OK, seriously, WHY didn't we see it coming?

"OK, enough! This tree has got to go!"

My comment in response to Paul Krugman's NY Times column today, "Lest We Forget".
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Your question is superb - How did those at the top not see this coming, or take it seriously, despite many stifled voices below pointing at it in alarm?

Yes, if financial things broke on this shoal, fix the financial things.

But, at the same time, this shoal has got to go, or it will just demolish the repair effort in a never-ending cycle of "How did that happen? Fix and forget."

This exact problem is well known and well documented by everyone, across industries, government agencies, auto companies, universities, etc. This process is ALSO broken, and needs to be addressed, by as many billion dollars as spent repairing the damage it caused.

Social decision making processes are no more abstract than financial markets, but get no respect, being in a higher leverage, further upstream, less visible place in the chain of events.

High-reliability human systems have been studied extensively, from Chernobyl to The Bay of Pigs to Challenger to aircraft cockpit teams to hospital surgical teams to the US Army Leadership Field Manual. The answer always comes down to the same thing -- dissenting views need to be heard, and dissenters need what Harvard Professor Amy Edmondson calls "Psychological Safety" or they will wilt and become ineffective. This is how humans always behave and unless steps are taken it always breaks along this fault line.

The right question then should be, who is going to take charge of seeing that those steps are taken and that level of social literacy achieved?

I can't emphasize enough how much more important this is than more math and science, in the absence of this. As T.S. Eliot said, we repeatedly get burned "dreaming of systems so perfect that no one will need to be good, but the man that is will shadow the man that pretends to be."

Much of my weblog is about what we really need to do to avoid such errors in judgment. I can only hope the right person wakes up and reads it and the links to sources such as MIT's papers or John Sterman's work on how poorly we can see systems that involve feedback.

"Why we have so much trouble seeing" (and what to do about it.)
http://newbricks.blogspot.com...

(photo by myself - "Fixed at last!" )

What about GM?

Toyota has a track record of taking over totally dysfunctional GM plants and making them functional by just changing management, with same unions, same facilities, same labor, same equipment. See history of NUMMI in Fremont, CA, going from GM's worst plant to the best in one year.

references:

Becoming Lean , Jeffrey Liker, page 62-63
http://books.google.com...

Stop Rising Healthcare Costs Using Toyota Lean Production Methods

By Robert Chalice (page 53)

http://books.google.com...

There may be no reason to lose the jobs, plants, or contracts.

Actually, what changed was not just management, but the whole underlying philosophy on which the plant was managed, which is the crucial change.

Chalice cites these factors as the new "five core values: teamwork, equity, involvement, mutual trust and respect, and safety."

In short, workers were treated as first class partners in the plant, not as some kind of "asset" to be "managed" and "controlled." They were listened to. They were respected.

Yes, that does make all the difference, in automobiles, as Liker points out, or in hospitals, as Chalice points out, supported by the Keystone study of John's Hopkins Dr. Peter Pronovost in Michigan, showing that when nurses were actually listened to by doctors, patients were significantly better off and had better outcomes.

Gasp. I took Dr. Pronovost's class in Patient Safety last year, and, yes, it really is that "simple." Culture drives safety and productivity. Culture drives the bottom line, not technology.

If you want things to work, you have to learn about human beings, and culture, and work within the constraints that puts on you. Humans are not machines and work way better than machines if allowed to (McGreggor's Theory Y), or way worse than machines if forced to (Theory X).

It's the job of the stockholders and stakeholders to realize that, and put management in place that will support the work force instead of trying to exploit it.

Period.

Systems thinking and health care - reflection

Thursday, August 24, 2006

Systems thinking about assembly line health care

Why are the Big Three auto companies going broke, and if their high-tech Detroit area assembly-line operation is our model for health care, is that our destiny as well?

Consider this recent news.

