Maintaining inefficiency is a good thing? Seriously?

Leave it to the professors at Harvard Business School to demonstrate a complete lack of lean thinking. A recent HBS Working Paper points out that increasing ordering capacity of the ultrasound service in a hospital led to longer wait times for that service. It turns out that the increased capacity led physicians to order more ultrasounds.

This type of finding isn’t new – transportation experts have known for a long time that building more road capacity doesn’t ease traffic congestion. The extra road room encourages more people to drive, with the result that the new, wider roads have just as much gridlock as before.

What’s so utterly disappointing, however, is the authors’ recommendation: retain the inefficient step in the process in order to discourage physicians from ordering ultrasounds. They write:

to improve hospital performance it could be optimal to put into place "inefficiencies" to become more efficient.

The authors have correctly recognized that given the opportunity, doctors will order more tests. But their solution of keeping inefficiencies in the system is as absurd as saying that we should make cars less stable in order to keep people driving within the speed limit. Or that we should have smaller freezers so that we can’t keep as much ice cream in the house and get fat.

The right recommendation – the lean recommendation – would maintain the local level efficiency improvement, while also including a structured problem solving initiative to reduce the number of unneeded ultrasounds. As Dr. Deming pointed out, the system in which people work drives the vast majority of their behaviors. The doctors aren’t simply ordering more ultrasounds because they can, irrespective of the benefit to the patient. They’re doing so because the system rewards that behavior.

You’d think that a Harvard Business School professor would know that.