tl;dr: In this post, Mark examines and challenges criticisms of Lean and Taylorism as presented in an article published in the New England Journal of Medicine. He counters the doctors' arguments, providing context and evidence to defend the effectiveness of Lean principles in healthcare settings. The article serves as a comprehensive response to common misconceptions about Lean, especially in the medical field.
If you're new to the idea of “Lean,” I invite you to download and read chapter 1 of my book Lean Hospitals.
Hat tip to Suresh for pointing me toward this article that was just published January 14th in the New England Journal of Medicine:
“Medical Taylorism“
NEJM is the same journal that published Dr. Don Berwick's article about Kaizen and Dr. Deming in 1989, an article that discussed how those concepts would be helpful in healthcare. Dr. Berwick realized, as he wrote, that not all factories are the same. Some are managed better than others. Employees are treated better in the “Lean” factories. Berwick was right to point out that medicine can learn from other industries… but that doesn't turn the hospital into an assembly line.
In the article posted today, Pamela Hartzband, M.D., and Jerome Groopman, M.D. (the later the author of the popular book How Doctors Think), rant about all sorts of things… some of which have nothing to do with Lean.
“Advocates lecture clinicians about Toyota's “Lean” practices, arguing that patient care should follow standardized systems like those deployed in manufacturing automobiles. Colleagues have told us, for example, that managers with stopwatches have been placed in their clinics and emergency departments to measure the duration of patient visits. Their aim is to determine the optimal time for patient-doctor interactions so that they can be standardized.”
What they're saying in the piece is that they fear having their patient interaction time squeezed or shortened inappropriately. If that's indeed happening, this is wrong headed and insulting toward Toyota. I'm pretty sure Toyota would not alienate physicians or other healthcare professionals this way.
Look at this video about Toyota helping reduce delays at UCLA-Harbor… it wasn't about timing doctors and speeding up appointments. It's about improving systems and reducing waste and delays.
Toyota-ism and Taylor-ism are not the same thing. Toyota operates in a far different way. Bob Emiliani writes passionately about how even Taylor and Scientific Management evolved and get an unfair bad rap today.
As I've written about before, some hospitals (or engineers working within them) have taken old-style Taylorism to an unfortunate extreme, including timing how long doctors are in the bathroom.
Stopwatching people in the bathroom or the exam room… that's wrong headed, and disrespectful, and it's not solving the problems that matter in healthcare (such as the patient safety crisis).
If that's happening, don't blame Toyota. It's not really Lean, it's L.A.M.E., or Lean As Misguidedly Executed. Criticize the behavior, instead of painting Lean with a broad brush.
I've participated in many Lean initiatives (and have documented others in my book and here on the blog) and the success came from ENGAGING people, including physicians, instead of telling people what to do or how to change. One such initiative helped a children's hospital reduce the waiting times for outpatient sedation MRIs from 12 to 14 weeks down to just 2 to 3… and they've sustained those results for years.
It's not credible to say Lean is inappropriate or that Lean doesn't work. That said, there are many wrongheaded things done in the name of “Lean,” when people don't understand the mindset and philosophy behind Lean.
Drs. Hartzband and Groopman have all sorts of valid complaints, including how EHR systems can make work more difficult and how CMS has “1000” performance measures that irritate physicians.
Neither of those issues have anything to do with Lean.
Again from the NEJM:
“Physicians sense that the clock is always ticking, and patients are feeling the effect. One of our patients recently told us that when she came in for a yearly “wellness visit,” she had jotted down a few questions so she wouldn't forget to ask them. She was upset and frustrated when she didn't get the chance: her physician told her there was no time for her questions because a standardized list had to be addressed — she'd need to schedule a separate visit to discuss her concerns.”
If physicians are being pressured into cutting time short with patients, that's wrong… it's not Lean. Having an inappropriately inflexible approach to patient care isn't Lean either.
They continue:
“We believe that the standardization integral to Taylorism and the Toyota manufacturing process cannot be applied to many vital aspects of medicine. If patients were cars, we would all be used cars of different years and models, with different and often multiple problems, many of which had previously been repaired by various mechanics. Moreover, those cars would all communicate in different languages and express individual preferences regarding when, how, and even whether they wanted to be fixed. The inescapable truth of medicine is that patients are genetically, physiologically, psychologically, and culturally diverse. It's no wonder that experts disagree about the best ways to diagnose and treat many medical conditions, including hypertension, hyperlipidemia, and cancer, among others.“
Of course patients aren't cars. That's a red herring argument.
