Tag Archives: Health care

Robots for Health Care from Toyota

Japan has an extremely rapidly aging population. This increases the need for health care and for assistance with everyday tasks from the elderly. Japan is also among the leading countries for developing robots for health care and living assistance.

I have written about the efforts to have robots fill some needs in Japan previously, on this management blog and also my partner Curious Cat Engineering blog: Toyota Develops Thought-controlled Wheelchair (2012), Toyota’s Partner Robot (2007), Toyota Human Support Robot (2012) and Pepper, A Social Robot from Softbank (2017).

Most often innovation efforts take the form of understanding the jobs your customers are using your products and service for now and developing new solutions to delight those customers. This is difficult for companies to pull of successfully.

Occasionally innovation involves meeting completely new needs of customers. For example Toyota started as a loom company and is now known as a car company. Making such a radical change is not often successful.

Will Toyota be able to add robots to the products it produces successfully? I believe they have a chance. But it won’t be easy. Obviously (as shown in posts on my blog for the last ten years) I respect Toyota’s management system. That gives them a chance to be successful. The product development system is going to be critical (ideas found in: Toyota Engineering Development Process and How to Develop Products like Toyota).

Toyota Sends Robots To The Hospital

Toyota demoed its Welwalk WW-1000 robot, a machine that can rehabilitate stroke victims some 60% faster than regular physiotherapy. The company also showed glimpses of other robotic technologies, for instance a Human Support Robot that picks up stuff, draws curtains, and performs other menial tasks a bedridden patient would normally need to call a nurse for.
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Toshiyuki Isobe, chief of Toyota’s robotics lab, said that the company is not fixated on being a car company. “Toyota started as a maker of looms, and only got in to cars later,” Isobe said. “Our mission always was to make practical things that serve a purpose. If there is a need for mass produced robots, we’ll make them.”

image of the Toyota support system for rehabilitation of walking in stroke victims

image of the Toyota Welwalk system

Understanding Design of Experiments (DoE) in Protein Purification

This webcast, from GE Life Sciences, seeks to provide an understanding Design of Experiments (DoE) using an example of protein purification. It begins with a good overview of the reason why multi-factorial experiments must be used while changing multiple factors at the same time in order to see interactions between factors. These interactions are completely missed by one-factor-at-a-time experiments.

While it is a good introduction it might be a bit confusing if you are not familiar with multi-factorial designed experiments. You may want to read some of the links below or take advantage of the ability to pause the video to think about what he says or to replay portions you don’t pick up immediately.

I have discussed the value of design of experiments in multiple posts on this blog in the past, including: Introductory Videos on Using Design of Experiments to Improve Results by Stu Hunter, Design of Experiments: The Process of Discovery is Iterative and Factorial Designed Experiment Aim.

He also provides a good overview of 3 basic aims of multivariate experiment (DoE):

screening (to determine which factors have the largest impact on the results that are most important)
optimization (optimize the results)
robustness testing (determine if there are risks in variations to factors)

Normally an experiment will focus on one of these aims. So you don’t know the most important factors you may choose to do a screening experiment to figure out which factors you want to study in detail in an optimization experiment.

It could be an optimized set of values for factors provides very good results but is not robust. If you don’t have easy way to make sure the factors do not vary it may be worthwhile to choose another option that provides nearly as good results but is much more robust (good results even with more variation within the values of the factors).

Decades Later The USA Health Care System is Still a Deadly Disease for Our Economy

Decades ago W. Edwards Deming named 7 deadly diseases of western management. One of those was excessive health care costs. Sadly that deadly disease has become much worse in the last several decades.

Americans pay 300% more for this prostate cancer drug than much of the rest of the world

Xtandi, a prostate cancer drug co-licenced by Japan’s Astellas Pharma and Medivation Inc. was developed at a U.S. university with grants funded by taxpayer dollars. That gives the federal government the right to revoke the patent if the terms are unreasonable, said the letter, dated Monday.

“We do not think that charging U.S. residents more than anyone else in the world meets the obligation to make the invention available to U.S. residents on reasonable terms,” said the letter, which had Sen. and presidential candidate Bernie Sanders, Sen. Elizabeth Warren and Rep. Elijah Cummings among its signatories.

