The consulting firm Kearney updates their numbers on the foreign sourcing and US manufacturing of products. Lots of interesting data.
Management
Supply Chain Management in a Time of Crisis
GE Healthcare, which is ramping up ventilator production, is using 3-D printing both to make parts directly and to make molds for injection molding. However, the chief engineer for advanced manufacturing at Healthcare says that some of the 3D-printing companies he has been talking to are shut down due to government edicts that deemed their work nonessential.
It sounds like they will get around this barrier…“We have a map of all the companies that have excess capacity, and so we’ll divert whatever print work we need to whatever company has got the ability right now, on top of the equipment we have at GE”…but I expect that there is going to be a lot of this sort of thing. There is no way that local or state officials can understand the supply chain dependencies that exist between a seemingly-minor local business and a major national priority somewhere up a level or two (or more) in the product structure. In some cases, all it might take is a letter from the top-tier manufacturer certifying the importance of the work the supplier is doing, but in many cases I suspect that the only rapid solutions will require Federal involvement.
Texas Aggie Doctor Reports — Clinical Pearls Covid 19 for ER practitioners
The following information is from a front line ER doctor using the handle of ‘nawlinsag’ on a Texas Aggie web site. I’ve included the link below. I’ve also included the complete text of his post in full in hopes medical professionals and lay people could get the most benefit from his observations of the course of COVID-19 in a small front line Louisiana hospital.
Short form: This is not the flu. It is a horror show of death and disablement that is crowding out all other medical care including an immediate downgrade of life saving cardiac care. Only on in seven people put on ventalators in this hospital is surviving, and then only after 10-t0-12 days of ventalator support.
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I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.
I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.
Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.
Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.
81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.
Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT’s of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.
China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.
Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.
Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.
Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.
A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.
Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.
Crisis Remote Working: What Will be the Long-Term Effects?
A lot of people…office workers, students…are going to be getting their first experience of remote working, and a lot of organizations are going to be getting either their first experience or a greatly expanded experience in managing this kind of work. What will be the long-term effects of this?…will people eagerly return to their brick-and-mortar working environment as soon as it is safely possible?
Certainly, there are a lot of workers who would welcome the opportunity to avoid their daily commutes. And there are a lot of employers who would be happy to save a lot of money on office space.
And there are surely some parents who would welcome the opportunity to keep their kids at home…there are also more than a few who have arranged their lives and their work schedules around the assumption that their kids will be in school for several hours every weekday.
Many of the remote working experiences are surely going to be suboptimal, however, given that there has been little if any leadtime to prepare systems, content, and procedures.
So what do you think?..a return to things the way they were, or permanent change?
Book Review: The Good Jobs Strategy, by Zeynep Ton
Retail businesses are associated with low pay and high employee turnover–especially in the case of those retailers who offer low prices–and the same is largely true of customer-service call centers. It has been generally assumed that low wages in these operations are a necessary concomitant of low prices for consumers, and that only businesses serving a premium-price customer base can afford to pay high wages.
Comes now Zeynep Ton, arguing that the low-wage strategy is not the only one available to retailers and other customer-service businesses that need to offer low prices, and that indeed often–usually–it is not the best strategy. She draws connections between the pay and hiring strategy of a business and the operational basis on which it is managed. To wit:
Low pay and high turnover implies minimal employee training, because you can’t afford extensive training for employees who are going to leave in a matter of months. Minimal training implies less operational flexibility, because employees will not be cross-trained for other functions. An environment of high turnover and not-well-trained employees implies that employee functions must be strictly proceduralized, often to the point of excessive rigidity. And the lack of flexibility driven by minimal training and experience makes it harder to build in appropriate staffing “slack” to handle peak demand situations. The lack of slack and flexibility leads to endless emergency rescheduling of personnel, reducing morale and further increasing turnover. (She provides some vivid examples of what this endless and short-notice rescheduling can mean to the personal lives of employees.)
On the opposite site, higher pay can contribute to lower turnover, making more-extensive training economically viable. Better-trained employees can more easily perform multiple functions, so that absences or staffing imbalances have a less-harmful effect. Better-trained and more highly-motivated employees don’t need micromanagement, either by human managers or by systems and procedures.
Ho, hum, you say, what’s new?…people, especially consultants and professors, have been writing for years about why employees should be treated well and how it pays off to do so. How is this book different from a million of others?
