Category Archives: Radiology Innovation and Quality

Disruptive innovation! Six-sigma! DMAIC! Sustainable growth rate!  These are words people throw around, but it’s the idea that counts, not just the acronyms.

Do More or Better – But Usually Can’t Do Both

Today’s world provides us with tools that make humans more capable than ever. Writers who used to make elaborate trips to exotic locations to gleam material for the next espionage thriller while talking to their book agent on the landline with expensive long distance fees can now do the research at their computers while setting up an Amazon self-publishing account.  Radiologists who used to be at the mercy of transcriptionists to translate their verbal stutters into fluent medical poetry days later now generate reports within minutes using voice recognition technology.

These are empowering tools, putting the ability to affect outcome directly in the hand of those holding the highest stakes.  In general terms, it makes sense that with advancements in technology, professionals can now (1) do the same amount of work with better quality, or (2) do more work at the same quality.

Unfortunately,  inadvertently what happens is we tend to be expected to accomplish more and do better (occasionally one also expects to feel less tired at the end of it!) Business school professors would teach that technology advances push the entire pareto-efficient frontier forward.  That is, assuming that you are already working at your absolutely most efficient way such that any improvement in speed will automatically have a quality tradeoff, then adapting a new technology may change the nature of the curve such that you can now move both “up” and “to the right.”  The truth is, I am so rarely pareto-efficient in the first place that if a new technology can somehow land me onto my existing frontier, it was well worth the cost.  And while technology like this, this, and this don’t literally breaking any frontiers, they do have the added benefit of putting productivity in my conscious thought and – at least temporarily – make me healthier and more productive.

The Irony of Complexity

Anyone who has worked on a complex problem knows that simplicity is the result of many, many hours of hard work. 

  • Colin Dunno, Designer at Dropbox, in response to the question, “What is the need for all the world class designers at Dropbox, for a product that seemingly has zero complexity?”

Like a figure skater on ice, to score you have to do hard moves but make it look easy.  If the product of your complex work looks complex, then there’s room for improvement.

Healthcare has plenty of room to improve.

“Doing QI” is Not The Same as Improving Quality (2/2)

There is a fine line between “quality improvement” and innovation. Some may argue that quality improvement is a fix – making something better, more successful, or less error-prone.  Innovation, they might, involves creating something truly new, something that had never existed.

But if one insists on that definition, then some of the world’s most respected “innovators” were not innovators at all.  Steve Jobs did not create the first portable MP3 music player, only the arguably best.  Alexander Fleming did not invent the first antibiotic, only the most effective and famous.  Issac Newton was not the first to describe gravity, only its most mathematically characterized incarnation.

Innovators is a misnomer, coming from the Latin word novus (i.e. new), convincing us that one must strive to create something novel (i.e. novus) to innovate.  Innovators do not create something new; they are fixers of broken systems.  They are masters in the their traditional crafts who felt unsatisfied with the status quo’s offering, be it in technology, medicine, or physics.  They are quality improvement experts.  They did not need Level-5, 5S’s, 5Y’s, 6-Sigma, 12-Step QAPI, DMAIC, FADE, DOWNTIME, Kaizen, balanced scorecard, Deming cycle, ad infinitum.

“Doing QI” Is Not the Same as Improving Quality (1/2)

I was once told that when someone boasts to love James Joyce’s Ulysses, to ask that person how the book ends.

Like to the lover of Ulysses, the next time you hear someone in love with “Toyota” please ask him/her to describe the Toyota Production System. The short version would do.

When we see others succeed, we ask, “How do you do it?”  They may reply, “Here’s how,” followed by a set of well-intended advice in shortcuts and tips.  We then create a spiffy mnemonic and hold it as the bible for replicating the others’ success.

When quality improvement becomes an increasingly rigid set of criteria, alphabet bundle, and kanzi, it becomes easier to think of it as an end in itself.  Let us “do quality improvement.”  Let us find a project to applying these incredible principles (and they are incredible, but they are not hammers).  Let us refer to it as “QI” because that’s a thing now.

But sometimes quality is just about mending the gap when you see one.  Sometimes being methodical helps, but being passionate – not just mending a gap, but your gap – is probably all the requisite there is.  “Doing the QI,” then, may sometimes become an unintended obstacle.

The Irony of Consolidating Innovation

Innovation competition is a common mechanism for developing novel products or or otherwise encouraging creative people to do what they do best – create.  Entire organizations are formed around innovation (IDEO being a high-profile example).

The logic that high rewards attract high performers is reasonable.  And consolidating resources to fund two critically acclaimed novel inventions arguably makes more sense than dividing up the limited funds among 20+ ideas with variable viability.

But these assumptions only work if one makes the assumption that the inception of an idea is a planned process with an “innovative index” directly proportional to effort.  Only then can one make the conclusion that bigger rewards draws better ideas – it does so because people try harder.

But what if creativity is not an effort-dependent activity?  What if innovation, like chemical reactions in equilibrium, only appears predictable on the macroscopic level but is in fact sporadic and dependent on some lucky combination of kinetic creative energy colliding against one another?