This specific example also highlights what I classified as a new deadly disease in 2007 – the broken patent and trademark system.

Both of these deadly diseases greatly damage the USA economy and the economic condition of USA citizens. It is disgraceful that the Democratic and Repulbican parties have allowed these deadly diseases to ravage the USA economy for decades.

The drug price situation in the USA is greatly exsaserbated by the corrupt political process. Drug companies give large amounts of cash to those we elect and then those we elect create system that damage the USA economy and provide drug companies huge extra profits inside the USA (those profits then allow the companies to charge other countries even less and still make a great return on their investment). I wrote about this in 2005: Excessive Drug Prices in the USA (and several times since then, Drug Price Crisis [2008] – it is a long term, huge economic problem for the USA).

Health care is extremely expensive everywhere. But in the USA the health care system is twice as costly as other rich countries. This is an enormous burden on the USA economy. Nothing else comes close to being as costly in terms of direct spending. And there a a great deal of other damage done that can’t be seen in just the 100% more the USA spends on health care than other rich countries spend. And the health outcomes are no better for the extra hundres of billions of dollars spent every year for health care in the USA.

The costs of decades of failure are extrodinary. We shouldn’t allow the political parties to continue to fail to sensibly address these problems. Even if we can just get to the point of costing 50% more than other rich countries our economy will be greatly enhanced, but we have not even been able to reduce the health care tax the USA health care system puts on us to just 50% more than other countries. That is a pretty sad state of affairs especially when you consider that other countries are not doing a great job – so we are twice as costly, not as some extremely wonderful amazing system but twice as costly as mediocre comparisons.

Extremely inflatted drug prices in the USA are a significant part of the problem but still only a portion of a system that has been costly the USA economy and citizens hundreds of billions of dollars a year (and untold soffuering in many other ways) for decades. We have to do better.

Getting Retweeted by Marc Andreessen Generated a Flood of Retweets

On Twitter today I was getting more than 30 times the notifications I normally get. So I took a look to see what is going on. One of my tweets was getting retweeted and liked quite a lot (nearly 100 times each, so far). I figure most likely someone with many more followers than I must have retweeted it.

A bit more investigation and sure enough that is what happened. Marc Andreessen had retweeted it. He has 432,000 followers (a bit more than my 1,600).

This minor internet enabled connection with fame is one of the fun aspects of the internet (to me anyway, I might be a bit odd). I emailed Tim Berners Lee (the creator of the world wide web) a long time ago (probably about 15 years – and I still remember) and received a nice reply. I have written a few posts on my science and engineering blog about his work over the years including a short post on the first web server (Tim’s NeXT computer).

For those that don’t know NeXT is the computer company Steve Jobs headed in between his stints at Apple. In 1999, I was giving a presentation at a conference on Using Quality to Develop an Internet Resource (link to my paper for the talk was based on). I was working for the Office of Secretary of Defense, Quality Management Office at the time. In cutting the time down I eliminated saying that the internet was created by the Department of Defense and giving a few sentences on that history as I figured everyone knew that history. After my presentation, one of the people that came up to talk and somehow I mentioned that history and the 3 people standing there didn’t know it and were surprised. Anyway that NeXT comment reminded me of that story…

The tweet Marc Andreessen retweeted was about research by scientists in London that developed pain-free filling that allows teeth to repair themselves without drilling or injections.

Several people responded that we will never see this in use (based on the idea that announcements of research breakthroughs often fail to deliver). Quite a few people we looking forward to the day when it would be available though. Including some that were sitting in the dentist office while they were reading about it.

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Visual Management and Mistake-Proofing for Prescription Pills

Good ideas often just require some sensible thought to think of an improved approach. Management concepts can help guide such thinking, such as mistake-proofing and visual management.

To apply visual management requires giving a bit of thought to how to make visually obvious what is important for people to know. Mistake proofing is often really mistake-making-more-difficult (for some reason this term of mine hasn’t caught on).

Image from PillPack, they provide a service to deliver packages based on your prescriptions.