The Good Jobs Strategy is, in my view, something quite different from the typical “just treat ’em right” sort of soft, warm, and cuddly advice often found in books and LinkedIn posts. The author ties the feasibility of the high-pay / high-expectations strategy to effective operational management, with the right systems, procedures, and incentives to enable such operational excellence.
An interesting example the author mentions is that of Home Depot. She credits much of the chain’s early success to its high-quality associates–“knowledgeable and helpful and willing to do whatever it took to help you, even if that meant explaining to you that you didn’t actually need what you came to buy.” The associates tended to be former plumbers, electricians, etc–and they were employed full-time. HD grew very rapidly–“customers were driving two hours to go to its stores and, once they experienced the service and great prices, they kept coming back”
But, with the growth came problems. There was a lack of discipline in the stores, in how the stores communicated with headquarters, how the company selected its products, and how it communicated with suppliers. “In 2000, bills and invoices were still processed by hand, and headquarters communicated to 1134 stores via fax because there was no companywide email.” In 2008, two senior IT executives (newly hired from Walmart) concluded that Home Depot’s IT systems were about where Walmart’s had been in 1991. In summary, HD had become “a classic example of a service company that did not fully appreciate the role of operations in making customers and investors happy…Operations are all those factory-like activities that a business has to carry out in order to provide whatever it is that it sells. ..In a retail store, for example, operations involves things like having the right product in the right place, having a fast checkout, and having a clean store.” Zeynep Ton says that internal measurement systems often don’t focus on such matters–at one retailer she worked with, “Twenty percent of the (store manager’s) score had to do with the store’s customer interactions.” In this chain, “mystery shoppers” would score the store on things like how the employees greeted customers and made eye contact. But, she notes, “kindness or friendliness won’t make up for operational incompetence. ..It is hard for your dry cleaner to make you happy if you can’t wear your favorite suit to an important interview because they didn’t get it cleaned on time.”
When Robert Nardelli became HD’s CEO in 2000, the systems and procedures problems were rapidly addressed. Gross margins and net profit margins increased substantially.
BUT, “the culture of cost-cutting was soon felt at the local level, where store employees, who were once at the center of Home Depot’s success and at the top of Home Depot’s inverted pyramid, became a cost to be minimized.” The company started hiring part-timers, in the name of both staffing flexibility and cost…the knowledge level of the typical employee encountered by a customer fell noticeably. By 2005, HD was ranked lower in customer satisfaction than was K-mart. Same-store sales growth fell and even became negative. Nardelli left the company in 2007.
Zeynep Ton summarizes: Operational designs don’t execute themselves. They depend on having the right people, and having those people motivated to do the right things.
The book discusses the actual complexity that exists in many seemingly-simple businesses, and the fact that individual employee decisions do make a difference. “If you are a supermarket employee shelving a case of toothpaste and all but two of the tubes fit on the shelf, should you take the two extras back to storage or would it be better to squeeze them onto the the shelf, even if it doesn’t look so good? If a tomato looks just a little soft, should you take it to the back room now or wait until it looks worse? Maybe it will be just fine for a customer who wants to make tomato sauce…it is hard, if not impossible, to make such work so simple and simple and standardized that anyone can do it without exercising judgment. Things happen in real time at retail stores, and employees have to learn to react.”
(It is incredibly refreshing to see a B-school professor thinking and writing at this level of detail and specificity)
One interesting company discussed in the book is QuikTrip, a large chain of convenience stores combined with gas stations. The company is very selective in its hiring….the author compares getting hired there with the difficulty of getting into an Ivy League college. In the Atlanta area, 90% of applicants don’t even quality for an interview, and of those who do, only one out of five is selected. Turnover rate among QuikTrip employees is only 13%, far lower than the industry as a whole. The chain emphasizes speed and flexibility…”QuikTrip’s fast checkout is a site to behold. One thing that makes it so fast is that any employee can use any register at any time without making the customer wait. If you regularly shop at a supermarket, you know it’s no fun waiting for the cashier do a changeover. The other thing that makes QuikTrip so fast is that employees have been trained to ring up three customer per minute.” She says that the employees can even calculate change in their heads!
Other examples discussed include Costco, Trader Joe’s, In-N-Out Burger, and the Spanish supermarket chain Mercadona.