Quality and Innovation

Today’s Op-Ed section in the Washington Post has a piece by Philip K. Howard called “Health Reform’s Taboo Topic”. The problem?

Health-care reform is bogged down because none of the bills before Congress deals with the staggering waste of the current system, estimated to be $700 billion to $1 trillion annually. The waste flows from a culture of health care in which every incentive is to do more — that’s how doctors make money and that’s how they protect themselves from lawsuits.

The article goes on to talk about “defensive medicine,” the practice of ordering tons of diagnostic tests to refine a diagnosis or a treatment plan for the purpose of avoiding malpractice suits. Howard suggests that physicians are cultured into this way of doing business as a defense against potential risks and potential malpractice cases – he even mentions one case where a doctor reacted to a lawsuit by changing his behavior in favor of defensive medicine. A solution, however, is possible:

Containing costs, as Rep. Jim Cooper (D-Tenn.) noted on “Face the Nation” recently, requires overhauling the culture of health-care delivery. Incentives need to be realigned. That requires a legal framework that, instead of encouraging waste, encourages doctors to focus on what’s really needed. One pillar in a new legal framework is a system of justice that is trusted to reliably distinguish between good care and bad care. Reliable justice would protect doctors against unreasonable claims and would expeditiously compensate injured patients. The key is reliability.

The culture of a system – in this case the U.S. health care system – influences the behavior of individuals within the system. This behavior can be waste-producing. When it is, we need to look towards the cultural influences or the structure of the incentives that drive that behavior, and examine ways to address the root cause(s).

It reminds me of the requirements gathering phase of a software development project. Stakeholders spend hours trying to hash out what functions and behavior they expect from their software, and how reliable they want it to be. It is always a challenge to avoid designing the system (that is, how it will look or act) when the essence of what you need to know is what the system needs to do.

I see evidence in the growing national healthcare debate that many people have opinions on the design of the system (e.g. who gets coverage, how pre-existing conditions are handled, how much it costs, who pays), whereas most citizens and Congressmen aren’t even touching the requirements for a successful system (e.g. what scenarios it should support, what behaviors it should provide incentives for, or its reliability/requirements for how much waste the system can and should generate).

In my opinion, one requirement for a successful health care system is that it provides incentives for you to remain healthy and stay out of doctors’ offices and hospitals. A tax credit for a health Body Mass Index (BMI), or maybe lower interest rates? I’d go for that… it would even stimulate me to boost the economy a little more by buying rollerblades or something.

In his weekly radio address, President Obama announced today a renewed intent to cut wasteful spending, and the upcoming announcement of even more decisive cuts. He also noted the appointment of Jeffrey Zients, a former executive and Director of Sirius XM, as the Obama Administration’s Chief Performance Officer. His official title will be deputy director for management of the Office of Management and Budget. Zients replaces Nancy Killefer, who rescinded her nomination in March.

There have been criticisms of Obama’s handling of the budget so far. For example, critics bristle at the thought that Obama approved the fiscal year 2009 budget with earmarks (this is covered in an article by George Stephanopoulos on March 1, “Obama Will Sign Omnibus Despite Earmark Pledge”). But the fiscal year 2009 budget – executed in March 2009 – is retroactive. It is intended to cover operations of the government and all government-funded agencies (including research facilities, and university-driven research and development) from October 1, 2008 through September 30, 2009. Failure to pass that budget would have meant a swift and immediate crisis, catalyzing a domino effect of layoffs in the highly specialized industries. This could have a nontrivial and long-reaching impact on national competitiveness by depressing not only technological innovation, but also by cutting off practical opportunities for university students and researchers to contribute to innovation as they receive mentorship and training.

More about Zients from the White House Blog:

Zients has twenty years of business experience as a CEO, management consultant and entrepreneur with a deep understanding of business strategy, process reengineering and financial management. He served as CEO and Chairman of the Advisory Board Company and Chairman of the Corporate Executive Board. These firms are leading providers of performance benchmarks and best practices across a wide range of industries.  Currently, he is the Founder and Managing Partner of Portfolio Logic, an investment firm focused primarily on business and healthcare service companies.

According to some researchers, it’s the end of the world as we know it – sometime this century, in fact. Economists and policy researchers have actually envisioned it coming for about three centuries, though.

