Friday, September 02, 2005

Reasoning by (Mis)Analogy Revisited: How is Health Care Like Manufacturing Toyotas?

As someone who has done a bit of academic work in health quality, an area that has not received a lot of support, I welcome every well-intentioned effort to improve quality. Furthermore, it is reasonable to try to apply lessons learned outside of health to improve health care.
That having been said, I remain troubled that a lot of thinking about health quality seems to depend on drawing misguided analogies. I had previously posted about how the former chairman of Intel likened health care to making computer chips.
The latest example appeared in the New York Times. This op-ed article, entitled, "The Health Factory," asserted that hospitals have a large

opportunity to reduce the rate of catastrophic medical error, if the hospitals would just follow the example of the world's most succesful industrial organizations. Companies like Toyota, Alcoa and Vanguard differ from one another in the products they produce and the technologies they employ, but they share a management approach that has resulted in a combination of safety, quality, efficiency, and responsiveness unmatched by their competitors.
It may seem a stretch to compare a carmaker's , aluminum refiner's, or mutual fund company's operations with a hospital's. But all these companies manage complex processes that require a great deal of problem solving.
To me, it seems a stretch to far. Once again, hospitals do not produce products, they provide services. Moreover, unlike, say a hotel or airline, they must provide unique services to patients who show up at unpredictable times with unpredictable problems, and combinations of problems.
Certainly, there are processes that occur in hospitals that are routine, such as, for example, washing linen or sterlizing surgical instruments. But there is tremendous variability in what goes on in every hospital Emergency Department, operating theatre, medical ward, etc., etc., etc.
It thus makes little sense to think that quality improvement measures designed for businesses whose goal is to produce identical products on assembly lines (e.g., Toyota cars and Alcoa aluminum ingots) are going to apply to most of what goes on in hospitals.
But forcing the application of such measures in situations where they do not readily fit is likely to produce worse, rather than better quality.
Maybe that's why the op-ed cited a single anecdote to support this argument, and started off by wildly inflating the dangers of hospitalization, likening it to "parachuting off a bridge."
I appreciate well-intentioned efforts to improve health care quality, but to be succesful, such efforts need to be informed by appreciation of the health care context.
In a larger sense, thinking about and managing health care as if it were a routine, assembly-line process, as Ludmerer wrote in Time to Heal, like "making cars or breakfast cereals," may be a cause of, rather than a solution to our current health care ills.

1 comment:

Anonymous said...

I disagree. Obviously performing surgery is different than producing a car. But it is equally obvious, I think, that the process of care, from intake to discharge, involved many steps that would benefit enormously from standardizing processes, empowering team members, and other strategies employed by these successful companies. Many of these are non-clinical steps that impact patient outcomes or, at the very least, costs. Others are clinical and as much as many physicians don't want to admit it, a lot of care could be made more uniform.

Health care, like every other endeavor, involves a series of steps. Health care is pretty darn complex, so it involves a lot more steps. Any series of steps can be broken down, analyzed, and improved upon. That doesn't mean "cookie-cutter medicine," performing each procedure exactly the same way, but it does mean looking critically at how care is delivered and thinking about how it could be delivered better. That's the genius of the Toyotas and Intels and Alcoa's -- they make systems improvement a key part of the culture. That's clearly not part of the health care culture.