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Mass Customization in Health Care

Posted Aug 26 2008 11:11am
Mass customization is a concept which, more than any other in the business world, has the potential of reaching physicians.

Attempts to improve health care quality and performance have relied on ideas imported from the business world, most specifically from manufacturing . Mass customization comes from that environment, but is also increasingly applied in the service industry .

The first system that I came across was Six Sigma . The attempt to reduce a defect rate to 1 in a million or 1 in ten million provoked ridicule among my physician colleagues in class. Eventually it sinks in that the defects in question are process defects: charts, weights, temperatures, getting medications given at the right time. It had little to do with what we physicians recognized as our jobs. Instead, Six Sigma referred to everything that went on around our jobs, enabling or obstructing our efforts.We were thinking health outcomes, they were talking process outcomes.

This is how a group of skeptical physicians and a diverse group health professionals, including pharmacists, nurses, program managers, administrators and epidemiologists, all got on the same page. I would never have imagined something like this was possible until I saw it for myself in my Master's class.

After all, if you think about the complexity of flying planes, and applied the same rigor as a pre-flight checklist to medicine, it would be a miracle if any metaphorical flight would ever take off. Flying planes is not as complicated or as filled with uncertainties as providing health care.

Years after my MPH, I recalled how the physicians, including myself, came around and thought there was an important lesson to be had. Physicians can become so insular as to reject the contributions of very smart people from outside health care, "because they just don't understand."

Well, personally, I'm a "lumper". I see more similarities in things than differences. All the while I try to respect the differences between people and their experiences, deep down inside, I know the differences are only superficial. Medicine is like any other industry, except that we deal with more uncertainty and do so almost automatically, by virtue of our training.

As an aside, I believe that this ability to handle uncertainty that should be our greatest strength and selling point, but somehow physicians manage to stumble over it. It seems that we become vulnerable to uncertainty when the link between what we do and health outcomes is questioned. However that is a property of the battlefield terrain, not of the soldiers that tread fearlessly on to battle on it. But enough of the battle analogy; let's move on to cars.

Later in my career, I came across the Toyota Manufacturing Process , also know as the Lean Methodology. This is rising in popularity in health care today . One of the first principles is that we don't know anything. None of the people at Toyota knew anything about building a car and decided to break the process down to its quantum bits and figure it out.

I don't think physicians would object to someone approaching them with that attitude. In addition, the physician would have to accept that they know nothing about all those little bits of process that surrounds everything they do (i.e the paperwork).

Physicians inherently recognize the amount of resources wasted, spinning wheels, waiting and delaying because there is always something that prevents them from getting done what needs to be done. As an intern, I used the age-old techniques of schmoozing and being nice to people to get scans done on my patients at the drop of a hat. My length of stay was the envy of many a supervising resident, who then proceeded to give me a hard time about why I couldn't get a nuclear scan for one patient (when I had reservations) but could get anything on anyone at any time.

I was just schmoozing and found efficiencies beyond the imagination of my supervising residents. And that was eighty years ago when there was very little we could do for patients compared to today. [OK, I'm not that old, but I am thinning out lately.]

"Lean" aims to make the system surrounding the actual delivery of care (in a physician's eyes) as waste-free and seamless and possible. I think the docs would buy into this one, but would hold back over the fact that they will remind us how their patients are different.

Everyone who has ever had to manage physicians is smirking right now. Riiiiight. Every doctor's patients are different.

Mass customization addresses that concern. Every patient is different and gets to choose from their incoherent Chinese menu of options under a physician's guidance. Every physician has their preference in treatment or test. Erythromycin or penicillin can be a gut call. Stress echo or PET scan should not be. Sometimes, the preference is just too expensive to be tolerated.

But every patient is different, or at least different enough to feel that their specific concerns are being addressed. Physicians generally do that very well, though probably not as well as the legion of customer-service-savvy alternate medicine providers like chiropractors and naturopaths. Going through a hospital or large clinic should not be an alienating, frightening crap-shoot. Will the nurse be nice? Will the radiologist know how to read the film? Does the surgeon know right from left?

Every patient is unique and must be treated that way. The systems the patients travel through are not unique and need to be smoothed out, made predictable for both the patient and the physicians who ultimately will provide the revenue stream for the entity. All of this depends on obsessive attention to processes that physicians do not traditionally view as their purview. But if we are forced to take a minute prior to a procedure to make sure we have the right patient and the right equipment for the right procedure, we will get safety right each and every time. Also efficiency will rise as the incidence of screw-ups (defects) declines.

That means more money, lower costs and better outcomes.
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