It then comes as no surprise that many NIH-funded projects are sustaining innovations, those creating incremental improvements to existing technology.  2% improvement in blood pressure control.  Statistically significant but clinically undetectable improvements in cholesterol control.   Seven Tesla MRIs.  Sustaining innovations, by definition, build on a solid precedence and have higher probability of showing positive results, albeit by a smaller magnitudes.

Disruptive innovations are the smartphones, the PCR machine, the first AML chemotherapy.  They wield the ability to change entire industries; they are also rare.  They are one-in-a-million chemical reactions that require collision at a precise angle with the right kinetic energy.  One might even say that at the start, the inception of a disruptive innovations is sporadic, a lucky accident.

If earth-shaking novel ideas occur by chemical reaction, then it may be clear what we as a society must do to foster them.  The chemist does not give her molecules incentives and rewards for making a carbon-carbon bond.  Instead, the chemist selects the ideal solvent to make the reaction possible, offers a catalyst to lower the activation energy, and gently heats the primordial soup of innovation.

Then she waits, for above all, innovation takes time.  Innovation can’t be made to happen; it can only be allowed to happen.

The hardest thing I’m learning

The hardest thing a novice radiology learns is where to see the critical finding leading to the right diagnosis.

The second hardest thing a novice radiologist learns is how to ignore the noise.

The Quest for Working Happily Ever After

Heart rate mildly elevated, the sweat glands open, eyes fixated on the task at hand.   Time feels slow – or even frozen – but also at once flies by between each glance of the watch.  It’s an experience termed flow, which has been famously described by Mihalyi Csikszentmihalyi in a book by its namesake.

Flow has many components, but the most easily understood set include challenge and feedback – engaging in a task just sufficiently difficult to the level of ability and knowing immediately whether you did the right thing.

Like Fight Club, the experience was in everyone’s face; Csikszentmihalyi just made it visible.  The experience was on everyone’s tongue, and he just gave it a name.  In fact, it’s an experience so addictive (yes, flow experience and cocaine both use the dopamine pathway) that we sometimes spend the entire first half of our lives seeking that experience which we call a career. Continue reading

The Two Faces of Physician Shortage

A medical residency is not easy.  Part of the coping mechanism involves complaining among your fellow residents about everything from the work hours to the deteriorating quality of vanilla pudding parfait in the cafeteria.  Generally the discussion goes something like this:

Resident A: “The vanilla pudding parfait has too much whip cream and not enough pudding.”
Resident B: “We get paid fifty-thousand dollars a year for working eighty hours a week, and they can’t even have a respectable dessert in the cafeteria.”
Residenc A: “I am going to go have a chocolate parfait.  That one comes with an Oreo.”

While Resident A is probably just partial to chocolate, Resident B’s observation begs for an obvious non-dessert-related question.  If medical residents create such immense value at a low cost to hospitals, then increasing the size of the residency program must also be highly desirable.  But the truth is even in the face of increasing demand for physicians, America is not making many more doctors to match the demand. Continue reading

Why Can’t Hospitals Stop Over-Billing Us? (Part 1/2)

Update: On January 5, 2015, Stephen Brill published America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System, expanding on his popular Time article.

It is an interesting book, not because I agree with Mr. Brill’s data but because it happens to be a useful exercise in how data sometimes can be applied/misapplied to streamline a compelling narrative.

Below is a shameless self-reblog from my response to the original Brill article focusing on how data from a sub-sub-sub-specialized hospital should not be used to comment on an entire set of hospitals, some of which struggle to serve as the safety net for a vulnerable population.

 


 

In an article titled “Bitter Pill: Why Medical Bills are Killing Us,” Stephen Brill outlines a well-researched investigation on hospital over-billing.  In the article, Brill begins by highlighting the unreasonable mark-up MD Anderson places on every medication, service, and imaging that it provides.  He argues that this “hard-nosed approach pays off,” earning MD Anderson $531 million operating profit in 2010, and that this comprises a 26% operating margin.  $1.8 million of that went to the pockets of Ronald DePinho, the president of the cancer center.

Although Brill never outright states the connection, his implication is clear: general hospitals are the oft ignored mammoth in the health care debate, operating under the veil of legitimate non-profit business.  A general hospital funds its astounding operating income by making the uninsured and under-insured suffering patients an offer they cannot refuse – a markedly inflated bill.  It then funnels this unfairly earned profit into the pockets to the Godfather of the organization.

The logic is sensational, if only it were correct.

Continue reading

Why Can’t Hospitals Stop Over-Billing Us? (Part 2/2)

In a prior post, I read Steven Brill’s story on health care hospital bills and offered a brief analysis of the “average hospital” in contrast with MD Anderson (spoilers: sub-specialty cancer treatment is profitable, the average hospital is not).  The data show that average hospitals are low-margin organizations.

Below, I argue that although the data disagrees with the vilification of general hospitals in “Bitter Pill,” the article is spot-on that medical bills are incredibly over-priced.

Then, I offer a hypothesis on why.
Continue reading