The “Axiom of Industry” applied to healthcare

One of the most interesting blogs that I have come across is the Covert Rationing Blog. The author, DrRich (Richard N. Fogoros, MD) has written a book, “Fixing American Healthcare”, which I am in the process of reading. So far, it is a fabulous book, and I am learning a lot. I did take exception to a point that was made on DrRich’s blog and follow up on that here, based on getting to that section in his book.

His “axiom of industry” is that standardization of an industrial process reduces cost and improves outcomes. This industrial  idea is being applied to healthcare. DrRich gives a example where standardization applied to healthcare works (hip replacement) and where it doesn’t work (congestive heart failure – CHF). The reasons he provides – although not exactly so stated – are that for hip replacement, one has a high state of knowledge, and for CHF, one has an intermediate state of knowledge and when the state of knowledge is not high enough, standardization will not work.

This is where DrRich needs to continue with his industrial analogy. There are many processes in industry with a high state of knowledge as well as processes with an intermediate state of knowledge. Yes, in industry, one standardizes processes with a high state of knowledge, but this does not happen when the state of knowledge is inadequate.  Here, one uses a variety of approaches, including trial and error; that is, observing errors and then applying corrective actions. FRACAS (Failure Reporting And Corrective Action System) is a formal name for this method and believe it or not the acronym TAAF (Test Analyze And Fix) is also used. Whereas observing errors and then fixing them is not often admitted by quality managers as the method used, it is at times the best method to improve a process.

In healthcare, this method is often used as well. As patients, we are aware of the physician saying, let’s try treatment XYZ and see what happens, implying that if the treatment doesn’t work (an incorrect treatment decision) another treatment will be tried. If this actually happens and the second treatment works, one might not be happy but it is possible that the physician nevertheless followed a reasonable course of action. Moreover, for a disease condition one is not always in a “standardization” or “trial and error” situation. One often uses a mixture of the two. And, there is always the possibility that the state of knowledge for a disease may increase at some point to allow for standardization. I previously commented that standardization of a process that is not ready is likely to lock in unknown errors.

The other point that DrRich makes is that patients are not widgets. The implication is a little ominous here, namely; that morally deficient industrial managers given the chance, would discard patients as readily as widgets. I commented before, that one is optimizing a process – the correct analogy is to throw out an incorrect treatment – not a patient. Moreover, widgets are usually thought of as low cost items. No one considers a patient as low value. So here the analogy must be between patients and high cost widgets (of which there are many). In industry, as in medicine, loosing (discarding) a high cost item is not good.

One needs to ask, how many medical conditions are amenable to standardization (e.g., have a high state of knowledge). Covert rationing may well be responsible for patients being treated as widgets, including misapplying industrial processes, but these processes themselves can be applied to healthcare to benefit patients, although they will not solve healthcare costs.

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2 Responses to The “Axiom of Industry” applied to healthcare

  1. Thank you for your insightful critique of my use of the Axiom of Industry as it is applied to healthcare. Your points seem to me to be quite correct, and I accept them completely.

    In reality, I am fully aware that not even all industrial processes (let alone medical processes) fit this Axiom as I have laid it out, and further, that not all “widgets” are easily expendable. (I especially appreciate this latter point, having consulted for some time in both R&D and in quality and reliability with companies making very expensive implantable medical electronic devices.) If I need to apologize for my admitted oversimplification of industrial processes, I will willingly do so – to industry. Not so much to medicine.

    For my description of how the Axiom of Industry is being applied to medicine comes directly from the field. This is how processes such as “critical pathways” are being taught and sold to doctors and administrators (from my personal experience), and how they are being applied in clinical medicine. “Standardization leads to high quality and low cost.” Period. And as I describe in my book, in some areas this approach works quite well while in others it is counterproductive.

    The real problem today is not in the arena of “critical pathways,” where the processes of care are devised, analyzed, and corrected locally, by doctors on the scene. This effort has generally been useful, since docs are good at recognizing where this approach works (e.g., hip replacement) and where it doesn’t (e.g., CHF), and simply not using it where it doesn’t work.

    The problem, rather, is embodied in the conceit that standardized processes (now called “guidelines”) can be promulgated centrally, by some body of experts in the thrall of centralized authorities, passed down to the front lines as received knowledge, and then formally policed for compliance (see: Pay For Performance, or rather, pay for compliance).

    Furthermore, patients not being widgets has an implication aside from their not being easily expendable (though under covert rationing I fear they are more expendable than many would think), which is that not all patients respond identically to the same medical process. That is, guidelines carefully devised to yield the best outcome across a population will NOT yield the best outcome for certain individuals. The doctor’s job is supposed to be to individualize therapy so that every person has the best shot at a good outcome, and strict guideline-based healthcare (where we are inarguably heading) fundamentally disallows – and systematically punishes – such individualization of care.

    Finally, I thank you very sincerely for your kind words about my book. If you still feel the same way about it when you’ve finished reading it, please spread the word. I’m afraid the marketing of this book (to apply, this time, a medical analogy to an industrial process) is 100% viral, and I can use all the word-of-mouth I can get.

    Rich Fogoros (DrRich)

  2. […] articles (the one that I am most proud of refers to the most cited publication in The Lancet). I do complain about a point made in Fixing American Healthcare. But it is a tiny point and does not detract from […]

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