Medical errors that shouldn’t happen

Summer activities have kept me away from blogging and I have a backlog of potential posts, but this one motivated me to finally break my inaction inertia:

http://www.nytimes.com/2010/08/21/health/policy/21tubes.html

The article is about medical errors in which patients are severely injured (or die) when the wrong tube is connected to them. For example, a blood pressure tube (which carries pressurized air) is accidentally attached to an intravenous line. There are two points to emphasize: (1) like many challenging quality problems, these errors are rare but not rare enough, especially if you are a victim of one and (2) the solution seems painfully obviously and surprisingly hard to implement.  Consider the frequency of this error. Nurses know that switching tubes can caused big problems and so they are very careful nearly all of the time. But given the number of patients each day that are at risk of a tube mismatch, errors will occur even if six-sigma quality is in place. The obvious solution is to eliminate this potential error by making the tubes incompatible – if the blood pressure tube can’t fit into the intravenous line, then even if the nurse attempts this connection, the error will be avoided.  The problem with this solution is that it requires coordination across numerous government agencies (within the U.S. and across countries) and many more companies. Nevertheless, failure to do something to do something seems negligent at best.

The article mentions another area in which the problem apparently has been solved – fuel filling stations. The idea is that you shouldn’t be able to put a gasoline nozzle into a diesel car and vice-versa. Of course, the number of fuels is much smaller than the number of tubes that can be stuck into a body, so you would think that at least this problem has been solved. But from personal experience I know that it was not solved (at least about 5 years ago) because I managed to fill my rental mini-van in France with 120 euros of petrol only to discover about 2 kilometers down the road that I had rented a diesel mini-van. (On a positive note, the white cloud that appeared behind our vehicle did amuse the kids in the car.) Nobody was injured but the engine needed (I was told) very costly repairs. Avis didn’t make a lot of money on that rental and I wonder why they don’t train their employees to mention to their customers that they really should pay attention to the fact that they are renting a diesel mini-van and not a gasoline mini-van. It is simply an important “safety tip”, like “don’t cross the beams” (for those of you who remember Ghostbusters).

Fixing health care – payment schemes and standardization

There is a lot of talk, as there should be, about fixing health care. Two articles in the NY Times this week discuss this – one describes a bad idea and the other a good one.

The first, (NY Times 4/29/2010) reports on a article just published in the New England Journal of Medicine on the work primary care physicians do.  First, they describe their pay …

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

Next they describe the work they do…

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

And now the interesting part…

The study, medical experts say, also suggests the direction of changes needed if family practices are to flourish and more effectively improve the health of patients and contain costs. It starts, they say, with compensating doctors for work other than patient visits.

Along those lines, from the article itself …

… our internal compensation system now recognizes telephone calls and e-mails as part of our productivity metric.

In other words, the argument is (i) to care for patients physicians must do much more than just visit with them, (ii) these non-compensated tasks are providing a burden and so (iii) we should consider paying them for those tasks …

At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it. Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure.

I realize that we need many ideas to fix health care, but this one doesn’t hold water. It may be unfair to characterize the idea as “payment for emails” but that is the spirit of their pitch. As an educator I can sympathize with their woes  – nobody pays me extra to email with students! What a wonderful world that would be… If I were paid to email students, then I could figure out how to write a macro so that my computer sends out emails every five minutes to every student. Cha-Ching! But that is my point – if you can’t monitor quality, you shouldn’t pay for a tasks.  Unless we have people checking that the physicians are sending out legit emails and phone calls, it  doesn’t work to pay them for those tasks. So in the end, if the goal is to make primary care more attractive to medical students, then paying more than $70 per visit may be the better approach. But that just looks like paying physicians more, and so nobody will write that up in the NY Times.

