What Is Healthcare's LEGO?

Last week the esteemed Jane Sarasohn-Kahn celebrated that it was the 65^th anniversary of the famous LEGO brick, linking to Jay Ong’s blog article about it (to be more accurate, it was the 65^th anniversary of the patent for the LEGO brick). That led me to read Jens Andersen’s excellent history of the company: The LEGO Story: How a Little Toy Sparked the World's Imagination. 

Credit: The Art of the LEGO

But I didn’t think about writing about LEGO’s until I read Ben’s Cohen’s Wall Street Journal profile of  University of Oxford economist Bent Flyvbjerg, who studies why projects succeed or fail.  His advice: “That’s the question every project leader should ask: What is the small thing we can assemble in large numbers into a big thing? What’s our Lego?”

So I had to wonder: OK, healthcare – what’s your LEGO?

Professor Flyvbjerg specializes in “megaprojects” -- large, complex, and expensive projects.  His new book, co-authored with Dan Gardner, is How Big Things Get Done. Not to spoil the surprise (which would only be a surprise to anyone who hasn’t been part of one), their finding is that such projects usually get done poorly.  Professor Flyvbjerg’s “Iron Rule of Megaprojects” is that they are “over budget, over time, under benefits, over and over again.”

In fact, by his calculations, 99.5% of such projects miss the mark: only 0.5% are delivered on budget, on time, and with the expected benefits.  Only 8.5% are even delivered on budget and on time; 48% are at least delivered on budget, but not on time or with expected benefits.  

As Professor Flyvbjerg says: “You shouldn’t expect that they will go bad. You should expect that quite a large percentage will go disastrously bad.” 

Healthcare has nothing to brag about.
Credit: Engineering News Record

He has two key pieces of advice.  First, take your time in the planning process: “think slow, act fast.”  As Dr. Flyvbjerg and Mr. Gardner wrote in a Harvard Business Review article recently, “When projects are launched without detailed and rigorous plans, issues are left unresolved that will resurface during delivery, causing delays, cost overruns, and breakdowns….Eventually, a project that started at a sprint becomes a long slog through quicksand.”

Second, and this is where we get to the LEGOs, is to make the project modular; as Mr. Cohen puts it, “Find the Lego that simplifies your work and makes it modular.”

Professor Flyvbjerg writes:

Modularity is a clunky word for the elegant idea of big things made from small things. Look for it in the world, and you’ll see it everywhere…software, subways, hardware, hotels, office buildings, schools, factories, hospitals, rockets, satellites, cars and app stores: They’re all profoundly modular, built with a basic building block. They can scale up like crazy, getting better, faster, bigger and cheaper as they do.

Like LEGOs.  Or, in Professor Flyvbjerg’s description, “Repeat, repeat, repeat. Click, click, click.”   If you’ve ever played with LEGOs, you’ll know what that means. 

It’s worth pointing out, as Mr. Andersen does in his book, that LEGO took some time to become the LEGO we now know.  It made a wide variety of (wooden) toys in its first couple decades, didn’t stumble upon the interlocking brick idea until the late 1940’s (an idea it copied from an English company), didn’t switch to plastics until the early 1950’s, and didn’t patent LEGO bricks until 1958.  That was also the time that Godtfred Kirk Christiansen, the second generation of family leadership, wanted to pick one product that it could develop a “LEGO system in play,” a variety of toys that “were easy to play with, easy to produce, and easy to sell.”  That was the LEGO brick, and it is why you can now design and build your own town or build a replica Millennium Falcon^TM with them.

Yep, those are LEGOs. Credit: LEGO

Healthcare has plenty of megaprojects – costing $1b or more – and many smaller ones, and I suspect most don’t end up being delivered on time, on budget, or with the full set of expected results.  Some of that is no doubt because of the failure to spend enough time planning, as Professor Flyvbjerg stresses, but I suggest that much of those failures come because healthcare either doesn’t have its LEGO or has the wrong ones.

Healthcare’s LEGO should be the patient.

Let’s take software projects. How many of you have multiple electronic records, some of which may connect with others, but still leave you feeling somewhat schizophrenic?  They were not designed around the patient; they were designed for hospitals, health systems, health care professionals’ offices. Health plans’ eligibility, billing and claims systems were largely designed around employers.  And almost everything in healthcare is designed to ensure billing could be done.  If healthcare software already has a LEGO, it is billing codes, because people working in healthcare want, above all, to get paid.

Or take actual healthcare construction projects, such as hospitals, medical office buildings, or other facilities. Historically, they’ve been designed around physicians -- how to make it easier for them to see more patients (billing, again), to encourage them to practice there instead of elsewhere, etc.  That’s why doctors rarely make house calls anymore, why too many patients who could be treated at home end up in the hospital, and why patients end up spending so damn much time waiting.      

Some might argue that in the new era of Big Data and A.I., the new healthcare LEGO should be bits. Everything is going to run on them; everything is going to be connected by them. There’s a logic to that, and that approach may seem tempting, but it’s a dangerous path. We could end up with an even more impersonal healthcare system than we have today.

We’re the LEGO brick. We’re the unit. And when I say “patient,” I really mean more broadly: people, whether they’re current patients, former patients, or future patients. It matters how we’re connected, to whom we’re connected, what the end goal for us is.  The healthcare system often thinks of us as our diagnoses or our bodily systems, but unless and until it looks at us as the entire person – the LEGO brick, if you will – we’re neither going to be treated the way we want nor achieve the health results we hope for.

Credit: Arts Brookfield

So if you are working on a healthcare project, take that extra time that Professor Flyvbjerg urges to really think about which people will be impacted, where, how, when, and to whom they are or should be connected.  Build those connections to create something creative, sturdy yet flexible, and effective. As Dr. Flyvbjerg writes: “It’s remarkable what you can do with blocks of Lego.”