The most recent tap on this subject came on March 7, 2009, when journalist and Hot, Flat, and Crowded author Thomas L. Friedman published an Op-Ed in the Washington Post, entitled “Is the Inflection Near?” He describes how the economic, financial and political systems that we have established in the world – particularly in the west – are inherently unsustainable, and that in order to achieve a truly green world, our fundamental systems for living life must shift:

Let’s today step out of the normal boundaries of analysis of our economic crisis and ask a radical question: What if the crisis of 2008 represents something much more fundamental than a deep recession? What if it’s telling us that the whole growth model we created over the last 50 years is simply unsustainable economically and ecologically and that 2008 was when we hit the wall — when Mother Nature and the market both said: “No more.”

We have created a system for growth that depended on our building more and more stores to sell more and more stuff made in more and more factories in China, powered by more and more coal that would cause more and more climate change but earn China more and more dollars to buy more and more U.S. T-bills so America would have more and more money to build more and more stores and sell more and more stuff that would employ more and more Chinese …

We can’t do this anymore.

What would you think if I told you that this was actually not a new idea, and that the notions Friedman presents were determined by a simulation done over thirty-five years ago? Furthermore, what if I let you in on the fact that people have been thinking about this conundrum since the late 1700′s? It may sound outlandish, but in this case, truth is stranger than fiction.

The simulation that I refer to was done in 1972, with a model called World3 which was coded in the object-oriented Modelica environment. It’s the subject of the Club of Rome commissioned study called “The Limits to Growth” (full text is here). Although the model has received criticism for some of its assumptions, a redaction in 2002 upheld many of the outcomes of the model. In 2009, Dr. Dennis L. Meadows (who directed this research) was awarded the 25th Japan Prize from The Science and Technology Foundation of Japan. Recall that the Japanese were the ones who initially recognized Dr. W. Edwards Deming for his contributions to revitalizing the economy – decades before the Americans embraced Deming’s teachings – and spawned the quality revolution in U.S. business in the late 1970′s and 1980′s that has embossed the landscape of how we do business today. From the Japan Prize announcement:

Dr. Dennis L. Meadows served as Research Director for the project on “The Limits to Growth,” for the Club of Rome in 1972. Employing a system simulation model called “World3,” his report demonstrated that if certain limiting factors of the earth’s physical capacity – such as resources, the environment, and land – are not recognized, mankind will soon find itself in a dangerous situation. The conflict between the limited capacity of the earth and the expansion of the population accompanied by economic growth could lead to general societal collapse. The report said that to avert this outcome, it is necessary that the goals of zero population growth and zero expansion in use of materials be attained as soon as possible. The report had an enormous impact on a world that had continued to grow both economically and in population since World War II.

We also have a rich literature dating back centuries that has studied the relationships between population, environment and technology. In the 1700′s, English economist Thomas Robert Malthus studied these relationships in terms of the projected effects of uncontrolled population growth. “Before Malthus, populations were considered to be an asset. After Malthus, the concept of land acquisition to support “future large populations” became a motivating factor for war.” (citation) The 20th century Boserupian Theory of Ester Boserup, in contrast, suggests that advances in technology will drive the capacity of the world to support population. Researchers like Steinmann & Komlos (1988) have simulated the interplay between both paradigms over time and suggest that there is a cyclical dominance. (I note that references to Malthus and Boserup, let alone Meadows’ World3 model, are rarely on the lips of policymakers.)

In my opinion, it is not climate change we should be worried about per se, but the social, economic and global political system that drives human interactions with each other and with the environment. Climate change may be a symptom, but it is just a tracer for the attitudes of unbounded material growth that are contributing to the effects (if you want to learn about climate change and policy, Prometheus is a good place to start – my point is not to argue the merits of “is it” or “isn’t it” happening because others including Pielke, Jr. do that very well). Regarding climate change, we need to decode what the data is trying to tell us about how we’ve structured our large-scale systems of interaction with one another – rather than merely trying to control our personal “carbon footprints” or recycle more (though these may be important ingredients in the solution).

There is nothing new under the sun. Only today, the forces of production, consumption and population have metamorphosed into a crisis of sustainability – a “perfect storm” to test our ability to live and work in the limit case.

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Steinmann, Gunter & Komlos, John (1988). Population growth and economic development in the very long run: a simulation model of three revolutions. Mathematical Social Sciences, Vol. 16, No. 1, Aug 1988. 49-63 pp. Amsterdam, Netherlands.

President-Elect Obama has hired a quality manager, and her name is Nancy Killefer. She is the newly appointed “Chief Performance Officer” whose mandate is to manage budget reforms while eliminating waste in government processes, ultimately making it more effective. An MIT & McKinsey alum, Time calls her the “first official waste watchdog.”