The second article (NY Times 4/30/2010) discusses the aggravation physicians deal with when trying to figure out how to get paid for the care they provide their patients. The problem is that patients have different health care insurers and each insurer has its own complicated policies for what will and what won’t be covered. This leads to lots of confusion and frustration:

With each plan permutation, it becomes more and more difficult for a doctor to know how to provide care that will work with a patient’s particular coverage. One of the doctors who was surveyed in the Health Affairs study wrote: “It’s like going to the gas station to gas up your car and having to change the nozzle on the gas pump because you have a Toyota and the pump was made to fit Fords.”

So why don’t we have gas pumps dedicated to specific vehicles? Because no vehicle manufacturer could gain a competitive advantage by doing so. Whatever benefit of exclusivity would be small compared to the inconvenience it would impose on consumers. But health insurance companies seem to think differently. They appear to view their tangled mess of quasi-infinitely varying coverage plans as a source of competitive advantage. Nevertheless, it seems substantial value would be created by forming a standardized delivery means for these plans. McDonald’s and many other firms understand the value of process standardization and it would be interesting to explore whether this idea could benefit health care. It is disappointing that this idea seems to be absent from the national debate on health care reform

WalMart in India

Retailing, like politics, is said to be “local”.  WalMart clearly knows the U.S. market, but to expand it needs to learn other markets as well. For two years now it has been pushing into India (see NY Times 4/12/10) and WalMart isn’t in Kansas anymore.

First, India has a quant law that prevents foreign companies from selling directly to consumers – a potentially big problem for a retailer. So WalMart has a 50/50 joint venture with an Indian company to get around that problem.

Next, to WalMart’s credit (and retailing smarts), they are not trying to replicate their hyper-efficient big-box model in India. It simply won’t work. Instead, they are learning how to compete in a new market. In particular, transportation in India is slow and costly, so sourcing has to be done locally. In addition, there are no large suppliers, like P&G. Finally, it has to sell food because consumer durables cannot be the main product category (the Indian consumer has to allocate a large fraction of their budget to food). 

The one “habit” that WalMart is transporting to India is their propensity for proactive supplier management. They are not content to sit back and buy what is presented to them. They see inefficiencies in food production and distribution, so they are directly addressing those inefficiencies. They are giving farmers productivity advice and providing logistical support to ensure timely deliveries of quality produce. In short, they are using their scale to invest in their supply base. To make these investments profitable, it is important to make sure that their competitors cannot take advantage of their suppliers’ efficiency gains – the last thing WalMart wants is to improve a farmer’s yield only to have the farmer start selling his produce to another retailer. I suspect this doesn’t happen because (i) WalMart is willing to pay a good price, (ii) WalMart can buy up all of the farmer’s good produce and most importantly (iii) farmers develop a sense of loyalty to WalMart for helping them out. Economists have a real hard time with loyalty, but in the real world it is a powerful force. WalMart seems to understand this.

Ford to build one Focus

Ford is trying to do it again. Do you remember the Escort? It was suppose to be the “world car”, but apparently there was only about one part that was common between the U.S. and the European versions.  But that was then and this is now. Ford is (and they are serious this time) committed to developing *one* Focus for the world (see NY Times, 1/9/2010)

The strategy is based on the premise that preferences are converging around the world and so the one world car strategy is feasible. Not only is this probably correct, it probably has been correct for quite some time – customers have always wanted a safe, inexpensive, fun to drive, fuel-efficient, stylish, reliable vehicle.  Car manufacturers like Toyota and Honda understood this (though Toyota has waivered from this strategy in recent years).  Mind you, the Focus is probably too much vehicle for the newly not-so-poor of India and China. But for the market that wants this size of a vehicle, it may indeed be possible to provide them with one vehicle around the world.

If the market will accept this approach, then there is a lot to be gained through operational efficiency. Ford could amortize the development and tooling costs over more vehicles. Multiple factories could produce the vehicle, thereby sharing production know how.  Procurement should be simpler and scale should give bargaining power. Finally, it may even be possible to share capacity across markets, assuming the car will be built in multiple markets as well.

And it is worth noting that they will not insist on “any color, as long as it is black”. The plan is to allow some market localization of interiors in such a way that it would not significantly alter the production process. Furthermore, there will not be a single marketing campaign, but more like 5-6 themes that are designed to the particular needs of the target market.