I've personally never seen or been involved in a Lean healthcare initiative that was trying to tell physicians how to be physicians. It was always about providing better service to physicians – making sure surgical cases start on time, etc.
Here is a blog post I wrote about “standardized work” a few years ago, which emphasizes, among other things, that Toyota has long emphasized that standardized work should be written by the people who do the work.
Micromanaging or interfering with the actual value-added work is not the goal (although it's effective when PHYSICIANS take on the challenge and leadership around improving their own work as physicians).
It's not really Lean when an organization focuses exclusively on cost or productivity.
Healthcare organizations and leaders have LONG focused on cost-cutting and pressuring people to work faster or to obsess over something like “patients per hour.” Those aren't Lean habits; they're healthcare habits (and traditional management habits).
The authors admit some positive things have happened:
“To be sure, certain aspects of medicine have benefited from Taylor's principles. Strict adherence to standardized protocols has reduced hospital-acquired infections, and timely care of patients with stroke or myocardial infarction has saved lives. It may be possible to find one best way in such areas.”
But…
“But this aim cannot be generalized to all of medicine, least of all to such cognitive tasks as eliciting an accurate history, synthesizing clinical and laboratory data to make a diagnosis, and weighing the risks and benefits of a given treatment for an individual patient. Good thinking takes time, and the time pressure of Taylorism creates a fertile field for the sorts of cognitive errors that result in medical mistakes. Moreover, rushed clinicians are likely to take actions that ignore patients' preferences.”
I'd agree with the authors that you can't turn all of the complexity of medicine into a checklist or a protocol. There's a lot of room for and need for clinical judgment.
“Rushed clinicians” is often the starting point before Lean (because there's too much waste and chaos around them). Lean isn't trying to speed up the doctors… it's about improving systems and processes and crreating a better environment for them and their patients.
“Yet students are now taught the principles of Taylorism and Toyota Lean as early as their first year of medical school. They enter clinical rotations believing that there must be one best way to diagnose and treat every medical condition.”
Is that really true, that they're being told Lean is all about a “one best way to diagnose and treat EVERY condition?” Again, that doesn't really sound like Lean to me.
Real Lean is built around concepts like:
- Putting the patient first
- Respecting people (see more)
- Engaging everybody in redesigning systems and continuously improving
- Solving problems and testing improvements in a scientific way
- Having a balanced set of goals, putting safety, quality, and patient flow first…
- Not blaming individuals for systemic problems
- Creating a better, less frustrating workplace
- Improving teamwork and collaboration across silos and disciplines
It's not about speeding people up or telling them how to do their work. (See my post on “Lean Mindsets“).
It might also be useful to see Toyota's own page about the Toyota Production System, which includes:
“People are the Most Valuable Resource: Deeply respect, engage and develop people.
Continuous Improvement: Engage everyone each and every day.”“Leaders inspire and develop people to surface and solve problems to improve performance.”
That's not classic Taylorism. Far from it.
The doctors also say, in their article:
“Medical Taylorism began with good intentions — to improve patient safety and care. But we think it has gone too far. To continue to train excellent physicians and give patients the care they want and deserve, we must reject its blanket application.”
OK… for all of the dissatisfaction, frustration, chaos, and waste that exists in healthcare BEFORE Lean… and the delays in care and harm that result for patients…
What are the doctors proposing as an alternative?
Groopman wrote about how doctors interrupt and jump to conclusions after, what, 18 seconds with a patient. Did he jump to conclusions about Lean after 18 seconds or does he legitimately have bad experiences with L.A.M.E. situations?
What's your reaction to the article?
Tomorrow, I'll go back to work with my head held high, off to a meeting to talk with a cancer treatment center that is looking to use Lean to further reduce delays in patients getting their initial consult. I'm trying to help others improve patient care and outcomes. It's noble work helping those who are doing noble work. I agree it's not all about efficiency, cost, margin, or profitability.
Enough with the rants about “Taylorism” and dragging Toyota or Lean through the mud… let's get back to work improving healthcare. Or at least trying.
Update: See this post from Modern Healthcare about this discussion.
