The Humunculus is a metaphor for Clinical Process Improvement Frameworks

During the last 20 years, we have experienced wave after wave of new frameworks for improving health care.  Each had its own terminology, ardently promoted and enforced by its zealous advocates.  Each had a lifecycle that began with a long incubation period, followed by a period of explosive growth in popularity and influence, rapidly leading to unrealistic expectations, followed by a period of decline during which the framework was declared to have been ineffective.  We’ve been through health maintenance, outcomes management, clinical effectiveness, managed care, disease management, chronic care, care management, practice guidelines, care maps, evidence-based medicine, quality functional deployment, continuous quality improvement, re-engineering, total quality management, and six sigma.  We’re still in the thick of lean, patient-centered care,  value-based benefits, pay-for-performance and accountable care.

Four things I’ve noticed about this lifecycle of health care improvement frameworks:

  1. They are formulated by conceptual thinkers, but then get taken-over by more tactically-oriented people.  The tactical folks often focus too much on the tools, terminology and associated rituals.  The framework always gets “simplified” to be more suitable for mass consumption.  For example, continuous quality improvement somehow morphed into being primarily about assigning a timekeeper during team meetings and communicating progress on a felt-backed “story board,” rather than finding people with systems-thinking talent and applying that talent to understand sources of variation in complex processes.
  2. During the early part of the growth phase, the advocates are always desperate for examples of success, and shower a great deal of attention on early projects that are described using the terminology of the framework and that appear to have succeeded.  The desperation usually leads advocates to lower their standards of evidence during this phase.  This leads to over-promising and unrealistic expectations.  It stimulates lots of superficial imitation by people interested in hopping on the bandwagon.  And, it plants the seeds for the eventual decline, when people determine that their inflated expectations were not met.
  3. The decline phase, when the framework is declared to be ineffective, seems to always happen before the framework was ever really implemented in the way envisioned by the original formulators during the incubation phase.
  4. All the frameworks are really just restatements of the same underlying concepts, but with different terminology and tools, and different emphasis.  In other words, they all have the same anatomy, but different parts of the anatomy are emphasized.

This last point reminds me of the “humunculus,” also called the “little man.” When I was in medical school in the late 1980s, we used heavy text books that generally did a bad job of teaching the information. One notable exception was clinical neuroanatomy. We used a small, paperback text book playfully entitled “Clinical Neuroanatomy Made Ridiculously Simple” by Stephen Goldberg, MD. It contained a collection of clever drawings designed to explain the structures and functions of the brain and spinal cord. Perhaps the most famous of the drawings was the humunculus.

Cross section of somatosensory cortex, showing mapping to sensory input sources

This drawing was adapted from earlier work by an innovative neurosurgeon named Wilder Penfield, who invented new surgical procedures for patients with epilepsy during the late 1930s.  During those procedures, he used electrodes to stimulate different points on the surface of the brain.  He drew diagrams similar to the drawing above showing that the surface of the brain contained a little man hanging upside down. The diagram shows that a disproportionate portion of the brain surface is dedicated to the sense of touch and muscle movements in certain parts of the body.  Lots of brain surface is dedicated to highly sensitive and nimble areas like the lips, tongue, hands and feet.  Very little brain surface is dedicated to the arms, legs and back.  Many anatomic illustrators have drawn the humunculus as a cartoon character showing how this disproportional emphasis on different parts of the body looks on the little man.

The Humunculus

The humunculus is a great teaching tool, making it easy to remember these aspects of clinical neuroanatomy.  But, I think the humunculus is also a useful metaphor for the distorted emphasis that various health care improvement frameworks have placed on various parts of the underlying anatomy of health care improvement.

Framework

Emphasis

Health maintenance Preventive services
Outcomes Management Measurement of function, patient experience and health status
Clinical Effectiveness Measurement of outcomes in real world settings, rather than laboratory controlled conditions
Managed Care Prospective review of appropriateness of referrals, procedures and expensive drugs, and retrospective review of cost of care
Disease Management Role of nurses in training patients to be more effective in self-management
Chronic Care Teamwork in primary care clinic and importance of organizational and community environment
Care Management Role of nurses in coordinating services delivered by different providers and in different settings
Practice Guidelines Consensus about which ambulatory services are appropriate in which situations
Care Maps Consensus about the sequence of inpatient services for different diagnoses
Evidence-based Medicine Weight of scientific evidence about efficacy of a service (without regard to cost)
Quality Functional Deployment Focus on the demands made by patients
Continuous quality improvement Small experiments to determine if incremental process changes are improvements
Re-engineering Designing new processes from scratch, rather than making incremental changes
Total Quality Management Importance of organizational culture and management processes
Six Sigma Focus on reducing frequency of defects
Lean Focus on eliminating non-value-adding process steps and reducing cycle time
Patient-centered care Focus on the needs of patients and the involvement of patients in their own care
Value-based Benefits Financial incentives to motivate patients to comply with recommended treatments that reduce overall cost
Pay-for-performance Financial incentives to motivate individual physicians to improve quality and reduce cost
Accountable care Financial incentives to motivate health care organizations to improve quality and reduce cost

Over the years, I have assimilated the concepts, terminology and tools from these various improvement frameworks into an approach that attempts to achieve balance, with each aspect of the framework shown without over-emphasis.

