I recently had the opportunity to attend an event by my institution’s human-centered design group. With escalating penalties for 30-day re-admissions on the horizon, they’d been charged with finding a way to bring our rates down. Like any set of Lean-trained professionals, they began delving into the chain of causes leading to patients bouncing back into the ER (i.e. the “5 Whys”). Their thought process was: We’re having too many 30 day re-admissions (why?). Because patients are missing their follow-up appointments (why?). Because they can’t arrange transportation (why?). At this point, two different threads emerged. On the one hand, public transport wasn’t sufficiently robust to deliver the patients to their appointments and take them home in a timely manner; on the other hand, patients had trouble arranging rides home because clinic appointments tended to run late and they never knew when they needed to be picked up. The latter is a process-centered, Lean-friendly kind of problem (and can be addressed as such). But what about the former? The logic was that “Either through re-admission penalties or taxi vouchers or some other way, we’re paying for these patients inability to find adequate transportation. So why not do it directly?” So the presenters began a pilot program providing transportation to patients who couldn’t find a ride.
Note that we only got “3 Whys” deep before we lost the distinction between the responsibilities of the healthcare system and the responsibilities of society at large. Since many hospitals are public institutions, I don’t believe this is necessarily wrong. However, we need to acknowledge the uncomfortable position this puts us in. The medical-industrial complex already plays a large role in our lives. By expanding the explicit responsibilities of healthcare organizations, we also expand their responsibility for the (generally unspoken) social determinants of health. Doing so creates redundancies and conflicts between different healthcare organizations and between healthcare organizations and the social support systems they try to supplement. Competition drives innovation, but economics of scale drives efficiency. The question is: how de we find a balance between the two?