“There probably are some hospitals or large physician practices that have time-study engineers running around with stop watches and calling it an application of “Lean” techniques, as Hartzband and Groopman assert. But process improvement malpractice shouldn't be used to condemn an entire approach to enhancing quality and productivity.”
And Paul Levy, former CEO of Beth Israel Deaconess Medical Center, writes a post, which says, in part:
“…what hurts more is the fact that our clinical staff at BIDMC, where the authors reside, were overwhelmingly engaged in the the philosophy and practice of Lean–at least during the time I was there. What's more, they enjoyed it and found that it made their lives better. Indeed, Mark Zeidel, our Chief Of Medicine, regularly offered many positive thoughts on these matters in his missives to his staff, called Kaizen Corner.”
See this follow up post from June 2016:
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Thanks Mark for including a link to my “18 second” blog post. For your readers who haven’t yet read Dr. Groopman’s “How Doctors Think”, I heartily recommend it.
regards,
C.
It is unproductive to fight the same battle for 100 years. The fact that this is our reality suggests great confusion still exists between Taylor’s work circa 1890 and the post-Taylor evolution of progressive management that began in earnest after his death in 1915 and which led to the Toyota Production System and the Toyota Way (and as it continues to evolve). It makes our job of advancing Lean management far more difficult. In fact, it imperils the existence of Lean. To me, these misconceptions have long been tantamount to an EMERGENCY that none of the big, influential Lean organizations have recognized or responded to.
I sounded the alarm beginning in 2007 (9 years ago!) in my six volume REAL LEAN book series, 2007-2010), which was largely ignored – to our own and other’s peril.
I am certain that Taylor, were he alive today, would be mystified at how people today remain stuck on his early work and writings (e.g. the “one best way”), and how the great work of other people that followed him and who built on his (and Gilbreth’s) work is so poorly understood.
I’ve been guilty of misunderstanding Taylor myself.
So there’s a difference between REAL Taylorism and Fake Taylorism?
Fake Taylorism (an expert lording over people with a stopwatch, telling them how to do their work) is about as common as Fake Lean or Fake Anything?
Yes! There was a huge fight back in the 1910-1935 time frame in which Taylor (when he was alive) and his followers (who carried on after Taylor died) advocated the Scientific Management SYSTEM, and consultants (“efficiency engineers”) who got work in companies by just using tools to achieve short-term gains. So, yes, there was in fact a Real version of Scientific Management and a Fake version of Scientific management. The “efficiency engineers” were characterized as “fakirs,” “quacks,” “cracks,” and “charlatans.” Fake Scientific Management was far more commonplace than Real Scientific Management. The “fakirs,” “quacks,” “cracks,” and “charlatans” were far more successful (financially) than Taylor’s followers. Taylor was wealthy for the invention of and patents for high speed steel cutting tools for machining metals. Real Scientific Management was not a moneymaker. Aside from the dozen or so organizations who adopted the system in its entirety (something like what today we would call “TPS and the Toyota Way”), Scientific Management gave him a lot of grief. He had to testify in front of Congress because he got blamed for all the Fake Scientific Management. It so worth reading his testimony to Congress.
I’m not impressed with these doctors.
Can I write an article for the “New England Journal of Lean” that decries “Medical Butchery?”
I mean, doctors and hospitals help SOME people, but can’t extend that into thinking modern medicine is good for all, considering estimates show up to 400,000 Americans are dying due to medical error.
What have these Harvard-trained doctors done, in their careers, to solve this problem? Are they just creating smokescreens and boogie men?
Interesting point and indeed this blog should be submitted to NEJM in reply to the rather disappointing article described.
When I was working on Six Sigma at my hospital 10 years ago I met a Harvard-trained doctor who HAD implemented Six Sigma in his fertility clinic with excellent results. At the time most of the hospitals presenting at Lean conferences were smaller ones, the prestigious colleges came late to Lean. This doctor surmised that the reason for this was medical narcissism among those who saw themselves as a cut above the rest. The “H” stands for Harvard and hubris but not for humility,” he joked.
The New England Journal of Medicine is supposed to be a peer-reviewed journal. “The New England Journal of Medicine employs a highly rigorous peer-review and editing process to evaluate manuscripts for scientific accuracy, novelty, and importance.” There is a serious flaw in the NEJM’s peer-review process to let something like this slip through unchallenged. Anyone who understands Lean would immediately see the issues you highlight in their paper. Because of this, it could call into question the quality and accuracy of all of their articles.
