Lockdown’s Loss Function

I’ve been studying lean in hospitals since the mid 1990s – co-wrote a book about it with a Nursing Director. I’m confined, but people tell me their gemba stories. It’s awful. It’s frightening. It’s inspiring.

A hospital is a complex being – think of an operating theatre and what the surgeon needs to perform – the staff, equipment and material she needs in her hand at the right moment. Wards, wards are complex creatures as well, if only to keep nosocomial infections down. This is a painful lesson we learned from Florence Nightingale in the XIXth century she used statistics to prove the correlation between forceful sanitation and mortality.

COVID spreads through a chain of contagion: as far as we know, one infected person can contaminate two to three other people. The arithmetic of it is dizzying. These 3 people can then contaminate 27 and so on. Yes, to slow contagion, we need to 1/ better isolate people with the virus (how do I know I carry it if I have no symptoms?) 2/ better protect people susceptible to catch it.

This is a new bug and thankfully most people seem to be okay-ish, some people get very ill and tragically, others suffer from respiratory complications that are hard to deal with – and possibly death. In a hospital the logistics of keeping someone on respiratory support are tremendous.

Lockdown of local infection nodes seems a sensible response, which poses two technical questions: 1/ how do you spot a contaminated focus node to confine it as much as you can? and 2/ what is the plan to get out of lockdown?

Locking down entire countries, however, is a bewildering reflex. How are you going to supply critical materials if truckers can’t find restaurants to eat in or hotels to sleep in for overnight trips? Supply chains are going to grind down to a hold, and as the system is both complex and reacts badly to such shocks, we can’t predict exactly where the supply failures are going to appear. In the hospitals I know, first it was sanitizing gel, then respirators, then masks – now protective gowns? What next?

Lean thinking is about thinking things upside down. Let’s imagine a Taguchi loss-function curve of lockdown:

The theory of lockdown is based on slowing the progress of the epidemic so that healthcare structures can cope with the peak influx of patients, and better care for them and nurse them to recovery. The premise is that hospitals’ own functioning will remain unaffected by the lockdown – only the demand for emergency respiratory care will reduce.

Shutting down the system that supplies hospital – and the support network for hospitals won’t leave them unaffected. Without masks or gel, caregivers run a greater risk of becoming ill themselves. Without school, many will have to stay at home to care for their kids (yes, emergency daycare centers are being organized within hospitals, but how attractive is that?) Without food, clothing, solid families behind them how will frontline staff cope?

Lean thinking teaches you the hard way there are never YES/NO solutions. Only difficult trade-offs. Lean thinking also teaches you that Ultra-Solutions, (to use Paul Watzlawick’s term: the cure is successful but the patient died) have massive, unexpected costs – they fail successfully. Understanding the Taguchi loss-functions of problems makes you realize that OK/NOT-OK simplistic thinking is the real cause of failure in the end.

In any systemic solution, such as this one, we need to return to the fundamental mechanism:

Duration of contagion x Opportunities for contagion x Transmissability of the virus x Susceptibility to catch it.

And accept that any successful solution will have to be multi-factor, such as:

1. Better hygiene: washing hands and sanitizing surfaces systematically, frequently and relentlessly will affect all terms of the transmission chain.
2. Masks for coughing sneezing people: stopping infected particles from spreading.
3. Testing and confinement: Recognizing who is contagious and asking them to isolate completely.
4. Locking down local outbreaks: Lockdown on neighborhoods and villages where an outbreak has been spotted;
5. Keeping the care support chains working: making sure the supply for care is running, staff, equipment and materials, which means making sure the support structures for every caregiver are up.
6. Localize key equipment production: global companies are scrambling to source masks from their Chinese subsidiaries for their Western employees – this is hardly sustainable. Production capability needs to be close to the point of use. Since Rome wasn’t built in one day, we need to start right away.

The global scope of the pandemic is terrifying. How do we keep our focus on treating the ill, and not protecting the bureaucracies? How do we keep our focus on supporting caregivers, and not playing God with our economies? Collective panics are hotbeds for magical thinking, knee-jerk bureaucratic responses and, ultimately, fuel for the madness of crowds.

This virus is not magical. Fighting it requires better understanding it through widespread testing (which we can’t do because the reactive reagent are supplied in China as I understand it) and robust supply of equipment and ammunition, as well as home base support. If this is a war, our soldiers need bullets and guns and food. How will we provide if production and supply chains are crashed because everyone has been ordered home?

Look up! We need to look up beyond the horizon of this week to look at the horizon of getting out of this mess – it was never going to be a simple yes/no answer, just as the epidemic was never going to come in one wave. It will ebb and flow. Reduce and return. It’s biology, not faith.

We need to balance warm hearts with cool minds, to understand that, yes, our frontline doctors and nurses need emotional support, but they also need medicines and protective equipment and working machines – and homes to go back to and not have to worry about their loved ones or dealing with shortages of service and delivery.

The pandemic is with us. It has caught up with us in some places, but clearly not all. By understanding the loss-function of our solutions, we’ll come to refuse to fail successfully and learn how to implement more practical, multi-action measures that don’t involve the police in the streets stopping people from going to work.

Wash your hands.