Faster, Better, Cheaper
Remember Veruca Salt in the movie, Charlie and the Chocolate Factory? Her famous quote is “I want it now, Daddy,” and, as I recall, the results were not good. So much for spoiled brats and overindulgent parents.
But is that the mirror of us all? Are we the NOW generation? Do we want quality or whatever else “now!” Look at the toys and technologies of the recent past. We all have cell phones, because we couldn’t wait to get home to call. And what is the chief selling point of the new iPhone? It’s faster.
Nothing wrong with faster, as long as there is economic advantage or people are willing to pay me to provide ever newer toys with ever shorter delivery times. Paul Borawski also talked about the rate of change in products and the role of quality in that process. It’s a real challenge to gather data on what customers liked/didn’t like about the last product and translate that into features for the next one. Of course, people don’t always know what they want and may change their minds by the time it reaches the market. (Remember the Edsel?)
How does this relate to healthcare? We’re beginning to see some interest in decreasing the cost of healthcare services. The recent issue of Health Affairs devoted to cost didn’t mention that factor, but others have. Most agree that there is considerable waste in healthcare as an industry, but there is wide disagreement on where that waste resides. (It’s always in someone else’s process.) Nevertheless, when we begin to get serious about taking waste out of healthcare processes, time will be an important metric. No one likes to wait, and waiting costs money for the institution. I used to know how much it cost per minute to have a patient in my surgery center, whether or not anything was happening to them. Obviously, the answer was to make things happen faster and get the patient out sooner. All, of course, without having them feel rushed. It is possible, and standard QI tools can help. Every month, we looked at a histogram of time in the surgery center, and pulled the charts of everyone who stayed beyond 2 SD. From the list of reasons for a prolonged stay, we constructed a Pareto chart and started on the longest bar.
There were lots of examples—some of them small details, but the bottom line was a win for everyone: the patient went home faster, the surgeon finished his work sooner, and the center made more money. All it takes is a goal: make things happen faster.
The other role of quality in this environment of change is that of a governor—is this change really adding value? Are we doing this faster just because we can, or does the patient or some other customer really value this change? Certainly a primary driver of increased healthcare costs has been technology. These new gee whiz tests and procedures that provide answers to questions not asked or do things we didn’t want done. The US Preventive Services Task Force has been fighting this battle for years—don’t have mammograms, don’t get PSA tests, and now don’t have tests for ovarian cancer. Their thesis is always that some false positive tests will prompt patients to have further tests or procedures that are not necessary. The alternative is that some patients will die from undiscovered cancer, but life’s full of choices. And it is cheaper.