If this strategy will work, then it probably is due to a commitment by senior management, in particular, the CEO, Alan Mulally.  He came from Boeing and noted that Boeing used one door on all of their planes sold throughout the world. Why should Ford need to design doors, steering wheels, etc, for each market? Very good point. Let’s hope the strategy works for them this time.

H1N1 Production and Forecasts

The following table provides a summary of the H1N1 vaccine forecasts and actual availability:

Date	Forecast (million doses)	Actual
7/30/09	120 by October.
9/12/09	50 by Oct. 15,
9/26/09	40  by mid October
10/17/09	28-30 by the end of October.	11.4
10/26/09	30 by the end of October
10/28/09		23.2

Why the error in their forecasts? My favorite quote (NY Times Oct 25, 2009) is

Dr. Thomas R. Frieden, the director of the Centers for Disease Control and Prevention, “We really thought that having five different manufacturers would buy us some insurance, that they wouldn’t all have problems.”

The implicit assumption in this quote is that yields would be independent across flu manufacturers.  This may be true if yield primarily depends on manufacturing choices that could differ across the 5 manufacturers. But the manufacturers all used the same seed stock (the virus injected into eggs that is suppose to replicate within the eggs to make the vaccine).  Consequently, if the seed stock isn’t very good, it doesn’t matter if you have one manufacturer or 100! If you are going to diversity your risk by choosing multiple suppliers, then you should make sure that their yields are uncorrelated. (On a related point, there was no shortage of nasal spray vaccine, because they had a much higher yield … and used a different seed stock.)

There are some other reasons for the errors.  In July the forecast was based on an assumption of a high yield. However, the actual yield would not be known until the first batches were completed in August. Therefore, it seemed premature to put any faith in the July forecast without better information.

So why were the September forecasts wrong? The government basically asked the manufacturers’ for their forecasts, and not surprisingly, they got optimistic numbers. I am not saying the manufacturers lied. Instead, they probably thought it was possible that they could improve yields quickly enough to make the numbers. For example Sanofi Pasteur’s initial yield was 1.5 doses per egg and they did manage to increase it to 3 doses per egg.

Some of the shortfall was due to shortages in parts. For example, MedImmune, maker of the nasal vaccine, had more vaccine than it could put into nasal sprayers (their yield was apparently 5 times higher than expected), despite having their supplier of nasal sprayers work 3 shifts, 7 days a week.

Finally, one of the manufacturers, from Australia, satisfied Australian demand first.

The lesson from all of this, dare I say, is “don’t count your chickens before they have hatched”! Production yields are uncertain, and the government could have benefited from learning more about what determines those yields, when information would be learned about those yields and relying less on manufacturers’ forecasts.

Capacity shortages of H1N1 vaccine

Have you been able to get your H1N1 vaccine? Probably not – it has been widely reported that there are delays in the distribution of this vaccine. The interesting question is why? Reading a bunch of articles on this topic doesn’t shed a whole lot of light. But one figure jumps out at you – as reported in WSJ (10/19/09 – Delay Undercuts H1N1 Vaccine Campaign), the U.S. government has ordered 251 doses from 5 manufacturers. The current U.S. population is just over 300 million, so they have ordered enough to vaccinate over 80% of us. To put this in perspective, the U.S. normally vaccinates about 100 million. In fact, 114 million dose of seasonal flu was ordered in addition to the 251 million does of H1N1. The two types of vaccines are made with nearly identical manufacturing processes. So that adds up to about 365 million doses of vaccines, which is at least 3 times the typical production volume.

Given that manufacturers had to more than triple their capacity, it is not surprising at all that they are behind schedule in production.  Making matters worse, the quick ramp up may have contributed to the their lower-than-hoped-for yields. 

So instead of complaining that you can’t get an H1N1 shot, maybe you should be thankful that they have been able to produce as much as they have. Given the number of deaths among children, let’s hope better news will come soon.

