Parameterizing Perfection: Practical Applications of a Mathematical Model of the Lean Ideal

To properly pursue perfection, we need to parameterize it. That is, taking perfection as the ideal, unattainable standard against which we judge our performance is equivalent to thinking of it as a mathematical model. Organizations are intended to realize their missions independent of the particular employees, customers, suppliers, challenges, products, etc. they happen to engage with at any particular time. Organizational performance measurement (Spitzer, 2007) ought to then be designed in terms of a model that posits, tests for, and capitalizes on the always imperfectly realized independence of those parameters.

Lean thinking (Womack & Jones, 1996) focuses on minimizing waste and maximizing value. At every point at which resources are invested in processes, services, or products, the question is asked, “What value is added here?” Resources are wasted when no value is added, when they can be removed with no detrimental effect on the value of the end product. In their book, Natural Capitalism: Creating the Next Industrial Revolution, Hawken, Lovins, and Lovins (1999, p. 133) say

“Lean thinking … changes the standard for measuring corporate success. … As they [Womack and Jones] express it: ‘Our earnest advice to lean firms today is simple. To hell with your competitors; compete against perfection by identifying all activities that are muda [the Japanese term for waste used in Toyota’s landmark quality programs] and eliminating them. This is an absolute rather than a relative standard which can provide the essential North Star for any organization.”

Further, every input should “be presumed waste until shown otherwise.” A constant, ongoing, persistent pressure for removing waste is the basic characteristic of lean thinking. Perfection is never achieved, but it aptly serves as the ideal against which progress is measured.

Lean thinking sounds a lot like a mathematical model, though it does not seem to have been written out in a mathematical form, or used as the basis for calibrating instruments, estimating measures, evaluating data quality, or for practical assessments of lean organizational performance. The closest anyone seems to have come to parameterizing perfection is in the work of Genichi Taguchi (Ealey, 1988), which has several close parallels with Rasch measurement (Linacre, 1993).  But meaningful and objective quantification, as required and achieved in the theory and practice of fundamental measurement (Andrich, 2004; Bezruczko, 2005; Bond & Fox 2007; Smith & Smith, 2004; Wilson, 2005; Wright, 1999), in fact asserts abstract ideals of perfection as models of organizational, social, and psychological processes in education, health care, marketing, etc. These models test the extent to which outcomes remain invariant across examination or survey questions, across teachers, students, schools, and curricula, or across treatment methods, business processes, or policies.

Though as yet implemented only to a limited extent in business (Drehmer, Belohlav, James, & Coye, 2000; Drehmer & Deklava, 2001;  Lunz & Linacre, 1998; Salzberger, 2009), advanced measurement’s potential rewards are great. Fundamental measurement theory has been successfully applied in research and practice thousands of times over the last 40 years and more, including in very large scale assessments and licensure/certification applications (Adams, Wu, & Macaskill, 1997; Masters, 2007; Smith, Julian, Lunz, et al., 1994). These successes speak to an opportunity for making broad improvements in outcome measurement that could provide more coherent product definition, and significant associated opportunities for improving product quality and the efficiency with which it is produced, in the manner that has followed from the use of fundamental measures in other industries.

Of course, processes and outcomes are never implemented or obtained with perfect consistency. This would be perfectly true only in a perfect world. But to pursue perfection, we need to parameterize it. In other words, to raise the bar in any area of performance assessment, we have to know not only what direction is up, but we also need to know when we have raised the bar far enough. But we cannot tell up from down, we do not know how much to raise the bar, and we cannot properly evaluate the effects of lean experiments when we have no way of locating measures on a number line that embodies the lean ideal.

To think together collectively in ways that lead to significant new innovations, to rise above what Jaron Lanier calls the “global mush” of confused and self-confirming hive thinking, we need the common languages of widely accepted fundamental measures of the relevant processes and outcomes, measures that remain constant across samples of customers, patients, employees, students, etc., and across products, sales techniques, curricula, treatment processes, assessment methods, and brands of instrument.

We are all well aware that the consequences of not knowing where the bar is, of not having product definitions, can be disastrous. In many respects, as I’ve said previously in this blog, the success or failure of health care reform hinges on getting measurement right. The Institute of Medicine report, To Err is Human, of several years ago stresses the fact that system failures pose the greatest threat to safety in health care because they lead to human errors. When a system as complex as health care lacks a standard product definition, and product delivery is fragmented across multiple providers with different amounts and kinds of information in different settings, the system becomes dangerously cumbersome and over-complicated, with unacceptably wide variations and errors in its processes and outcomes, not to even speak of its economic inefficiency.

