Tag Archives: news

Lean Thinking and Health Care Reform

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.

New Quality Manager for Obama: Zients replaces Killefer

obama-headIn 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.

Systems Thinking Predicts Economic Collapse in 21st Century

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.

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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.


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.

A Quality Manager for Obama

nancyPresident-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!

Quality and the Decline of the U.S. Automotive Industry


capriceWhy are Ford, Chrysler and GM in trouble? Can a financial bailout help?
In late 2007, I wrote a 7,000 word article examining the ups and downs of the U.S. auto industry. Using a historical analysis of high-level metrics and examining the evolution of quality perception and quality improvement in the auto industry, I show that a financial crisis could actually be detected a year ago.


Citation

Radziwill, N.M. (2008). The Role of Quality in the Decline of the U.S. Automotive Industry. Unpublished manuscript, retrieved on Month DD, YYYY from http://qualityandinnovation.com/wp-content/uploads/2008/11/radziwill_qualitydeclineusautoind.docDownload the report by clicking on the title; contact me if you would like to run this in your magazine or journal.

Abstract
In 2007, in response to disappointing market shares over the previous few years, General Motors (GM) launched an ad campaign to convince consumers that the quality of its vehicles was comparable to foreign manufacturers in order to catalyze sales and grow market share. This situation was not unprecedented. In 1982, the National Academies recognized a similar crisis and launched a study to investigate why it occurred. What quality-related root causes have historically led to deteriorating conditions within the U.S. automotive industry? How can auto manufacturers and U.S. policymakers use this information to strengthen this sector of the economy in the future? An analysis of the economic, regulatory, and financial impacts of quality is used to identify the points in time at which quality-related causes led to a downturn in the U.S. automotive industry. The results are used to gauge the managerial implications that could avert such events.

Excerpt from Conclusions
What can manufacturers do to prevent quality-related downturns within an industry? Based on the analysis of this case in automotive manufacturing, there is no substitute, first and foremost, for effective financial management. Ensuring positive cash flows and profitability means that assets will be available for investing in new initiatives that improve quality, or for the marketing efforts that will reveal and promote a quality reputation. According to the ACSI’s most recent ten-year report, U.S. manufacturers continue to compete on price while foreign manufacturers continue to compete on quality. Though some argue that quality is becoming competitively neutral (Harbour, 2006), there are clear lessons from history that this focus erodes market share and challenges productivity over the long term. Although U.S. automakers are now as efficient as any other manufacturers in the world (Warner, 2005), and quality levels are competitive, the financial crisis may be so severe that the industry could require strong federal support, and potentially intervention, to fully recover.

Here are some additional perspectives from other blogs:

Government Plays a Role in Productivity-Oriented Competitiveness

I read an article this morning about a 13-year old Somalian girl who was stoned to death for being raped. The article also characterized, in simple terms, the social and institutional landscape of her country:

Somalia is among the world’s most violent and impoverished countries. The nation of some 8 million people has not had a functioning government since warlords overthrew a dictator in 1991 then turned on each other.

A quarter of Somali children die before age 5; nearly every public institution has collapsed. Fighting is a daily occurrence, with violent deaths reported nearly every day.

Although the issue of the level of governmental control is prominent in the 2008 election, something I reflected on a couple weeks ago, it is critical to remember that macroeconomic stability is a precondition for economic growth. If the goal is growth, not just survival, we must strategically architect our country’s policies and institutions to make it happen and to make it sustainable.

The World Economic Forum takes a “productivity-oriented view” of competitiveness. Raising productivity means making better use of the policies, institutions, and resources that are available to an organization. (Notice that this suggests productivity is actually a continuous improvement process, not simply achieving a certain level of output, or achieving targeted growth.)

This organization produces an annual Global Competitiveness Report that reports a metric, the Global Competitiveness Index (GCI), calculated for almost every country in the world. The GCI factors in elements from “nine pillars” of competitiveness: institutions, infrastructure, macroeconomy, health and primary education, higher education and training, market efficiency, technological readiness, business sophistication and innovation. The WEF emphasizes that:

None of these factors alone can ensure competitiveness… [for example] the value of increased spending in education will be undermined if rigidities in the labor market and other institutional weaknesses make it difficult for new graduates to gain access to suitable employment opportunities. Attempts to improve the macroeconomic environment—e.g., bringing public finances under control—are more likely to be successful and receive public support in countries where there is reasonable transparency in the management of public resources, as opposed to widespread corruption and abuse. Innovation or the adoption of new technologies or upgrading management practices will most likely not receive broad-based support in the business community, if protection of the domestic market ensures that the returns to seeking rents are higher than those for new investments. Therefore, the most competitive economies in the world will typically be those where concerted efforts have been made to frame policies in a comprehensive way, that is, those which recognize the importance of a broad array of factors, their interconnection, and the need to address the underlying weaknesses they reveal in a proactive way.

In my opinion, what a nation really needs to increase productivity, enhance competitiveness, and promote sustainable economic growth are two elements that are not mutually exclusive: 1) a National Innovation Agenda, and 2) a multidisciplinary team of systems engineers who understand quality improvement, with broad perspectives and a penchant for data-driven decision making, advising the highest levels of government. This team’s responsibility would be to understand the structures, health and interconnections of the nine pillars of competitiveness – and how to continually improve them as a system, recognizing that we can’t do everything and we must aggressively prioritize to achieve progress.