Unlike Aaron Carroll at the Incidental Economist, I was a policy and process analyst major in younger days. But we had the same concept of the binding constraint:
the rate limiting step. See, in any chemical reaction, there’s always one part that is the slowest. If you want to speed things up, you’re going to be able to make the most difference by focusing on that step….
I had to do laundry last night. We had an adult whites and towels load, an adult colors load, a referee load, and the kids load. The process is fairly simple; put clothes in washer, wait for washer to buzz, move clothes from washer to dryer, reload washer and wait for dryer to buzz. The binding constraint in that process flow is the dryer as it takes roughly two washer cycles for a dryer cycle.
In order to maximize the amount of sleep I got, I had to optimize the binding constraint. That meant I put all of the clothes in the washer on an extra five minute spin cycle to wring out as much moisture as possible. That meant that as soon as I heard the dryer buzz, I went downstairs and changed the loads to minimize its non-use, and it meant that I hung my jeans and towels out to finish drying instead of putting them back in the dryer for another twenty minutes. The dryer was idle for maybe five minutes from start to finish. The washing machine was idle for a significant portion of the time, but the process was nearly as efficient as possible because I optimized the usage of the binding constraint.
Aaron notes that we don’t focus on the binding constraints or the rate limiting step in health care:
Bill and Melinda Gates are doing it right. From 1990 to recently, the childhood mortality rate has been cut in half. Why? Cause they pay attention to the things that matter. What kills kids worldwide? Malaria – and they’re hard at work on a vaccine. No worries about phantom illnesses or the craze of the week. Instead, they’ve got a solid focus on the things that actually matter….No fancy new medicines. No genetic tests. And it’s easy to roll your eyes and say this is common sense stuff, and it is in much of the developed world. But I think the Gates want to do the most good they can for children worldwide, period. And they can do so by improving things for those who have it the worst. That’s the rate limiting step. Further, they can do the most good in the places that need it the most by focusing on the things that are actually killing kids. In this case, it’s nutrition, hygeine, and infection control….
Rocket science is cool if the goal is to go to Europa (even if we’re warned not to) but it is not a panacea. However the United States treats high end medical science as an end all and be-all. There is plenty of research to show that talking to patients about their goals, desires, and constraints leads to better health outcomes at lower cost and resource utilization that the best pill. There is plenty of research that shows wrapping social services around individuals at high risk lowers medical utilization and net spending than telling people to come to the emergency room if they feel ill. There is plenty of research that basic checklists minimize errors. Yet we don’t do that. It is easier to get a massive capital intensive installation than revamping business practices to emphasize the human and humane.
So we spend money on the sexy and the shiny instead of the simple and effective.
The lessons for the US are clear though. What’s the number one killer of kids in the US? Accidents – by far. But the number of foundations and NIH dollars going into that is miniscule. Know what consistently makes the top five? Suicide and homicide. How much time and money do we spend on researching ways to reduce that?
We don’t want to focus on those issues because of Freedumb ™.
If we focused on suicide and homicide that would mean that we actually have to talk about guns in a rational, adult manner where costs and benefits of having an absurdly heavily armed population is a reasonable thing to talk about. Instead of how guns are non-prescription Viagra or major tribal cultural markers. It would mean talking about how are communities are designed so that it is almost impossible for children to safely walk to the vast majority of their daily places of life. It would mean talking about mental health without stigma. It would mean that we as a society are also a community with shared responsibilities.
Those are evil and deviant thoughts so we chase shiny objects instead.