Healthcare, Meet Southwest

Customers experiencing long, often inexplicable delays, their experiences turning from hopeful to angry to afraid they’ll never get back home.  Staff overworked and overwhelmed.  IT systems failing at the times they’re most needed.  To most people, that all probably sounds like Southwest Airline’s debacle last week, but, to me, it just sounds like every day in our healthcare system.

Credit: ABC 7 Chicago

Southwest had a bad week.  All the airlines were hit by a huge swath of bad weather the weekend before Christmas, but most airlines recovered relatively quickly.  Southwest passengers were not so lucky; the airline’s delays and cancellations numbered in the thousands and stretched into days.  Overnight, it seemed, Southwest went from being one of the most admired airlines – loyal customers, on-time service, happy employees, consistent profitability – to one with “its reputation in tatters.”

CEO Bob Jordan has had to do his mea culpas, and he’s not done. 

Some pointed to Southwest’s reliance on point-to-point flight schedules, in contrast to other airlines’ use of hub-and-spoke models, but most seem to agree that the root problem was that its IT infrastructure was not up to task – particularly its employee scheduling system, which told its employees who needed to be where when and how to accomplish that.   Casey A. Murray, president of the Southwest Airlines Pilots Association, told The New York Times: “Once one card falls, the whole house falls here at Southwest.  That’s our problem. We couldn’t keep up with the cascading events.”

Mr. Murray also told NPR: “We're still using not only IT from the '90s, but also processes when our airline was a tenth of the size. And it's really just not scaled for an operation that we have today.” Aviation analyst Scott Hamilton agrees, telling KERA News: “But the policies of being a skinflint on technology fall to Herb Kelleher and every succeeding CEO since then…I think this was benign neglect on the part of the leadership at Southwest across several administrations.”

There’s a term for this, as Zeynep Tufekci wrote in a NYT op-ed: “technical debt.”   Technical debt doesn’t mean that the underlying code is necessarily flawed or poorly written so much as it reflects decisions made at the time of development to defer getting the code “perfect” in lieu of simply getting it implemented.  It’s work that is still going to have to be done someday.

Product Plan has a number of definitions, such as Trey Huffine’s  “technical debt is any code added now that will take more work to fix at a later time—typically with the purpose of achieving rapid gains,” or from Holvitie, et. alia:

Technical debt describes the consequences of software development actions that intentionally or unintentionally prioritize client value and/or project constraints such as delivery deadlines, over more technical implementation, and design considerations

Conceptually, technical debt is an analog of financial debt, with associated concepts such as levels of debt, debt accrual over time and its likely consequences, and the pressure to pay back the debt at some point in time.

Credit: Melv1n

The point is that it is a debt that will come due, as Southwest painfully learned.  “It’s more than just the storm of the century,” said Andrew Inkpen, a professor of management at Arizona State University’s Thunderbird School of Global Management, told Washington Post.  “This exposed them, but they were going to get exposed at some point or another.” 

In a report for CISQ, Herb Krasner estimates that U.S. software technical debt is approximately $1.52 trillion (and the cost of poor software quality is $2.41 trillion).  Shocking but not surprising numbers, since a 2020 McKinsey CIO survey found that:

• 10-20% of the IT budget on new projects was diverted to technical debt issues;
• Tech debt amounts to 20-40% of the value of the entire technology estate (before depreciation).
• 60% felt their organization’s tech debt had risen perceptibly over the past 3 years.

No wonder that Professor Tufekci warns: “Without more government regulation and oversight, and greater accountability, we may see more fiascos like this one, which most likely stranded hundreds of thousands of Southwest passengers — perhaps more than a million — over Christmas week. And not just for a single company, as the problem is widespread across many industries.”

Including, and perhaps especially, healthcare.

Professor Tufekci goes on to blame short term profit incentives, like compensation based on quarterly earning and stock prices, for allowing technical debt to accumulate.  She notes:

…there are strong incentives to address any immediate problem by essentially adding a bit of duct tape and wire to what you already have, rather than spending a large amount of money — updating software is costly and difficult — to address the root problem. Then you can cross your fingers and hope that whatever catastrophe may be in the making, it erupts under someone else’s future tenure.

Ultimately, the problem is that we haven’t built a regulatory environment where companies have incentives to address technical debt, rather than passing the burden on to customers, employees or the next management.

Healthcare didn’t need a bad winter storm to expose its technical debt; it had a pandemic.  From front line caregivers to the healthcare supply chain to the public health agencies intended to lead the fight against such mass health events, healthcare’s technical debts became obvious.  We didn’t have the data, we didn’t have the communication, we didn’t have the right tools, we didn’t have the necessary flexibility.  Our healthcare system didn’t collapse, but it wasn’t far off, and it was only staved off by heroic efforts of healthcare workers and at an uncountable cost of lives. 

llustration: Bráulio Amado for Bloomberg Businessweek

But we didn’t need a pandemic to recognize healthcare’s technical debt.  Healthcare is heavily dependent on software, but find me someone who is happy about any of it -- from billing systems to scheduling systems to electronic records to claims systems to an explosion of digital health “solutions.”  Technical debts are obvious to anyone who has ever had to fill out the same information several times, get a CD to take test results from one healthcare organization to another, or send a fax.  Talk about 1990’s IT!

Healthcare has had its Southwest moment, and, unlike Southwest’s issues, people died.  Most of healthcare’s technical debts “only” result in extra work and/or inconvenience, but some of them have more serious consequences, including loss of life.  It cannot afford to have keep having technical debt issues that someone is pushing off until “someone else’s future tenure,” as Professor Tufecki put it.  

Healthcare CEOs: you do not want to be the next Bob Jordan.  Start paying off your technical debt.