Monitor the Right Things and Fix the Right Problems

You may have glanced at my previous post and skipped it, thinking that another article related to the pandemic would not matter to your business. But it does. It’s an example of monitoring the right things and fixing the right problems, both of which are crucial for effective business operations.

Why bother with business books to learn about it? It’s far more interesting to read some of Temple Grandin’s books. She is famous for applying her autism as an advantage, understanding farm animals and advising about how to handle them not just more compassionately, but more effectively.

She is often called in when a huge facility with many animals is not performing well financially. In one case, she found the workers had an enormous list of metrics to track every day. Despite so much tracking, bosses could not see how to improve lagging productivity.

She cut down the list of things to monitor until it was on the order of a dozen items and productivity rose nicely.

But a Guru Said…

A saying can have a nice ring to it without necessarily being true. “You can only manage what you measure” is one of them.

What is your business intended to do? Produce something or measure everything?

Grandin’s method measures only the most important results, the measures that will go astray when something is wrong. When a problem arises, then it’s time to look closely at whatever feeds into the item that raised a flag.

In a factory I’ve worked with for over 20 years, the most important measure to watch for during every production shift is the percentage of material that turns out as first grade product. When first grade yield dips, it’s time to drill into other metrics to find and correct the problem. When first grade yield is up, the only reason to pay attention to myriad other details is to capture a reference set of data to compare against when troubleshooting is needed.

How Does This Relate to Utah’s Monitoring Kits?

Now we can see how Utah came up with its program for reducing its COVID-19 death rate. It’s obvious that they did what Grandin does.

Most places focus on testing people who develop symptoms, then telling those who test positive to quarantine themselves, perhaps tracing their contacts and asking those contacts to self-isolate, which they may or may not do. People whose test results are false negatives are not quarantined and do not trigger contact tracing. Data suggests about a third of COVID-19 patients don’t develop symptoms, so they bypass testing, quarantine and contact tracing completely. But even for cases that are confirmed by testing, the patients are generally stuck at home unless and until they get sick enough to go to a hospital. That point is often too late in progression of the disease for doctors to set up the best chance for good recovery.

The entire usual approach relies on measurement of a number of items and in many places this approach has not dramatically reduced death rates. We can’t test enough people. We can’t test them often enough. We miss asymptomatic cases entirely… The system has too many holes and it isn’t focused on what is most important. It monitors the wrong things and doesn’t even begin to fix anything until a case is in full bloom. Patients would fare better and the load on medical staff would be less intense if we nipped cases when they are budding.

Thinking It Through

Let’s go through the problem solving process like Grandin would or like Utah evidently did. Start with the key metric and step backward from there.

If we’re doing everything as well as we can, the death rate will be as low as we can make it. That is the main item we want to focus on.

What most directly affects the death rate? What can we do about it?

We know from clinical data that if a patient deteriorates enough to be put on a ventilator, the odds of death skyrocket. We know that early medical intervention greatly reduces the chances of needing to be intubated and put on a ventilator.

What kind of early intervention is most helpful? How can we recognize who needs it and the right moment for it?

Clinical records answer the first of those questions. The most significant early intervention is supplemental oxygen as soon as it begins to be needed. The second of those questions is more thorny.

SARS-CoV-2 is sneaky. Patients often aren’t aware they need help breathing until the amount of oxygen in their bloodstream (oxygen saturatiion) is alarmingly low. Among the most stunning surprises to doctors, COVID-19 patients can be fully engaged on their smartphones in a hospital when their oxygen saturation level is so low that they should be unconscious. By the time patients recognize that they need help breathing, it may be too late for supplemental oxygen to be enough.

This is why programs that rely on people to report symptoms every day have not done as much good as expected. Infected people can tell you whether they are coughing or have a fever, but by the time a patient reports shortness of breath, they may have gone past the time when supplemental oxygen would be enough to keep them out of the intensive care unit.

The genius of Utah’s system is using an inexpensive device to monitor oxygen saturation and pulse rate objectively. The patient may still not feel bad enough to call a doctor or go to a hospital, but the pulse oximeter’s numbers identify who needs early intervention and when it is time to go to a hospital for it.

The trouble is not huge yet. The patient may be able to go to a hospital on their own instead of needing an ambulance. Doctors can put the patient on supplemental oxygen right away and maybe avert any need for a ventilator.

You Can Think This Way Too

Disclaimer: I’m not on the inside of Utah’s health care system. I’ve made assumptions about how Utah came up with their unusual way of finding pandemic patients and getting them into treatment, and I’ve simplified the situation to fit into this short article. In particular, I haven’t folded in lockdown measures, mask mandates and so on. Today we are only looking at what it takes to help people who get COVID-19 to survive it.

But we get the concept, right? Monitor the right things, the items that will go awry when something goes wrong. Fix the right problems, as close to the root as you can. This approach tends to take less effort for a better result.