Agree! Remember the resignation of long-time editor Marcia Angell in 2009? What was the NEJM response to that?
The ‘Perspectives’ section does seem to favour this type of article. The guidelines say ‘many Perspective articles include an element of opinion — indeed, some read like op/eds, though others resemble brief magazine features, mini review articles, or “think pieces” ‘.
The NEJM is a prestigious journal, and this will be quoted and cited. It will be important for people responding to realise that this is not an evidence-based piece – it’s opinion based. Separating out for people what’s Lean and what is not, is probably a good place to start when responding to clinicians (or anyone else) who cites it.
The basic tone is not new. I remember a heated meeting a quarter of a century ago when some older doctors decried the existence of clinical guielines, and the use of audit: these topics wouldn’t raise an eyebrow now. Seeing Lean working in health settings will have the same effect in the long term.
I’m surprised the authors didn’t:
1) Have specific stories instead of general rants
2) Didn’t couch things in terms of “in our experience…”
3) State that these were opinions. They’re writing as if they have authoritative facts and statements.
I wonder how the MD authors would react if Jenny McCarthy was allowed to publish an anti-vaccination opinion piece in the NEJM?
They’d probably react just the way I’m reacting to their piece.
Karli Coe, PE: Good read… diagnosis after 18 seconds… wow.
Karen Alexandre, Ph.D.: Thanks for sharing. Timing doctors’ bathroom visits in the name of efficiency? Disturbing. It’s disappointing when human factors/outcomes (job satisfaction, in this example) are ignored in the design/implementation.
Jason Lockette, MD, MBA: I’m amazed that physicians vilify standardization and ignore the problems that result when we don’t practice evidence-based medicine. The authors speak highly of protocols related to stroke and MI but those were initially resisted based on the same arguments peppered throughout their article. Some surgeons still resist checklists and time-out procedures in the OR despite the fact that they work.
Cortney Beshara: Michelle and I were just talking about the very thing you mention in your comment. We both have military backgrounds where checklists are an essential part of many job functions and in many cases… Save lives. People forget where they put their keys… Checklists eliminate a majority of human error.
Michelle Kling: Interesting read. From an OR Nurse perspective, I’m tired of convincing surgeons that checklists ensure quality healthcare while producing the best patient outcomes. Seems they rather be convinced that nursing is an actual science and that nurses are not only there to wipe the sweat from thier brow while sitting under those hot OR lights.
Mark
Thanks for the post. Ultimately things like this can not only damage the potential for more great work you and others are doing with engaged or about to be engaged organizations, but it is hard to think that harm will continue to be done by these misunderstandings that they way we have always been doing things (my personal kryptonite) is ok. Or worse that someone was about to take the chance of reaching out for help only to read that lean is of limited use and may harm patient outcomes and minimize the role of Doctors. While I believe in the free exchange and challenge of idea, The thought of continued patient harm and skyrocketing cost is something I refuse to accept as something that is unavoidable. Perhaps I suffer from idealism? In what ways can we apply countermeasures to these types of publications? I’m going to guess that the NEJM doesn’t care about my opinion but perhaps we can arrive at countermeasures as a larger group? Again perhaps I’m just an idealist without a plan?
Mark, I would encourage you to submit a differing viewpoint to the perspectives section of the NEJM. I am sure that there is a physician that would be willing to co-author with you.
The authors appear to have been “burned” at some point by measurements and metrics. Sadly, when data is used to punish instead of to create awareness and understanding the current condition, we tend to eventually get bad data.
All we can really do is endeavor to help each person we interact with understand that the principles and behaviors that you outline in your post about Real Lean are designed to create awareness. They are also designed to help build an understanding about just how great the gap is between where we want to be and where we actually are in delivering great care to the patient/customer. Only then can we pick up a problem and start the process of improving the current condition.
Thanks for sharing this.
I’ve asked some physician leaders who are Lean thinkers to submit comments. The reality is that comments would mean a lot more coming from somebody like Dr. John Toussaint, considering it’s the NEJM.
And I’ve said before that “data is for improvement, not for punishment”
https://www.leanblog.org/2012/07/blame-shame-is-shameful/
Thanks for sharing and reinforcing that view.
Mark,
Thanks for responding to this piece. Rest assured, the Physician execs at Simpler will have a response for the authors.