From the Washington Post:

“We can no longer afford to sustain the old ways when we know there are new and more efficient ways of getting the job done,” Obama said during a news conference this morning at his transition office. “Even in good times, Washington can’t afford to continue these bad practices. In bad times, it’s absolutely imperative that Washington stop them and restore confidence that our government is on the side of taxpayers and everyday Americans.”

This is a fantastic indication of our new administration’s commitment to quality, and its recognition that the current economic crises can only be solved by fiscal pragmatism and solid foundations.

Regardless of what happens next, I am pleased to see that our new administration’s attitude is so positive:

As he named Killefer, Obama promised to scour the federal budget to eliminate what doesn’t work and improve what does to “put government on the side of taxpayers.” He said: “We can no longer afford to sustain the old ways when we know there are new and more efficient ways to getting the job done.”

Nancy, you should join ASQ (if you’re not already a part of the organization). There are 100,000+ of us, more or less, that not only support you but want to help you develop a high-performance government. We come from all industries, are adept at process improvement at creative solutions for increasing efficiency, and can be effective advocates for your mission. Let us know how to help!

Innovation is in the eye of the beholder. The solution offered by the American Competitiveness Initiative focuses on absolute innovation, but does not consider relative innovation. Catalyzing relative innovation still requires a capital investment, but will focus less on the basic R&D issues and more on the issue of appropriate technology, even within the host country.

My Proposed Two-Pronged Approach to a New American Competitiveness takes these factors into consideration, and recommends two things we should do as a country:

1: Provide Practical Innovation Education to Everyone – We must educate EVERYONE on what innovation really is – the act of making ideas and inventions useful and relevant to people and social groups. Innovation is always relative, not not always absolute. Innovation is about creative problem solving that improves efficiency or productivity, expands capabilities, or enhances quality of life. We can all innovate in our local communities, even if we don’t come up with the complex or high-tech ideas ourselves! The key question is: How can we make individuals’ lives better? Innovation is not a mysterious practice reserved for scientists, engineers, or people with creative ideas. We can all be innovators.

2: Implement a National Quality Agenda – This idea, originally raised by ASQ President Robert Saco in the October 2008 issue of Quality Progress, embraces a “systems thinking” approach to resolving key social and sustainability issues at the national and international levels. How do we look at long-term issues through the lens of “systems thinking”? How do we transform our government’s budgeting process to accurately enact strategic themes and priorities, and promote real collaboration and cooperation that is not confounded by fictitious budget partitioning? How do we embrace innovation to make things better for all people? Saco introduces it this way:

What is to be done? Mr. President, in brief, we need a National Quality Agenda to broaden our thinking in terms of systemic and long-term issues and solutions. You cannot afford to ignore longer-term stealth issues like healthcare, energy, infrastructure and education. Ignored, these matters will ensure the accelerated decline of the nation. Government must not do everything, and with a looming federal deficit of $500 billion, it simply can’t do everything.

Yet, by promoting initial conditions that frame an appropriate long-term agenda and nurture an environment of possibility and collaboration, the stage is set for real progress in the months and years to come.

New is not always better. Innovation, however, always seeks to make things better! (In case this seems like a paradox to you, the missing link is invention – inventions are always new, but they don’t necessarily need to be useful to many people to retain their novelty.) Sometimes, just looking at how to change our perspectives, simplify our existing structures, and take a quality-driven approach, we can uncover new ways to innovate. Are you ready to take the leap?

In a 2004 post, one observant blogger noticed that the presidential campaigns for George W. Bush and John Kerry weren’t “doing something new, something uniquely suited to the new medium that wasn’t possible before but perfectly fits with the types of communication the Internet enables.” This person remarked that “right now political activity online is in the eToys era. What will be the Google of politics?”

In November 2008, this question was answered:

For a couple of generations, it was conservatives who had the more effective political infrastructure. They used direct mail and talk radio to run circles around liberals in raising money and communicating their message around the filter of the establishment media. Some of that money flowed into think tanks that helped nurture ideas and operatives. 2008 was striking because the technology/communications advantage was decisively with the Democrats. Obama and other Democrats used this to raise vastly more money than McCain and to mobilize legions of people who had not previously been engaged with politics.

The mission of Google is to organize the world’s information – to transform the relationship between people and information in such a way that collaboration, innovation, and insight are electrically catalyzed. The mission of the Obama campaign was to organize and inspire the people of the United States – to transform people’s perceptions of relationships with one another and convince them that they could achieve a more hopeful future together. And they used Web 2.0 to do it elegantly. Not only did this campaign spread the infectious meme of hope to so many young Americans, including those who previously didn’t have it, it was very easy for anyone who wanted to contribute to know exactly what to do. The Obama campaign made its needs actionable so it was easy for anyone with a little motivation to get involved, and make a difference.