I believe mistake-proofing should put barriers in the process that make a mistake hard. Often what is called mistake-proofing doesn’t really fit that definition. The pill package shown above for example, doesn’t prevent you from continuing past the time on the package (Monday at 8AM) without taking the pills.

To call it mistake-proofing I would like to see something that makes it harder to make the mistake of failing to take the pills: something that blocks progress beyond that time without taking the pills.

Even something as simple as an alert to your smart phone that gets your attention and doesn’t allow the smart phone to be used without indicating you have taken the pills would reach the “mistake-proofing” level in my opinion (for someone that has their phone with them at all times). The Apple Watch could be a good tool to use in this case. Even so those wouldn’t make mistakes impossible (you can say you took the pills even if you didn’t, the phone/watch may lose power…). It would depend on the situation; this smart phone/watch solution is not going to be good for some people.

Another idea is that these pill packages should be tied to the room (in a hospital) and at home if a home care nurse (or even family or others) are responsible for assuring the pills are taken with a big display that perhaps 30 minutes before the pill is due posts a message that says “pills to be taken at 8 AM” and once that time is past it could become more obvious, perhaps after 15 minutes it produces an audio alert. The actual solutions are going to be better from those that know the actual situation than someone like me just thinking up stuff as I type.

But the idea is pretty simple: when you have processes that are important and at risk of failure, design processes with elements to make mistakes hard (and ideas such as mistake-proofing and visual management can help you guide your mind to ways to create better processes).

The entire process needs to be considered. The pill packages are nice, because even in failure modes they provide good feedback: you may still fail to take them at the right time, but you can look at the location where the pill packages are kept and see
if any have a time before right now (in which case you can follow the medical guidance – take the pills right now, contact the doctor, or whatever that advice is). Of course even that isn’t foolproof, you could have put the package into your purse and it is still sitting in their but you forgot.

Still the pill packages seem like a good mistake-making-more-difficult solution. And it seems to me that process has room to make mistakes even more difficult (using a smartphone addition, for example).

Continual improvement requires a continual focus on the process and the end user for ways to increase reliability and value. Each process in question should have engaged people with the proper skills and freedom to act using their knowledge to address weakness in the current process that are most critical.

Failure to take prescriptions as directed in a common problem in health care. Knowing this should make those involved in the process think of how they can use concepts, such as mistake-proofing, to improve the results of the system.

Too often to much focus is on making better pills compared to the effort is put into how to improve results with simple concepts such as visual management and mistake-proofing.

Each small improvement contributes to creating a more robust and effective process. And engaged people should continually access how the containing systems, new processes and new capabilities may allow more small steps to provide value to those relying on your products and services.

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Some Thoughts on Investing from My Recent Interview

In the first few years of this blog I posted occasionally, but still much more than the last few years, on investing and economics. Now I mainly post on those topics on the Curious Cat Investing and Economics blog (see how the name and that practice are in sync with each other?).

I was recently interviewed about investing strategies and thoughts and decided to share that with the readers of this blog. Some excerpts from the interview:

I have maintained a portfolio that I call the sleep well portfolio for 10 years (started April 2005). I hardly have any turnover (under 2% annually I think) and hold stocks I would be comfortable locking in a vault for 10 years. The largest holding there is Apple, followed by Google; I also still really like Google as a long term investment. The stocks in the portfolio for the entire period are: Google, Amazon, Toyota, Intel, Pfizer…

We got out of the “Too Big to Fail” crisis, but have not addressed the core problems – and likely have made them much worse. We didn’t take the opportunity to address the financial system risks created by the actions of “Too Big to Fail” banks. And it seems to me we have left the central banks in a very vulnerable position. They have already played strategies that previously seemed impossible due to the position they were placed in, and if it happens again, what are they going to be able to do? I think the risk of massive economic failure is large enough to consider in an investment portfolio.

How would you suggest an investor guard against the potential for a massive economic disaster?

John Hunter: My main thoughts on that are to greatly value companies that are likely to weather economic calamity greater than any since the great depression. Having tons of cash obviously helps (Apple, Google…). Having a business model that puts a company in a position to make money (even if it is a lot less than they are making today) if the economy does extremely poorly, is also good (Apple, Google, AbbVie…).

