressures of high wages have driven productivity ever higher.  We just don’t need that many workers making widgets anymore.  But without paid workers to buy widgets, we don’t need to make so many widgets, so we’ll lay off a few more workers. That’s where we are now.  It’s called recession.  Getting out is hard to do.  Government spending helps, but that only works if you simultaneously raise taxes.  Not gonna happen in the present environment, so unemployment will be with us for the long haul, and may actually get worse. 

5. Aging Population.  ASQ starts this discussion with a prediction that working longer may become an option “if not a requirement,” and I’ve got to agree with this one, with one asterisk.  The requirement part implies extending the retirement age for Social Security.  This makes a lot of sense, and there is talk of indexing the SS retirement age to life expectancy and thus return the duration of retirement to about 10 years.  Current U.S. life expectancy is about 78.   One of the big problems with this is that if the job demands physical effort, it’s hard to keep up when your 70.  Manual laborers will lose out.   ASQ talks about the high cost of healthcare for all these geriatric patients.  Maybe we should revisit Soylent Green.   Healthcare expenses do go up with age, but not as much as you might expect. Furthermore, the increasing number of elderly is not a key factor in the costs of Medicare.  The reason Medicare is such a budget buster is the high and rising costs of individual healthcare services.  Not only are our healthcare costs higher than any country in the world, we provide more of those services per patient than any country in the world.  So, yes, Medicare is a serious problem for the U.S., but no, the aging population is not making it worse--not by much anyway.

6. 21st Century Quality.   For this discussion, ASQ defines quality as what the customer wants.  They present an interesting concept that quality has moved from production lines to process improvement to enterprise assessment.  Whither goest quality as a concept in the future?  Some say nowhere.  In healthcare, at least, attempts to institute “quality” have not produced any system wide gains in efficiency or in quality of care.  In fact, the results of data from NCQA and AHRQ show little if any improvement over the past several years.  Anyone who is surprised at this should remember that any system produces the results it was designed to produce.  Is “quality” an obsolete term?  Has the concept outlived its usefulness?  What is the meaning of quality in a service economy?  Is there any place for it in the future?

7. Innovation.  ASQ initially expresses some confusion over the difference between innovation and improvement, then makes no prediction for the future importance of either.  Just a term they thought they should mention.  Hard to argue with that. 

On predicting the future:  I went backpacking with the Boy Scouts, and one of our assignments was to predict the weather.  For six days, there was a morning haze followed by sunny skies.  We, of course, predicted more of the same for the seventh day.  It rained.  Poured down rain.  This illustrates the difficulties of predicting the future by extrapolating from the past.  That’s what ASQ has done:  they picked some trends and extended the line to the next point.  This doesn’t allow for unexpected events (like earthquakes) or disruptive innovation that may make your business obsolete.  The C&O canal in Washington, DC was supposed to be the transportation mode of the future.  Until railroads, that is.

This report by ASQ is almost totally devoid of documentation or data to support the few predictions they make.  For the most part, that’s OK in this venue.  However, when you make an outrageous statement like unemployment will go away, you better have charts and graphs. 

Let me offer my own take on the next ten years.  Mark your calendar and call me back.  I’ll buy drinks if I’m wrong on more than two and ASQ was right.
1. Global responsibility:  There are no incentives for either governments or corporations to be socially responsible.  They will not. A few isolated examples, but generally no.
2. Consumer awareness.  Has reached its peak.  Certainly in healthcare, further attempts to better inform consumers will fail, partly because most patients are incapable of understanding and partly because they don’t care.
3. Globalization.   No one will talk about this in ten years.  No book titles.  No speeches.
4. Rate of change.  Will slow to a snail’s pace.  We may see expansion of wireless networks to broad geographic areas, but it will be the same Internet.  Lots of refinements of gadgets--better iPads--but nothing innovative.
5. Workforce.  Wages will fall, mostly by a drop in benefits, particularly health insurance and retirement.  Healthcare and technology will be the biggest employers, but unemployment will not be much different from today.  The Very Rich will emerge as a distinct class of World Citizens without allegiance to any country.  The gap between the Very Rich and the rest of us will widen.
6. Aging.  The 70 to 90 year old group will become the new middle class. They have money to spend and time to spend it, in modest amounts.  The health in this group will improve, and the time between sick and dying will shorten.  Suicide will become a more common cause of death.
7. Quality will decline in relevance as a buzzword.  In healthcare, quality will come to mean compliance to standards set by government committees or think tanks.

Maybe the world did end yesterday, and I just missed it.  Catch you in 2012.

Saturday, May 14, 2011

Leadership in Healthcare

On reviewing Paul Borawski's writing about ideas for education, I looked for common themes--some high level principle that could apply to healthcare also.  I came away with leadership.  Every organization needs a strong leader--someone to point the way and inspire the troops to follow.  This is true for education, and it is also true for healthcare. 
Why?  What do leaders do, and how is that different from managers or supervisors? There is even a Journal of Leadership in Health Services.  Leaders should be visionary and determine the best direction for the organization.  Take charge and accept responsibility.  General George Patton is quoted as saying, "Tell the troops what you want done, but don't tell them how to do it.  They will amaze you with their ingenuity." 

