Tactics Lag Technology: Especially in Medical Quality
Another incident shaped my thinking as powerfully as tactics lag technology, and the two tales are related. This is another story that goes back forty years. I remember the struggles of the American automobile industry and how Japanese cars were becoming dominant. When I learned an American was behind the Japanese success, I was shocked. It was the same story as my first piece on tactics lag technology. W. Edwards Deming approached the American automotive industry first, but they ignored him.
“Essentially, his idea was to record the number of product defects, analyze why they happened, institute changes and then record how much quality improved. The essence was refining the process until it was done right.”
Deming’s ideas intrigued me, and I made it my business to learn more. “….. Deming was misunderstood in America. Considered too much of an educator to help the top-down management style in Detroit, the U.S. auto companies weren’t interested in his theories on worker relations and better efficiency. The rejection led Deming to travel to Japan after the Second World War where the emerging auto industry accepted and implemented his ideas …Deming encouraged Japanese auto companies to concentrate on constant improvements, better efficiency, and the idea that if you had to do it once, do it right.… Deming saw a different way for auto businesses to operate. He saw the “assembly-line” mentality of low-income workers being forced into repetitive jobs, while the rich few controlled things from above, as a mentality of the past.“ People are entitled to self-esteem,” he once said. “Our system crushes it out.” Deming taught the Japanese the essence of teamwork and, in turn, developed the principles of quality control. Japan was receptive to Deming at a time when America was not, in part because Deming’s ideas dovetailed with so many of Japan’s own traditions. Japan had long held that hard work and quality craftsmanship were important virtues. Deming thought that companies must treat workers as associates, not hired hands, and he blamed management if workers were not motivated to work well.” J Edwards Deming had started coaching the Japanese automakers just after World War II. Thirty-five years later, in the early 1980s the American auto industry finally asked for his help, but it was too late. Our auto companies were mortally wounded, and the taxpayers had to bail them out in 2008. Once again, I realized these lessons applied directly to American medicine.
Finally, American industry has made great strides. General Electric and six sigma have become a standard for many businesses. American medicine talks the talk, but it does not walk the walk. They talk about quality improvement and quality cycles, but the product is flawed, and the cost is high. It seldom “moves the needle”. American medicine continues to function as a cottage industry with top-down leadership.
The content one this site is all about optimal medical therapy, and for good reason. Individuals with cardiovascular and related conditions who are on optimal medical therapy live longer healthier live at lower cost. Optimal medical therapy (OMT) for these diseases is a product just like a car or a hamburger. It is very well defined, just like the quality interventions in the auto industry. For diabetes, there are five proven goals that define OMT.
1. Blood Pressure 130/80 or less
2. LDL or bad cholesterol 100 or less and on a statin (non HDL cholesterol of 130 or less)
3. Hemoglobin A1c of 7 or less
4. Not smoking
5. On aspirin if complicated by arterial or chronic kidney disease
These goals are simple and straightforward and yet our performance is as awful as the American automobile industry in the 80s. Only about twenty percent of American diabetics achieve these simple goals concurrently. The main measure of quality is variation.
“Because it is almost impossible to achieve zero defects -- a concept known as infinity sigma -- six sigma allows for 3.4 defects per million opportunities for a defect to occur. In contrast, three sigma allows for 66,807 defects per million opportunities.” One sigma is 690,000 errors per million. Twenty percent achievement of OMT in diabetes represents roughly 800,000 errors per million. So we are achieving a fraction of a sigma in diabetes management. Of course, six sigma cannot be achieved in managing diabetes in humans, but I have seen two sigma achieved by a provider. (308K errors per million -69% accuracy)
OMT is a product, but even at the simplest level there is extreme variation. In Minnesota, they measure the percent of patients achieving the five OMT in goals in diabetes (the D5) concurrently and report medical group performance publicly. The worst practices achieve OMT in 16% of diabetic patients. The best produce that product in 57.5%. The average performance is 45% which is double that of the rest of the country simply because of measurement and transparency. I know individual providers who have achieved 65%. OMT is not just about achieving these goals, however. It is also about using the best lifestyle measures and medications to achieve them, which are equally well-defined. It those factors are considered; performance is much worse. If one medical group is achieving OMT in 16% of diabetics and another is achieving 58% there is huge variation that is harming patients every day.
Here is the way the six-sigma master study guide describes variation: “Variation is the enemy! It can introduce waste and errors into a process. The more there is, the more errors. The more errors, the more waste…. it’s a lack of consistency. Imagine that you’re manufacturing an item. Say, a certain sized screw. Firstly, you want the parameters to be the same in every single screw that you produce. Material strength, length, diameter, and thread frequency all need to be uniform. Secondly, your customers want a level of consistency. They want a certain size of screw to all be the same. Using a screw that’s the wrong size might have serious consequences in a construction environment. So, a lack of consistency in our products is bad. We call the differences between multiple instances of a single product variation.” It is no different in medicine. Variation is terrible for the patient and the practice. If the providers don’t produce optimal medical therapy using evidence-based care processes consistent with best practice and achieve OMT goals, patients continue to have more problems and they ultimately require more effort. OMT improves health, saves money, and reduces reworking patient interventions just as in other industries.
The number of patients achieving OMT in diabetes is 20% nationally. When I worked with a large number of primary care practices in Louisiana, those are the kind of numbers we found repeatedly in practice after practice even though the practice leaders were confident they were doing as well as anyone. Once they came to grips with the data, there was a tendency to blame the patient. “We can’t be held accountable for patient noncompliance. I tell them the right things, but they don’t listen.” I have treated hundreds of diabetics and consulted with many practices. The patients are not the problem. Practices fail because they don’t apply the new science and systems to produce optimal medical therapy. The Louisiana initiative doubled the number of patients achieving OMT. It is not that hard. Every practice in this country should be required to post their performance on OMT in diabetes and vascular disease using standardized criteria.
OMT is a product. It is that simple. Quality is a systems property. If you don’t use carefully designed systems and protocols, you will never consistently produce OMT. With systems and protocols, you can explain how you achieved your great results, spread it, and scale it. When American automotive companies ignored Deming, they just lost business. Because American medical leaders have not adopted Demings approach to produce OMT, Americans are losing life and limb while paying too much for the privilege. The content on this site is designed to help medical professionals and patients understand OMT and produce it. There are dozens of us working to make the change. Won’t you join us? There are not that many people who “get it.” If you get it, we need your help.