Quality, Incentives and Healthcare

The opportunities for improved quality in healthcare are enormous.  Now, there is more incentive for the industry to take quality seriously – Medicare will stop paying for 10 conditions that it deems to be “reasonably preventable”.  For example, Medicare will no longer pay for the treatment of patients who received incompatible blood transfusions. No doubt, some of the techniques that have been used to improve quality on the factory floor will also be useful in the hospital – reporting defects so that attention can be focused on them, changing labels on sensitive medications so that additional care is given to them, asking all attending a surgery to count sponges and instruments to confirm that no unwanted objects have been left in the patient, etc. And, additional quality improvement techniques may be developed that are tailored just for healthcare.

New York Times, Sep 30, 2008: http://www.nytimes.com/2008/10/01/us/01mistakes.htm

Environmental Kaizen

Kaizen, or “continuous improvement”, means constantly working towards improving processes, no matter how small the improvement.  The idea of kaizen has famously been applied at Toyota to their manufacturing process but the concept has also been applied by GM to make their manufacturing plants more environmentally friendly.

GM’s Lansing Delta assembly plant in the the world’s only to have received Gold Certification from the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) system. They achieved this goal by making many small (and some large) improvements to their processes. For example, they use bright lights were tasks are needed and dim or no lighting where light is not needed (such as where robots are working).  The restrooms use rainwater collected from the roof and the roof is painted white to reduce heat absorption. (Both the light and rainwater examples emphasize that an important resource should be used only where needed.) But more important than any single idea, the implementation of Kaizen changes how employees view their environment and motivates them to generate further ideas.

Automotive News, August 11, 2008 – GM Factory a Model of Sustainable Manufacturing

Dabbawala and six sigma

Based in India, the Dabbawala organization is the buzz of the six sigma consulting world. To quote from the Economist’s article: 

“Using an elaborate system of colour-coded boxes to convey over 170,000 meals to their destinations each day, the 5,000-strong DABBAWALA collective has built up an extraordinary reputation for the speed and accuracy of its deliveries…

At 9am every morning, home-made meals are picked up in special boxes, which are loaded onto trolleys and pushed to a railway station. They then make their way by train to an unloading station. The boxes are rearranged so that those going to similar destinations, indicated by a system of coloured lettering, end up on the same trolley. The meals are then delivered–99.9999% of the time, to the right address.

Apparently there is now an HBR case on the organization.  This is probably worth checking out further if you need to discuss quality management.

The Economist, July 10, 2008
THE CULT OF THE DABBAWALA

Quality management at the American Red Cross

According to the FDA, the American Red Cross is not as good at ensuring quality in the nation’s blood supply as it should be.  In fact, ” … despite $21 million in fines since 2003 and repeated promises to follow procedures intended to ensure the safety of the nation’s blood supply, it continues to fall short.”

This article describes some basic failures of quality management and illustrates some opportunities. For example, the Red Cross lacks a system to track errors (blood units that should not be introduced into the system) and hence has no mechanism to identify root causes and to develop solutions. 

Next, because it is a large ($2.1 billion in revenue) and decentralized organization (they use to have 53 operating regions and now 10) they lack uniform standard operating procedures.  Even when they have standard procedures, workers do not always follow them.  For example, a phlebotomist is suppose to swab a patient’s arm for 30 seconds and then let that area dry for 30 seconds, but those times are not always followed.  One solution is to make phlebotomists wear timing devices to ensure compliance. Another is to redesign the process to be more robust, especially with respect to ensuring that people comply with the standards.

The news is not all bad. A key lesson from quality management is the elimination of variability.  Red Cross workers sometimes forgot to ask all of the pre-screening questions to potential donors, thereby letting some donors pass even though they shouldn’t (e.g., if they had visited a malaria risk country).  To standardize the process, now potential donors must complete an on-line questionaire – the computer doesn’t forget to ask the question, so variability in the process is reduced.

NY Times 7/16/08 – Problems persist with Red Cross blood services
http://www.nytimes.com/2008/07/17/us/17cross.html