It is possible for the economy to be hit so hard Apple, Google, etc. lose money. But if that happens, I believe huge numbers of other companies are going to be out of business, and the economy will be in shambles…

The sleep well portfolio has beaten the S&P 500 by about 220 basis points (on an annual rate of return basis) (see details on how marketocracy calculates returns – they reduce returns by 200 basis points to simulate investment adviser fees). The interview includes much more details as well as links to posts on my investing blog going into more detail.
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Management Blog Review 2012: Gemba Walkabout

This is my second, of two, 2012 management blog review posts. In this post I look back at the last year on Mike Stoecklein’s Gemba Walkabout blog. Mike is the Director of Network Operations at Thedacare Center for Healthcare Value.

In a very long post, Some thoughts on guiding principles, values & behaviors, he provides a sensibly explanation for one the real difficulties organization have making progress beyond a certain point (project success but failure to succeed in transforming the management system). “I’m not saying this approach (focus on tools, teams, events) is wrong, but I do think it is incomplete. I think we also need to work from right to left – to help people understand the guiding principles, to think about the kinds of systems they want and to use tools to design and redesign those systems. Dr. Shigeo Shingo said, ‘people need to know more than how, they need to know why’.
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Most managers view their organization like an org chart, managed vertically. They assume that the organization can be divided into parts and the parts can be managed separately
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It’s what they believe, and what they don’t know is that is is wrong – especially for a complex organization.
If their thinking was based on the guiding principles (for instance “think systemically”) they would manage their organization differently. They would see their organization as as set up interdependent components working together toward a common aim.”
Reflections on My (Brief) Time with Dr. Deming – “The executives thought he was pleased. When they were done with their ‘show’ he thanked them for their time, but he wanted to know what ‘top management’ was doing. He pointed out that they were talking about improvements on the shop floor, which accounted for only about 3 percent of what was important.” When executives start to radical change what they work on the organization is starting to practice what Dr. Deming taught. Mike recorded a podcast with Mark Graban on working with Dr. Deming.
Standard Work and PDSA – “What I have noticed is that sometimes people insert another wedge (shown as black) in the diagram below. So, progress gets stopped because some seem to believe that standard work doesn’t get adjusted as you make improvement.” This is a brilliant graphic including the text standard work misued. The 2 biggest problem with “standard work” in practice is ignoring the standards and treating them as barriers to improvement. Standard work should be practiced and if that is a problem the standard work guidance should be changed.

image showing how failure to adjust standard work can block progress

During the year stay current with great posts twice a month via the Curious Cat Management Improvement Carnival.

Management Blog Review 2012: Not Running a Hospital

Paul Levy started the Running a Hospital blog when he was the CEO of Beth Israel Deaconess Medical Center. Thankfully he has continued the blog, renamed to Not Running a Hospital, after leaving that position. Paul provides a huge number (the lowest number of posts in a month was 32) of valuable posts focused on health care, but worthwhile for everyone interested in improving the practice of management.

In addition to his blog, during 2012 Paul published a wonderful book – Goal Play!: Leadership Lessons from the Soccer Field. In my first 2012 management blog review I take a look at Not Running a Hospital.

Some of the thoughtful posts by Paul in 2012:

How to get better at harming people less – “Imagine what we as a society would do if three 727s crashed three days in a row. We would shut down the airports and totally revamp our way of delivering passengers. But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country.”
Medtronic’s Lean Journey – “They knew they would have to think big, but then sweat the details. Over time they figured out how to collaborate.
There were five stages in the process:

1 — Define our operating standards, who we aspire to be.
2 — Set a global expectation to accelerate improvement.
3 — Develop the ability to assess current state.
4 — Create ongoing mechanisms to learn and leverage to close gaps.
5 — Continually check and adjust.”
Sarah Patterson informs about Lean – “Would like Va Mason org to operate like an aircraft carrier. How to run a complex business safety.
Aircraft carrier = an airport on top of a nuclear power plant comprising a bunch of 19 year olds!