Obama is the Google of politics: He has technological expertise and an audience his political competitors simply cannot match. Looking ahead to 2010, House and Senate Democrats will be jealously eyeing Obama’s e-mail lists and technology secrets — giving him even greater leverage over them. Republicans will be forced to invest serious money and time to narrow the technology gap.

Now that the campaign that organized the Google of politics transitions to the White House, I am hopeful that this penchant for innovation might infect other areas of government. I don’t have my expectations set unreasonably high, but I’m pleased that we can try out a new mindset in American government. I am tired of the politics of fear, I am conscious of idealism, and I am dedicated to action. I know that millions of Americans don’t feel this way today, and are wary of what a new Administration might bring… to them I say, keep an open mind. The condition of the country could get worse, but it could also get better. Let’s be open to learn from a new experience. Whether you voted for him or not, it is possible to acknowledge Obama’s campaign as both masterful and innovative; one that efficiently leveraged the power of collaboration in remarkable ways in just 21 months.

Today is Monday, November 3rd. Election Day, when the U.S. picks its 44th President, is less than 24 hours away. And as of Saturday night, just 72 hours before the polls close, 27 MILLION early votes and absentee ballots had already been placed. This represents almost 13% of the total population that’s eligible to vote this year, and 22% of all the people who voted in 2004. (The numbers are from Michael McDonald’s dataset; he is an associate professor specializing in voting behaviors. The VEP column in his table represents the total number of eligible voters over 18 and not in prison, on probation or on parole. )

Remember, long ago (or maybe more recently) in statistics class, when you learned that you could learn a lot about the properties of a population by taking a random sample? Having approximately 20% of the vote already in from a sample expected to be between 120 and 150 million is extremely significant – remember, these are actual votes, and not someone’s report of what they may or may not vote “for real”. Assuming that systematic errors have not played a large part in early voting behavior, the winner is already determined, and we just don’t know it yet.

“We go around in a circle and suppose, but the answer lies in the middle and knows.” –Robert Frost

However, ignoring systematics is indeed a significant assumption, one that’s discussed by Peter Norvig, Director of Research at Google, in his excellent explanation of the accuracy of polls. Which is why the campaigns are rightly pushing EVERYONE to get out there and vote – to mitigate the impact of systematic errors. (After all, you don’t want to stop voting if the other side keeps voting.) So if you are reading this and you haven’t voted yet, DO IT! Go vote!

I see three potential scenarios:

• Breakthrough: the decision has already been made, is accurately reflected in the actual sample of early votes, and the votes placed on Tuesday won’t change the pattern at all. The additional votes amount to nothing (other than beating down or insuring against systematic error).
• Breakdown: a flood of voters overwhelm the capacity of the voting stations, the voting machines just can’t handle it, and the polls close before everyone can get through the door and get an error-free ballot submitted. I think there might be social unrest if this is the case.
• Breakout: a single demographic (or two) comes out in droves to vote on Tuesday, breaking out of wherever they’ve been hiding, and shifting the balance of the race in a huge upset. Certainly a possibility.

Whatever happens, the 2008 Election reflects a mythical struggle between structure, order, hierarchy, stability, and tradition on one side; revolution, dynamism, community, collaboration, and exploration on the other. One potential leader clearly has more experience on one side of the coin, and the other potential leader is stronger in the opposite area. Each candidate has plenty of experience on the side of the coin he’s promoting. The difference will be how the voter determines which standard the candidate’s experience should be measured against!

Why am I interested in all this? First, because polling is measurement, and quality assurance requires effective measurement. But more importantly, because the themes of this election parallel the struggle that many organizations face with quality and innovation – getting the job done reliably is paramount, and experience is important, but we cannot lose sight of the way we need to reinvent ourselves and our companies to continue being competitive. Accepting the wilder side, where structures are not sacrosanct and community is more productive than hierarchy, is hard to swallow.

The old methods that tell us how to manage projects, do budgeting, evaluate employees, and manage change are incomplete in such a global, dynamic competitive environment. New organizational models that help us deal with complexity more effectively will be required, but will the 2008 Election usher one into the institution of government?

36 hours from now (hopefully), we’ll know.

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Other Resources:

Peter Norvig, Director of Research at Google, keeps a 2008 Election site with the most comprehensive collection of data-based reports I’ve encountered

CNN’s early voting map shows how many early ballots were cast according to state and proportion of Democrats/Republicans voting

If the whole world could vote, according to the Economist, the “Global Electoral College” would be stacked.