Your points are all spot on. The question that you ask, though, that is a great point for the authors is this….”What are the doctors proposing as an alternative?” – The fact that they only bash the current system without proposing an alternative is part of the reason the HC system is in the condition that it is today.
[…] I’ll not go through all the details. Mark Graban does that in excellent fashion here. […]
More from LinkedIn:
Collin McLoughlin: Passing judgment on Lean by using Taylorism as a model is like using the medical science of 100 years ago to diagnose a patient.
Meredith Carter GAICD: Yes LAME is not LEAN. Doesn’t make inefficient good for patients either.
John Lee: Those who don’t understand Lean use straw man arguments such as comparing patients to cars and pejorative terms such as “cookbook medicine.” The “rights” of decision and information support are completely congruent with a skilled, independent clinician’s work and mindflow
Another great LinkedIn comment:
Aaron Spearin, MBB, PMP: I still find it amazing this far down the line how poorly guided an execution can be. Personally, I’d like to find the root cause. Bad consultants? Or misguided self-taught neophytes in an already bad culture? Or the office suits distorting a program to fit their own vision of it..? I’ve seen all of these at different times. And to have such a poor perception become editorialized in a medical journal says to me the perception is too common in the medical field, which I find inexcusable . Poor adoption in a for-profit business (widget maker) that only injures itself in a free market is easier to dismiss. To me it speaks for the masses who were never really serious about improving so fundamentally that they are willing to assess and change their own behaviors. Too often “change” is someone else’s responsibility.
Yeah, all of those things happen… especially when hospital leaders already have a cost-cutting orientation, and when they don’t respect employees or have a combative relationship with doctors… or when they’re focused on money instead of truly meeting patient needs.
I also wanted to share an interesting contrast between Lean and traditional management in this NYT article:
When it’s NOT a Lean culture: “At Haier’s factory in South Carolina, Chinese managers had to be sent back to Asia because they were alienating workers and threatening productivity.”
Funny… The way “coöperation” was spelled in The New Yorker article, with the umlaut, is how the word was spelled in the early 1900s, in the days of Frederick Winslow Taylor. Interesting that the editors didn’t remove it. Must have been intentional.
It must be the “New Yorker” style guide, in general, because they spell it that way here too:
http://www.newyorker.com/culture/culture-desk/the-curse-of-the-diaeresis
They’re old school.
It’s a good idea to get physician leaders and some front line clinicians with positive experiences to respond directly in NEJM. It doesn’t seem like enough, though, with all the bad feeling expressed and, as previous comments point out, potential damage done.
Maybe you (Mark), John Toussaint, and/or others could get a spot on “Explore the Space” podcast with Mark Shapiro. He’s exploring issues facing contemporary medicine from a physician’s perspective. It’s open-minded and generally well done. A good listen, BTW, for the lean healthcare crowd, especially given the “doctors resist change” bias that arises from time-to-time. We would do well to keep listening to all parties and remember that “90% of resistance is cautionary” (attributed to Shigeo Shingo).
Andrew… I know Dr. John Toussaint and some others will be responding. It will mean more coming from the MDs.
Thanks for the thought about the podcast.
I’ve never been one to jump on the bandwagon of blaming doctors for being difficult or being “resistant to change.” The resistance is usually pretty proportional to the lack of leadership from hospital executives or physician leaders.
More from LinkedIn:
Christian M. Rizo MBA, PMP: I really sometimes don’t understand why they are being so dismissive right away with LEAN. We are at a tipping point where we need to be thinking of fixing the whole system rather than saying “business as usual”.
France Bergeron: What many people don’t get with Lean is a deep understanding of Lean as collaborative science. An object study that is scientific (flow), a solid scientific method (PDSA) and tools to make work visible therefore measurable, and above all people who collaborate to define problems and counter them, together.
See also this post by Paul Critchley, who has been a guest blogger on this site.
https://www.linkedin.com/pulse/nejm-lean-somethings-missing-paul-critchley
What we should be developing is a solution/service called the ‘patient project’. This puts the patient at the centre of all activities as they journey through the health system. Resources, skills, knowledge, etc are consumed around the patient as this journey takes place. Trying to run a hospital with what is an ‘ERP’ and a transactional focus only suits administrators and is destroying clinical systems/knowledge/capabilities.