This framework puts the patient in the center, surrounded by the health care processes, which are surrounded by improvement processes.  It attempts to balance between focusing on care planning (the clinical decision-making regarding what services are needed) vs. focusing on care-delivery (the teamwork to execute the care plan and provide health care services to the patient).  It balances between measuring outcomes and measuring quality and cost performance.  It balances between implementing best practices through guidelines and protocols vs. improving practices through performance feedback and incentives. By avoiding a distorted over-emphasis on any one part of the anatomy, hopefully it can have greater lasting power than some of the more humunculus-like frameworks that have come and gone.   This framework is described more fully here.

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“Can I get a Fast Pass?”: Learning from Disney about health care quality

While returning from a vacation to Walt Disney World yesterday, my family and I were in a disorganized crowd at the Orlando International Airport boarding the tram that shuttles travelers between terminal buildings.  A man yelled “Can I get a fast pass?”  Everyone laughed.

Anyone who has been to a Disney park knows that a “fast pass” is a little ticket that can be obtained at the entrance to popular rides that gives an assigned time after which you can return to the ride and avoid having to stand in a long line.  They are lifesavers, particularly to families with kids on hot days.  Going through the “fast pass return” gate to a ride always makes you feel like you were lucky to win a prize or that you are a special guest.  It is a process design that anticipates a customer problem and prepares in advance to resolve the problem, thereby delighting the customer.  

Over the course of our vacation, my wife and I noted hundreds of little ways that Disney was “thinking.”  Signage that always seemed to point to where we wanted to go.   Rubber tubing inserted in the train track slots at cross walks to keep buggy wheels from getting stuck.  Masking tape applied to the pavement just before the evening parade and fireworks to mark places OK for standing and removed just before the end of the parade.   The list goes on and on.

Once aboard the Orlando Airport shuttle, after making sure my daughter had a good grip on the pole (the one with the germs of thousand of travelers!), my thoughts wandered to the business trip I had taken the week before, when I missed my return flight from Chicago because I waited for more than an hour in the security line at O’Hare Airport.  While waiting in that line, I had plenty of time to study the processes at the airport to try to figure out why they are so un-delightful.  At O’Hare, at the security entrance to terminals E & F, travelers must choose among four roped-off waiting lines.  Fifteen minutes into the line, I noticed that my line and the line next to me were moving far more slowly than the other two lines.  After another half hour of waiting and inching closer to the inspection area, I had the diagnosis.  Out of 5 x-ray baggage screening machines, Homeland Security had staffed only three of the machines during this Saturday morning of Spring Break week.  (Perhaps they lacked “intel” about school schedules in the homeland?)  Two of the waiting lines fed into their own screening machine.  My waiting line merged with the other slow line to share a single screening machine.  I finally made it up to the ID check lady.  After she checked my ID against the home-printed boarding pass (some other time we can try to figure out how that is adding security value), I politely asked if I could make a suggestion and explained the problem with the lanes and suggested that they close off one of the two slow lanes.  She looked at me with a quizzical “and you think I care?” look.  After another 10 minutes in the line, I noted that there were about the same number of staff standing and watching as actively interacting with travelers or their bags.    I overheard one of these watchers say to another “What a mess.  It’s enough to make you want to help out.”  The other watcher smiled at the joke.  After I finally got through and finished hopping on one one foot to tie my shoes, putting my belt back on, and repacking my computer bag, I realized that I missed my flight.

So, why has Disney been able to outperform O’Hare, Orlando International, and Homeland Security in customer experience?

I believe that the answer is culture.   I’m a person that usually focuses on numbers and science, and the concept of “culture” sometimes seems too vague for my taste.  But, it is undeniable that some organizations achieve a culture that emphasizes quality and customer satisfaction, while other organizations do not.  In my experience, small organizations tend to have an easier time achieving such culture, since each member of the organization is close to each other and to the customer.  But Disney is a huge corporation.  I suspect that Disney has built up their culture over many decades, attracting employees that find Disney’s culture attractive, selecting employees that already have personality and character traits compatible with their culture, training new hires in their philosophy and the processes and techniques they use to pursue that philosophy, and creating an experience for those employees that their ideas count and their effort is appreciated and rewarded.

On Sunday morning, I overheard two Disney employees talking to each other, greeting each other with cheer.  One said “I’ve got to hurry over to the mono-rail, which is backing up for some reason.”  The  Disney employee was in a hurry, but took a moment to express cheer and respect for a fellow employee.  The employee had a sense of urgency to solve a problem with customer experience.  But the last three words caught my attention.  ”For some reason.”  The employee had an inherent interest in the causes of the problem, not just in the problem itself.  I was left with the impression that this employee was going to help out with the current situation, while simultaneously trying to figure out and subsequently address the reason that it happened this Sunday morning, so it does not happen again on the next Sunday morning.

So what can we learn from Disney and airports about the quality of care in Accountable Care Organizations (ACO)?

For ACOs to be successful, they must be competitive — not only to purchasers, but also to patients.  They have to create processes that anticipate the needs of the patient, and solve problems before they happen.  They need to be able to learn what works and does not work.  They need to be able to overcome the professional cultures that sometimes emphasize technical competency and physiologic outcomes to the exclusion of humanistic competency, and the satisfaction and delight of patients and their families.

The idea that we in the health care field can learn from those in the hospitality field is certainly not new.  At health care professional meetings, such as meetings of the American Medical Group Association (AMGA), I’ve been to numerous presentations over the years by executives from Disney, Marriott, Ritz-Carlton and other hospitality companies about how they select and train people, how they have huddles at the beginning of every shift, how they empower people to solve customers’ problems, and how they reward people that delight customers.  And many hospitals and physician organizations and some health plans have taken this advice to heart and made significant progress to nurture a patient-satisfying and quality culture.  But, I think everyone would agree that we still have a lot to learn and a long way to go.

 

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