Lean manufacturing meets health care

The coverage on health care reform has been driving me crazy lately. As the saying goes, there are two things that are good to have, but you don't want to know how they're made: laws and sausages. For weeks, article after newspaper article has described the art of sausage-making.

But one report in recent days didn"t cover so much sausage-making. In The New York Times Magazine, David Lenhardt wrote an in-depth expose, not on which lobbying group cut this or that deal with that lawmaker, but on practices that actually might improve the health system. Not surprisingly, the ideas aren't part of any of the health care bills floating around the Capitol. Many special interests are blocking any big changes to the systemagain, sausage-making I don"t like reading about.

Instead of lingering outside congressional offices, Lenhardt went to Intermountain Medical Center. For years doctors at the Salt Lake City hospital did something novel for the health care profession. Starting with a trial for treating acute respiratory distress syndrome (ARDS), doctors have written detailed protocols on how to carry out treatment.

As Lenhardt explained, "The crucial thing about the protocol was that it reduced the variation in what the doctors did. That, in turn, allowed [doctors] to isolate the aspects of treatment that made a difference. There was no way to do that when the doctors were treating patients in dozens of different ways"—setting ventilator levels differently, for instance. Doctors periodically met to tweak and perfect the procedures to come up with the best solutions for tough problems. The result: Doctors at Intermountain, following a continually improving work process, increased its ARDS survival rate to 40 percent. Nationally, the survival rate is about 10 percent.

Before the study, one of the doctors confessed something interesting: "I thought there wasn't anybody better in the world at twiddling the [ventilator] knobs than I was."

Does this sound familiar? This doctor could be a press brake operator or press die setter who has his own way of setting tooling; or a shop floor mechanic reaching for tools on his cluttered bench, where only he knows where everything is (though somehow you notice him spending a lot of time looking for tools). Documenting procedures, identifying and minimizing variation through statistical analysis; brainstorming to discover ways to make things more efficient: All are tenets of lean manufacturing, Six Sigma, and other improvement and quality programs that have pervaded manufacturing for years. Their common goal is to eliminate variation and waste in the process to improve efficiency and quality. Manufacturers are making things faster and better.

These same principles, it seems, carry over to health care, only in that industry it's called "evidence-based care." Committees of doctors gather, like a kaizen event in lean manufacturing, to develop the best protocol to overcome a problem. Successful treatments (evidence) are tracked; and the most successful treatments are perfected and polished, and documented into the protocol.

Both manufacturing and health care can't be perfect. Never does a shop have zero defects and 100 percent on-delivery, just as no hospital has a zero mortality rate. Try as we might, we can't make ourselves immortal.

Complications arise when you talk about the business side of things. Manufacturers settle for a certain quality at a price people are willing to pay. An engineering tweak here or there may improve quality a little bit, but the extra expense doesn't make it worthwhile. Health care is different, and I've written about this in a previous blog. Even if insurance wasn't in the picture, many of us with a sick loved one would be willing to pay any price, run any test, even if there was an extremely small chance of those tests doing any good. This is life and death, after all.

Health care also has an incredibly messy payment structure, the dreaded "fee for service." The more procedures doctors perform, the more they're paid. The fewer they perform, the less they're paid. Can you imagine a contract fabricator getting richer because his shop made a product in more steps and therefore cost more than his competitor?

So yes, lean practices in the halls of medicine aren't a cure-all. But they certainly would make a bad situation much better, and may even give us better care for less money—probably better than any 1,900-page piece of health care legislation.