With respect to the above I reference two studies. Firstly, the University of Sydney undertook a study of the use of ‘e’ systems across NSW Health and secondly, from the UK there has been a significant review (600 pages plus) of the value of ‘e’ to health professions. The Australian study laid bare the systemic information system issues and the UK study concluded that information technologies have significant potential but no appreciable or observable value has been added to health service operation by the adoption of ‘e’ to date – in the case of the UK report that is an interesting observation given the estimated £20billion worth of ‘investment’ made in ‘e’ health.
Whilst the UK study did not implicitly analyse the underlying information services/system issues the Australian study did. The same conclusion can be draw from both studies in that the use of ‘e’ technologies as they stand have not delivered beneficial outcomes. This observation applies to the health initiatives not only in the UK but also in Australia and other countries as the same paradigm of technological deployment; IT architecture and software vendors are involved.
The patient project can be built and a platform exists to do it.
More from LinkedIn:
Jamie Flinchbaugh: One contributor to this problem is that lean was not born in the academic halls and therefore many academics don’t know how to effectively study it from the outside. Then of course, they try to study it from the outside through publicly available data and interviews. Steve Spear remains one of the few who researched from within. And lean cuts across disciplines, so most academics can only see a piece of it. And so we don’t only blame academics for poor research of lean, lets not forget the too-high percentage of companies implementing lean poorly, which can have you easily draw a conclusion that it doesn’t work .
Steve Spear: Thanks for raising this and raising it loud. It’s a critical issue. The transition from art/craft to science is the coalescence of a community around a phenomenon, a theory, and the fundamental principles that define it.
Steve Spear: For a variety of reasons, our community has resisted this, so tools/techniques aren’t often explained by the principles they support/express, and even the same idea has expression through multiple lexicons. It’s confusing enough even for those in the know, more so for those not.
Steve Spear: What’s the phenomenon: Superior performance–far more yield from far less effort. What’s the theory: superior knowledge and skills as the accumulation of superior learning–local and systemic, large and small. What’s the theory: the rigorous application of feedback to the design and operation of systems, to the problem solving of systems, and to the sharing broadly what is learned locally.
The comments on the NEJM article are interesting.
People confuse Taylorism and Toyota / Lean.
People confuse the problems with excessive measurement with Lean.
People say “patients aren’t widgets” (of course they’re not).
They don’t understand that Lean is built on patient focus, respect for employees, and continuous improvement.
There’s so much confusion out there. People are talking past each other because I’m defending Lean and what they’re complaining about isn’t Lean at all.
It could be ignorance or a lack of education about Lean.
It could be that some people are working in organizations that are practicing L.A.M.E. instead of Lean.
Arguing about all of these seems like fiddling while Rome burns.
My NEJM comment, which had limited space, and is being held for review:
The authors unfortunately confuse Taylorism with Toyotaism, or “Lean.”
They also confound the issue by raising valid concerns about excessive or inappropriate measurement and EHR systems making live more difficult. Neither of those problems are driven by Lean principles or methods. In fact, a Lean thinker would stand arm in arm with the authors to decry waste in all forms, including bad quality measures and lousy computer systems. Lean is about serving the patient, creating a less frustrating workplace, and making things easier while ensuring quality and safety.
I’d also join the authors in decrying Taylorism. But, again, Lean is not the same thing.
Taylorism is a century-old model where engineers and managers designed the work, and workers just shut up and did the work.
The Toyota model builds upon what was taught by W. Edwards Deming, where employees at all levels are respected and are treated as partners in quality improvement and process improvement. Patients are not widgets, facts are facts. Lean is helpful and transferrable as a philosophy, and improvement methodology, and a management system. It’s about people leading people and improving the way work is done.
Re. Failed systems of measurement, Bob Wachter (author of The Digital Doctor, Internal Bleeding, and others) had this piece in the Sunday NYTimes, yesterday:
How Measurement Fails Doctors and Teachers
My reaction to that is that some measures are a waste. Or, what’s easy to measure isn’t necessarily important to measure. I have many teachers amongst family and friends, so I’m sympathetic to heavy handed measure or blaming individuals for system problems.
I would submit that part of the measurement problem is that we don’t have sufficient methods for IMPROVEMENT. This leads to people gaming the numbers when that’s easier than actually improving… and when there’s a climate of fear.
Just doing away with some measures might reduce some frustration, but will that help our health system improve?