New York Times
August 19, 2006
Ford Is Slashing Production 20% for 4th Quarter
By MICHELINE MAYNARD

DEARBORN, Mich., Aug. 18 — The Ford Motor Company, which is struggling to keep its grip on second place in the American car market, said Friday that it would cut by one-fifth the number of vehicles it plans to build in the final three months of the year.

The slowdown represented the deepest production cuts since the industry’s crisis of the 1980’s. It also underscored the difficulty that Detroit, whose business relies on sales of sport utility vehicles and pickup trucks, is having as gas prices remain around $3 a gallon. Detroit’s market share has dropped to its lowest level in history, while Asian brands, known for their fuel efficiency, are setting sales records...

On Friday, Ford officials contended that no one in the industry could have anticipated that gasoline prices would remain so high ... [emphasis added]

The mental-model of fine-tuning assembly-line clinical medicine may break down when seen through public health's wider lens, or in light of the impact on the humans whose bodies and lives provide the pixels on which this video is displayed, or be fine in both those contexts but have issues when seen in terms of globalization and the increasing ability of patients to fly to Singapore for surgical care at a total cost well less than similar care here.

The "systems thinking" approach suggests that we should spin through all those lenses on our microscope and consider whether each one makes sense, before we fixate, as Ford and GM seem to have, on activities that are perfectly sensible when removed from global context, but that look different when viewed in situ.

In clinical care systems we know that the parts do not exactly fit, and are not always well-coordinated. We take as an unexamined given that with just a little better training, a few more messages here and a new EHR message-store component there, surely this will come-together, click, and emerge as a dynamically stable and scalable system that cranks out top-notch patient care and dollars like a fine-tuned machine. Won't it?

In the 21st century, Peter Senge said, it is not enough that organizations persist well, they also must be able to change well. And Cybernetics 101 teaches us that in order to change well, a system needs to be able to see well. Perception is everything. We should confirm that those specs are reflected in the Electronic Health Record brave new world we're building nationally, before too much concrete is poured that will need to be ripped out and redone.

Like GM, we both face the twin questions of how humans fit into the assembly line model, over extended time periods, and, stepping back, whether the product those lines are producing is, viewed in global context, the product consumers will be buying next year.

We have to make sure not only that we're solving the problem right, but that we're solving the right problem. And, in the way of systems, we have to ask whether the way we're structuring humans and machines to solve the one problem doesn't create, as an "unintended side-effect", an emergent interference with our ability to see many small signs on the front lines that things are changing and the old model doesn't really fit the new reality.

Or are we somehow blinding ourselves to marketplace changes that seem obvious to the world not embedded in our own internal story? Ford executives asked who could have known that gas prices might rise? Hmm. Somehow they managed to assemble a workforce of half a million people with a resultant net organizational IQ of less than the average teenager. We need to ask where their collective common-sense-emerging process broke down, to be sure we're not following in their footsteps and mimicking their behaviors a little too closely.

Obviously, the problem is subtle. This is the way with most system problems.

There's lots of blame being spread around for "obvious" events and causes and decisions, including health care costs in another reflexive feedback loop, but we of systems thinking world know those are typically red-herrings and just symptoms of far more subtle problems in systems dynamics space. We are in desperate need of a "macroscope" that makes this almost invisible tissue stained and visible to the naked eye at last so we can see not just the microbes that we deal with daily, but the living dysfunctions that appear capable of infecting human organizations and causing Detroit blindness.

I'm not forecasting what tomorrows customer and problems will be, only that they will not be the same as yesterday's, in some really important ways. But I am saying that, based on the inexorable evidence and outcomes of the US automobile industry, there is something deeply but subtly wrong with the assembly-line model on a system dynamics basis - something that results in organizational blindness and incapacity to adapt.

It would seem the better part of valor to figure out exactly what that is, and make sure we don't inadvertently copy that into health care delivery systems as well.

Bottom line, literally: it would seem worth easily a billon dollars and a million votes to the Michigan economy to understand that answer in depth, and not just superficially. Whatever it is, there's a lot more where it came from.