Introducing SPC (and Relationships) into Health Care

The Sunday NY Times Magazine's cover story ("Dr James Will Make It Better", by David Leonhardt) was a fascinating look at something called 'evidence based care.' Dr. Brent James has introduced measurement into the hospital system where he works, and it sounds much like statistical process control (SPC), which has been the foundation for continuous, radical improvements in manufacturing and service industries for decades. Although I've read of other hospital systems that have used lean principles to reduce error and costs, this article implies that it's revolutionary for doctors to change the way they administer medicine based on data-based protocols. Although as a patient you may respect your doctor because of his scientific expertise, apparently many doctors have a deeply held belief that their greatest value derives from intuition. One doctor put it this way:

“I thought there wasn’t anybody better in the world at twiddling the knobs than I was,” Jim Orme, a critical-care doctor, told me later, “so I was skeptical that any protocol generated by a group of people could do better.”

This kind of thinking led to extreme variation in ventilator settings, which had less than optimal outcomes for patients. A group of doctors used data to establish a protocol that James introduced as 'defaults' to the doctors in his hospitals. The soft approach worked:

The crucial thing about the protocol was that it reduced the variation in what the doctors did. That, in turn, allowed Morris and James to isolate the aspects of treatment that made a difference. There was no way to do that when the doctors were treating patients in dozens of different ways. James has a provocative way of describing his method to doctors: “Guys, it’s more important that you do it the same way than what you think is the right way.”

Although I found myself troubled by the revelation that doctors often make their most critical decisions for a patient (what medicine, when, and how much) based on SWAG, I suppose I am to admire scientists such as Dr. James applying well-established process improvement techniques to remove variability and improve patient outcomes (often called 'life'). This reminds me of the insights I discovered in the book "Sway" (Brafman and Brafman): humans tend to go to their gut instincts especially when the risks are high, rather than use facts and logic to guide them.

As I contemplate where 'evidence based care' might take us (robotized treatment centers?), I am reminded of an interesting viewpoint from a doctor who approaches her job dramatically differently from the 'doc in a box' industry. The Nov 2009 issue of The Sun Magazine offers an interview with Dr. Pamela Wible of Oregon (see print version for complete text). She found the 'assembly line' practice in a clinic dehumanizing to her and to her patients, and so she went solo, and reshaped her job to support a strong relationship with each of her patients. She treats the person, not simply the part of the person that needs healing. She says, "I've reduced costs by humanizing the experience. People want to be cared for, which doesn't necessarily require lab work or MRIs." How she defines her work is this: "The most important therapy I deliver is a human relationship. I'm not doing anything controversial or woo-woo. I never thought of myself as practicing alternative medicine until a colleague pointed out that spending time with patients is now "alternative."'

I think it's possible to provide evidence-based care within the context of human relationships. The fact that Dr. James introduced data-based protocols initially as 'defaults' implies that he understood the importance of relationships in gaining buy-in and necessary feedback to improve the process and therefore the patient outcomes. He needed doctors like Jim Orme to enroll themselves in the process for the protocols to be used and tested. He couldn't achieve that without understanding the impacts on his relationship with these doctors.

Dr. Wible conducted eight community forums before opening her practice. She heard from her community what they needed from their health care provider. She used this data to design her practice. The three priorities for her community were: human respect; simplification; payment. I don't think her community is much different from most; these seem both basic and intuitive. The disconnect between customers and the health care industry on what customers value is wide and deep: consider the ubiquitous drug and hospital advertising that focuses on technology, complexity, and consumption.

I'm encouraged to hear different perspectives on how to transform health care and produce better results for more people. Neither viewpoint is comprehensive: yes, evidence based care is preferable to gut instinct, but doctors must care for people, not statistics. Yes, it's helpful for the doctor to listen to her patient and inquire into the patient's nutrition and home life, but science must also be applied to extend healing beyond what a lay person can do on her own. Business has long believed that the only way to reduce costs is to mass-produce and cheapen the product. These two stories illustrate that higher quality and personalization are not only preferable, but can also reduce costs and improve lives.