More discussion from LinkedIn and my response:
Joy Furnival: we need to reflect hard as a lean practitioner (and academic) community about why there is still so much mis-understanding about lean, and badly practiced lean. What is it that we can do better and what is it that we are doing that is contributing to this that we need to change?
Great question, Joy Furnival. My hypotheses would be:
1) Lack of education / ignorance about Lean… combined with a word that has very negative connotations… people project or guess what Lean would be, and it’s not positive.
2) Distrust of management and leadership and poor relations… therefore something suggested by management (Lean) must be bad
3) Poor implementations of so-called “Lean” (which are really L.A.M.E. or Lean As Misguidedly Executed) where the blind are leading the blind, not really using Lean principles, and upsetting people in the process.
4) Existing mental models of cost cutting, top-down leadership, etc. are incompatible with Lean, so new Lean tools get overlaid on the old mindsets and leadership style.
I agree with you, I think there are also issues with how we are doing ‘lean training’ and the proliferation in certification…I feel it is too easy to get a certificate with little practice and experience… but it is what customers often want….
I also wonder about if as a community we are too isolated from other forms of QI and this contributes to the lack of understanding about shared strengths and what we can learn from each other…the recent podcast from IHI open school (Scoville) about IHI-QI and lean is a great example of what we need to do more of.
FInally, I wonder about the financial context and how this affects lean in healthcare differently, re growth.
Joy, do you have a link to the podcast? I can’t find it on the WIHI website.
I agree that it’s too easy for somebody for feign “expertise” (or even competence) based on an easy online certificate. And, the organizations who hire or employ them to “implement Lean” don’t know any better.
Link to Scoville podcast on lean vs IHI-QI
and also
link to associated white paper published last year on same topic.
Still quite high level, but shows potential of what can be learned in both directions, and helps to challenge the ‘one method is better than the other’ debate that certainly exists in UK healthcare. Think there is a lot to learn via spread approaches and engagement work from IHI,and the use of the collaborative model and similarly about yokoten in lean. There is also much for the IHI approach to learn from lean especially imho re capacity and demand stuff in lean re takt time and cycle times etc. All teach, all learn.
Thanks, Joy.
And agreed that there’s lots to learn, all around, from many different sources.
This video you shared with me on Twitter states that the IHI approach has been pretty project based, whereas Lean has more of an ongoing management system to contribute.
We can blend both approaches, of course.
The “framework for spread” from @TheIHI is similar to my work in teaching change management models.
I do recommend checking out the comments on the piece, including some from some MDs and other Lean thinkers who really criticize what was written and/or they defend Lean, such as:
Hear my podcast with Dr. DeChant: https://www.leanblog.org/230
I saw this article about a Children’s Hospital in Troy MI that was designed using “Lean design” practices.
The CEO (not a physician, it seems) was talking about Lean and said:
Exactly the same… to what extent is that statement going to be true? To what level of detail?
Are the surgeons on board with this? Are they driving this discussion? The hospital says they involved surgeons and staff in the Lean design process, which is the right thing to do (and one thing that makes it “Lean design”).
Or, are they being alienated by leaders who are forcing this idea on them? Or, is the CEO out of touch and just thinking the work will be done “exactly the same way” but the surgeons are rolling their eyes and doing it their own way??
I’m sure if there’s an emergency situation, the procedure won’t be done “exactly the same way.”
I don’t think that “eliminating variation,” as that article talks about is the goal, nor is it practical.
We can “reduce variation” (for the benefit of everyone involved) — by engaging surgeons and the people who do the work. I hope that’s what’s happening.
Dr. Greg Jacobson, a practicing ER doc and Kaizen practitioner and advocate addresses the NEJM article in the first few minutes of this video:
Very interesting discussion. I agree with you that a misuse of Lean is LAME. In Canada, where health care dollars are limited and hospitals are not allowed to run deficits, lean may be implemented in a LAME way. I think in Canada “fear” may also be playing a large role in how “leadership” implements their version of “Lean”. In Canada, cuts to front line clinicians has occurred, levels of care have been changed, urgent care centres have been created etc. There may be little left to cut as far a clinical services go so administration may be feeling like they are a primary target. Trying to meet the metrics (# of patients seen, length of stay, cost per patient) may become more about job preservation than patient care. Just my opinion.