In contrast with the widespread use of fundamental measures in the product definitions of other industries, health care researchers typically implement neither the longstanding, repeatedly proven, and mathematically rigorous models of fundamental measurement theory nor the metrological networks through which reference standard metrics are engineered. Most industries carefully define, isolate, and estimate the parameters of their products, doing so in ways 1) that ensure industry-wide comparability and standardization, and 2) that facilitate continuous product improvement by revealing multiple opportunities for enhancement. Where organizations in other industries manage by metrics and thereby keep their eyes on the ball of product quality, health care organizations often manage only their own internal processes and cannot in fact bring the product quality ball into view.

In his message concerning the Institute for Healthcare Improvement’s Pursuing Perfection project a few years ago, Don Berwick, like others (Coye, 2001; Coye & Detmer, 1998), observed that health care does not yet have an organization setting new standards in the way that Toyota did for the auto industry in the 1970s. It still doesn’t, of course. Given the differences between the auto and health care industries uses of fundamental measures of product quality and associated abilities to keep their eyes on the quality ball, is it any wonder then, that no one in health care has yet hit a home run? It may well be that no one will hit a home run in health care until reference standard measures of product quality are devised.

The need for reference standard measures in uniform data systems is crucial, and the methods for obtaining them are widely available and well-known. So what is preventing the health care industry from adopting and deploying them? Part of the answer is the cost of the initial investment required. In 1980, metrology comprised about six percent of the U.S. gross national product (Hunter, 1980). In the period from 1981 to 1994, annual expenditures on research and development in the U.S. were less than three percent of the GNP, and non-defense R&D was about two percent (NIST Subcommittee on Research, National Science and Technology Council, 1996). These costs, however, must be viewed as investments from which high rates of return can be obtained (Barber, 1987; Gallaher, Rowe, Rogozhin, et al., 2007; Swann, 2005).

For instance, the U.S. National Institute of Standards and Technology estimated the economic impact of 12 areas of research in metrology, in four broad areas including semiconductors, electrical calibration and testing, optical industries, and computer systems (NIST, 1996, Appendix C; also see NIST, 2003). The median rate of return in these 12 areas was 147 percent, and returns ranged from 41 to 428 percent. The report notes that these results compare favorably with those obtained in similar studies of return rates from other public and private research and development efforts. Even if health care metrology produces only a small fraction of the return rate produced in physical metrology, its economic impact could still amount to billions of dollars annually. The proposed pilot projects therefore focus on determining what an effective health care outcomes metrology system should look like. What should its primary functions be? What should it cost? What rates of return could be expected from it?

Metrology, the science of measurement (Pennella, 1997), requires 1) that instruments be calibrated within individual laboratories so as to isolate and estimate the values of the required parameters (Wernimont, 1978); and 2) that individual instruments’ capacities to provide the same measure for the same amount, and so be traceable to a reference standard, be established and monitored via interlaboratory round-robin trials (Mandel, 1978).

Fundamental measurement has already succeeded in demonstrating the viability of reference standard measures of health outcomes, measures whose meaningfulness does not depend on the particular samples of items employed or patients measured. Though this work succeeds as far as it goes, it being done in a context that lacks any sense of the need for metrological infrastructure. Health care needs networks of scientists and technicians collaborating not only in the first, intralaboratory phase of metrological work, but also in the interlaboratory trials through which different brands or configurations of instruments intended to measure the same variable would be tuned to harmoniously produce the same measure for the same amount.

Implementation of the two phases of metrological innovation in health care would then begin with the intralaboratory calibration of existing and new instruments for measuring overall organizational performance, quality of care, and patients’ health status, quality of life, functionality, etc.  The second phase takes up the interlaboratory equating of these instruments, and the concomitant deployment of reference standard units of measurement throughout a health care system and the industry as a whole. To answer questions concerning health care metrology’s potential returns on investment, the costs for, and the savings accrued from, accomplishing each phase of each pilot will be tracked or estimated.

When instruments measuring in universally uniform, meaningful units are put in the hands of clinicians, a new scientific revolution will occur in medicine. It will be analogous to previous ones associated with the introduction of the thermometer and the instruments of optometry and the clinical laboratory. Such tools will multiply many times over the quality improvement methods used by Brent James, touted as holding the key to health care reform in a recent New York Times profile. Instead of implicitly hypothesizing models of perfection and assessing performance relative to them informally, what we need is a new science that systematically implements the lean ideal on industry-wide scales. The future belongs to those who master these techniques.

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