Managers, by contrast, make it happen.  They marshal resources, assign tasks, monitor progress, etc.  Also needed, but a different focus.  supervisors make sure everyone comes to work and has the tools to perform their assigned tasks. 

So, what about healthcare? Taking the hospital as the prototypical example, healthcare organizations use a matrix organizational structure.  This works best in project oriented environments where a given employee may work on different projects sequentially and there is some advantage to sharing lessons learned with others in the same discipline or carry knowledge from one part of the organization to another.  The disadvantage with matrix structures is the confusion that comes with having multiple bosses and the fact that no one is ever in charge of anything.  I remember the chief of the surgery clinic at the University of MI saying one day, "I'm supposed to be in charge of this clinic, but no one here works for me." 

When no one is in charge, no one takes responsibility for what happens.  My wife and I were waitting in a pre-op area, when she noticed a nurse putting paper into a red-bag trash can.  She had heard me talk about the relative costs of red and white trash, so she knew this was wrong.  "Why is she doing that?"  The simple answer was that no one cared.  No one was responsible for that area.  No one's annual bonus depended on the efficient operation of day surgery.  So they put non-hazardous trash into the red bag and paid dollars per pound instead of putting it into the white bag that cost dollars per ton.

This is a major problem with healthcare today.  No one is in charge.  Institutions and sections within institutions are allowed to operate inefficiently, because there is no leader to stress efficiency and cost saving as a goal.  To some extent, the above examples could be explained by the lack of a profit motive in most large hospitals.  A moment's thought, however, will dispel that thought.  What's your favorite airline?  Least favorite?  Why?  Where do the employees of the best airline get their attitude?  Out their thumbs?  Are they born that way?  I was strolling up and down the corridors at Dulles airport recently, waiting for my flight, when I heard cheering and applause at a gate ahead of me.  I thought it must be some group charter, but as I got closer I could see that it was just a routine Southwest Airlines flight.  No one cheered at the Lufthansa gate.  Someone up the food chain set the tone for those employees.  That's leadership.

We recently returned from a cruise where a daily activity was getting people off the ship and on to buses on shore.  One group of employees assigned bus numbers for various tours.  The security group checked passengers off the ship.  Another group drove the tenders to the dock.  I'll let you imagine the chaos that ensued when these groups didn't talk to each other.  Leadership.  Someone needed to be in charge.  Responsible.

This is not to say that chaining the organizational structure of healthcare institutions and assigning leaders would solve all the problems.  Leaders don't always make wise decisions.  However, if we determined a new direction that would solve problems, we would have a mechanism for instituting those changes--a single, responsible individual in charge. 

Leadership in education, and leadership in healthcare. 

Sunday, May 8, 2011

Wrong Target

Hard to hit the bull’s eye when you’re aiming at the wrong target.  A recent opinion piece in the Washington Post summed up the “two monumental issues:” how to provide access for everyone, and how to control costs.  The first issue—access—has been largely solved by the recent healthcare insurance reform law.  However, the cost issue remains.  These authors join countless others in aiming at health insurance, without targeting the systems of healthcare services that drive the cost of insurance.  The premiums for health insurance merely reflect the costs of the services received by the insured population.

Everyone now views with alarm the relentless rise of healthcare costs in the U.S.  Medicare, in particular, has been projected to consume 100% of the discretionary spending in the federal budget in our lifetime.  No need for budget debate; it will all go to Medicare.  Unfortunately, the current discussion focuses on Medicare as the insurance plan for the 65+ population.  Costs to health insurance companies would be less if we provided less care to individual patients, so most cost reduction schemes seek to reduce the care provided.  For Medicaid, we will reduce eligibility, so there are fewer people in the pool.  For Medicare (and others), we’ll have an expert panel to decide what therapies will be covered and which will be excluded—similar conceptually to the British NICE panel.  (See article in The Atlantic on “My Drug Problem.”) Still, we are left with high-cost individual healthcare services.  It still costs more to have hip replacement in the U.S. than anywhere else in the world.  This, of course, is the basis for the Medical Tourism industry.  

Suppose, instead, we pointed our weapons at the cost of individual healthcare services by invoking price competition.  We’ll still provide a hip replacement (THR) to anyone who needs it, but we’re taking bids.  Yes, it’s more complex than ordering copy paper, but those are solvable problems.  They have been solved in other realms and can be solved in healthcare.

What would you do on the other side?  Your hospital has been doing THRs forever, but you just lost your bid to a hospital in the next town, because you charge too much.  In most industries, the instinctive response would be to look for ways to reduce your cost.  This would lead you to a process engineer who would use LEAN techniques to identify waste in your current processes.  Estimates of waste in healthcare vary from 20% to 50% of costs, so there are enormous opportunities here.  There are other tools and techniques, and there is value also in an overall Management System to organize those tools and ensure they are used effectively.  (Disclosure: I’m one of the authors of this book.)  These tools are not entirely new to healthcare, but price competition is a new concept

So too is the concept of an overall management system, such as ISO 9001 to manage improvement efforts and ensure they are focused on common objectives.