Correction: In Ontario, hospitals are not allowed to carry a deficit. Fear may also be playing a role in clinician/administrative relationships. Everyone is worried about job loss. I
Two quick comments.
1 – For every truth (or principle) there are 1,000 perversions of it. Lean is no different.
2 – How many doctors does it take to change a light bulb? None, if it doesn’t want to change. Now apply the metaphor to Lean.
There will always be early adopters who hopefully get it right.
Skeptics who may or may not adopt.
And, finally, scoffers who will work against any change.
Here’s a blog post by Dr. Paul DeChant on this topic:
TAYLORISM VS. TOYOTA – MANAGERS WITH STOPWATCHES VS. RESPECT FOR PEOPLE
Check it out…
Here are some reflections from Pascal Dennis on his blog.
[…] the lean community, there was a bit of a to do! (see Mark Graban’s fab thread and comments here). Not only was it perceived that the author was incorrect to say this, but also that he compared […]
John Shook, a former Toyota employee, and CEO of the Lean Enterprise Institute has finally posted a response:
“Malpractice in the New England Journal of Medicine”
Bob Emiliani has raised valid points about asking why the physicians would write this piece from this perspective.
Dr. Groopman has not responded to any tweets. I could email him and ask him to discuss this, privately, or I’d be happy to have a civil podcast discussion with him.
If we ask “why?” in this forum, it would only be guessing, but some possibilities include:
1) They have been directly tormented by what I’ll call Neo-Taylorism that’s being done under the guise of Toyota or Lean… and they are rightfully upset about that
2) It’s also possible that they haven’t been involved in Lean at BIDMC… that could be their fault (they’ve chosen not to participate in training or improvement events) or it could be a management problem in that somebody hasn’t tried to engage them
3) It’s also possible they are just reacting to what they think “Lean” is based on conversations with colleagues within BIDMC or elsewhere. I believe them when they say colleagues have had negative things to say about their experiences
4) It’s maybe also possible that they are reacting to traditional top-down command-and-control mandates, poor technology, and cost cutting… and conflating that with “Lean”
I can’t fault somebody for writing about their own personal experiences and reactions. But, I really would like to know if the esteemed doctors were writing from experience or just speculation.
[…] serves as a bit of a counter, saying “Lean does work,” to the recent NEJM article where two doctors claimed that Lean is inappropriate for […]
[…] I blogged about, the NEJM recently published an editorial where the authors confused Lean with top-down […]
Here is a response that was published on the “Health Affairs” blog:
The Toyota Production System: What Does It Mean, And What Does It Mean For Health Care?
John Toussaint, Patrick H. Conway, and Stephen Shortell
[…] might remember the hubbub (and my blog post) about this article that somehow appeared in the NEJM: “Medical […]
The NEJM published two letters to the editors and the MDs’ response:
https://www.leanblog.org/2016/05/nejm-authors-double-down-on-tps-taylorism/
[…] of Medicine… except what they described didn’t really sound like Lean (as I wrote about here and here – and also see Dr. John Toussaint’s […]
Also see this:
“Medical Taylorism:” An Article that Does a Huge Disservice to Needed Healthcare Transformation
By Dr. Patricia Gabow and Ken Snyder
Dr. Gabow was CEO of Denver Health…
Deming advocates at process stability and understanding variation. So, no matter what industry one is in, they cannot really discover or improve effectively with an unstable process. It is similar to scientific experiments and controls.
Great article here by a former Boston hospital CEO and good friend of this blog, Paul Levy:
LINK
It essentially serves as a great rebuttal to those who say Lean doesn’t apply in healthcare or that Lean is somehow about telling others how to do their work.
In part:
Great overview of Lean by Paul in that piece.
[…] there exists deeply-rooted negative associations of Lean to things like layoffs, (Fake) Taylorism, and bureaucratic (check-the-box) Lean. We should expect Lean to have limited appeal going forward, […]
[…] over the NEJM opinion piece written by Dr. Jerome Groopman and Dr. Pamela Hartzband. See my first post about their article. There are more links at the bottom of this […]
Dr. Groopman is being ridiculous. The article is an embarrassment.
A parallel to his thinking about Lean would be an article in NEJM about aviation.
1) Friends told me about a bad flight they were on, where there was a lot of turbulence and a crash landing
2) Therefore, aviation is dangerous
3) Aviation is not appropriate for human travel
4) Believe me because I’m a doctor