$100 bills on the pavement – and in the hospital

hospital decor

In writing this article, it occured to me that one way to describe my own approach to economics is the search for the $100 bill on the pavement.

That is, if you can find ways of bringing new ideas into some well developed framework (well new-ish ideas or just ideas that are commonplace in other frameworks) then you’re often looking at ‘low hanging fruit’. Some small, often relatively painless change which can bring big benefits. As I lead my life I see these things all the time.

As one of the few economists to have been really struck by production systems like JIT or TQM it always struck me that this is what they’re about. The relentless search for ideas – from wherever one might be able to get them for relatively painless, evolutionary improvements. large and small.

And as Toyota found out as it pioneered what is now called TQM (and various other things) often the $100 bills turn up from making the effort to try to bring insights from one place into some system that hasn’t bothered to invite them in. Engineers and system designers hadn’t bothered involving employees adequately in the design of their jobs, or suppliers adequately in the design of what they supplied.

When I read this article by Virginia Postrel I have all the same thoughts. How many times have I visited a hospital where the patient has an ‘on-off’ switch for their lights. Now the teensy weensiest bit of thought about the situation the patient is in would lead one to install a switch with some capacity for dimming – so the patient or the nurse can set a level of light that seems right at the time. Now of course lots of hospitals have this. But whenever I see the lots that don’t I sigh with exhaustion. What hope is there for us if we can’t build beds for patients in hospitals that show the slightest thought for the patient?

I like the story (perhaps apocryphal) of Robert Menzies PM being driven through a suburb in Canberra, asking which architect had built a row of lousy houses and asking if they could be sacked.Anyway, surprise surprise, patients react well to being treated like human beings in hospitals. Virginia Postrel’s article tells us some things which some people might find surprising, but which seem natural enough.

Roger S. Ulrich, now at the Center for Health Systems and Design at Texas A&M . . . looked at patients recovering from gallbladder surgery in a hospital that had some rooms overlooking a grove of trees and identical rooms facing a brick wall. The patients were matched to control for characteristics, such as age or obesity, that might influence their recovery. The results were striking. Patients with a view of the trees had shorter hospital stays (7.96 days versus 8.70 days) and required significantly less high-powered, expensive pain medication.

Looking at the picture above it occurred to me that one of the things that’s going on with the pictures behind the great monster MRI machine – or whatever it is – is the conveying of the idea that we are biological, not mechanical beings. That the machines existing in hospitals take their context from our biology, not the other way around. Now that’s a theme to conjure with in a hospital – one that if it were acted on in a systematic way might lead to much better experiences in hospitals.

Postrel’s article is a bit unsatisfying because in it, aesthetics appears as a kind of ‘add on’. Add some picture of nature and trees and nice things and people are happier, get better faster and so on.

I’d prefer if it was written up from within a TQM kind of paradigm – people designing and running hospitals should be doing what they can to see things from the patients’ perspective and a whole bunch of things would follow – not least higher hospital productivity conventionally measured. The $100 bills of money would pile up, but so too would the ‘utility’ of patients who’d enjoyed their stay more, or disliked it less, not to mention the morale, work quality and satisfaction of the staff and so on.

Certainly one of the things that those successfully implementing TQM note is the way in which one thing leads to another. In the example quoted, shorter, happier stays lead to less ‘high powered, expensive pain medication’ which has its own spinoff benefits – fewer complications, less stressed staff and so on.

Now if a decent outlook saved over a day in hospital, perhaps some nice surroundings (including a dimmer light!) would make a further contribution and on it goes. . . .

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Patrick
Patrick
13 years ago

Isn’t that selling Postrel kinda short? I thought that aesthetics was close to her raison d’

Dave Bath
13 years ago

Nicholas said: “well new-ish ideas or just ideas that are commonplace in other frameworks”
That’s one problem with the 2020 gabfest – cross-domain thinking is diminished by the breakup into committees. The best ideas will probably touch base with MOST topics.

BTW: Large windows in a well-lit ward make it easy for others to see in, which can be a privacy issue unless the grove is well-designed (e.g. evergreens rather than leafless in winter).

But NMR/MRI’s are troubling (having to basically avoid breathing and moving for around 8 minutes at a time), in a VERY claustrophobic space, with only a little mirror to the outside world. At least my hospital offers some music, although the choice was limited (the Vivaldi’s 4 Seasons, while the best of them for me, got really annoying after about half an hour.

But the boolean lights observation is a beauty!

Chris Lloyd
Chris Lloyd
13 years ago

“Hospitals ..are designed for doctors.” Dear right Patrick. Not only hospitals but the medical education system (artificially restricted so that kids need 99.5 to enter). Hospital systems are also designed for doctors.

I was recently asked to donate some of my bone marrow. I have been on the registry for some 10 years, after a friend died. You would think that under these circumstances my needs would be given some weight. It was the middle of term and I did not want to miss too many night lectures. But no. It was an invariable requirement that the donor (me) go in on a Tuesday, have the operation on the Wednesday and expect a day and a half recovery time. Wouldnt want to clash with Mister Specialists golf arvo would we? The idea of scheduling the operation on a Friday was greeted with utter incomprehension from the nurse.

Low hanging fruit and $100 bills on the payment exist because of mis-aligned incentives, lack of accountability and straight out corruption. When you see easily corrected inefficiencies there is usually an unconscionable rort not far out of view. In the long run it is better concentrating on the structural deficiencies rather than the symptoms.

Patrick
Patrick
13 years ago

but rather to assume that people actually want to do a good job

I agree that this is essential. It is almost always true, in my experience. It is just frightening what one person’s idea fo doing their job can translate into as experience for someone on the other end of their job.

SJ
SJ
13 years ago

Looks more like an x-ray machine, not that it’s of any great importance.

SJ
SJ
13 years ago
Chris Lloyd
Chris Lloyd
13 years ago

Nick, I am not assuming people want to do a bad job. That is only one of a holy trinity mis-aligned incentives, lack of accountability and straight out corruption

I would have said that TQM proves my point. What was the incentive for a bloke on the line telling the boss how to better organise the process? He would be considered a trouble maker or a smart-arse and even if something good came of it, he would not get credit or payoff. It required a complete mindset change to set up the incentives for this to happen.

In relation to your comment on tarrifs, I think my comment stands up well: When you see easily corrected inefficiencies there is usually an unconscionable rort not far out of view. In the long run it is better concentrating on the structural deficiencies rather than the symptoms. It may have taken 20 years after Black Jack McEwens death, but it was corrected in the end.

So returning to your example, the question to my mind becomes: what is the structural defect that leads to hospitals not bothering with dimmer switches. I am no expert on the funding of hospitals, but I expect that if a patients is unstaisfied with the lighting, food or friendliness of the nusing staff, then it does not cost the hospitals anything or at least those hopsitals that do not have dimmer switches.