Aircraft carrier needs complete alignment with the mission. If not done well, puts others at risk.

Aircraft carrier requires an incredible commitment to adoption of standard work. Relentless focus on training.
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Create jobs that are doable. Train people to do them. Hold people accountable to them.
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Adopted TPS=customer first, highest quality, obsession w/ safety, staff engagement, successful economic enterprise
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Senior leader regular gemba rounds to view one aspect of standard work.”

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USA Spent $2.6 Trillion, $8,402 per person,17.9% of GDP on Medical Expenses in 2010

Total health expenditures in the USA in 2010 reached $2.6 trillion, $8,402 per person or 17.9% percent of GDP. All these are all time highs. Every year, for decades, health care costs have taken a larger and larger portion of the economic value created in the USA.

In 2009 the USA Spent Record $2.5 Trillion, $8,086 per person 17.6% of GDP on Medical Care.

USA health care spending grew 3.9% in 2010 following an increase of 3.8% in 2009. While those are the two slowest rates of growth in the 51 year history of the National Health Expenditure Accounts, they still outpaced both inflation and GDP growth. So yet again the health system expenses are taking a bigger portion of overall spending. This has been going on so long that the USA spends double what many other rich countries do on healthcare with no better results.

As a result of failing to address this issue for decades the problem is huge and will likely take decades to bring back just to a level where the burden on those in the USA, due to their broken health care system, is equal to the burden of other rich countries. Over 2 decades ago the failure in the health care system reached epidemic proportions but little has been done to deal with the systemic failures. Dr. Deming pointed to excessive health care cost, back then, as one of 7 deadly diseases facing American business. The fact that every year costs have increased more than GDP growth and outcome measures are no better than other rich countries shows the performance has been very poor. The disease is doing even more harm today.

Some good things have been done over the years, most notably by Don Berwick while at the Institute for Healthcare Improvement. He was effectively thrown out of office by the politicians recently. The same politicians that have through decades of such foolish acts contributed more than any other group to the broken health care system that burdens the USA today. In the last 10 years a significant amount of good work has also been done in “lean healthcare”: applying lean thinking to healthcare. But it is similar to the quote that a “bad system will beat a good person.” With all the bad systemic issues the efforts, good as they are, in lean healthcare are mainly improving around the edges. Of course, “around the edges” of a $2.6 Trillion dollar system can still be extremely valuable and important.

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Management Improvement Blog Carnival #150

Mark Graban is hosting Management Improvement Blog Carnival #150 on the Lean Blog, highlights include:

Watching Waste in the ER! – As part of his relatively new blog, Anthony Scott (Frontline Lean) writes about his experiences with waste in an emergency department. The waste isn’t surprising to those who have been a patient or those who have worked in the E.D. Scott is a supervisor in a lean manufacturing setting and he applies lean thinking to this unfamiliar environment.
Case Study: The Nordstrom Innovation Lab – Eric Ries (Startup Lessons Learned), author of the excellent book The Lean Startup, has a post with video featuring the use of “Lean Startup” methods and mindsets within a Fortune 500 company. Eric writes, “It’s one thing to talk about “rapid experimentation” and “validated learning” as abstract concepts. It’s quite another to see them in action, in a real-world setting.”
Top 3 Things I’ve Learned After 18 Months in Healthcare – My friend and DFW-area neighbor Mike Lombard (Hospital Kaizen) reflects on his first 18 months after transitioning from manufacturing into healthcare. In addition to his main points, Mike ends the post with an invitation for others to Move to Healthcare, writing, “Like I said earlier, I’ve learned a lot (a lot more than is shown here) and I continue to learn everyday. If you’re an engineer, project manager, quality professional, operations manager, or any other type of business professional, you can make the move to healthcare. Just be ready to focus on people, deal with complexity, and be proud of your work. Most of all, be ready to continuously learn and improve.”

I know we are all busy but, Mark, has done a great job highlighting some excellent posts. Take a look at the full carnival post and each of the posts. It is very nice to see how many great posts we are able to find for every carnival. A decade ago finding this kind of content was nearly impossible.