The article, “Medical Taylorism,”[1] by Pamela Hartzband, M.D. and Jerome Groopman, M.D., in the New England Journal of Medicine, reflects a major misunderstanding of the principles and practice of the Toyota Production System, or Lean as it is often called. Specifically, the article appears to conflate poor implementation with the underlying principles. Several commentators, including many from the Lean community, have weighed in on this debate, but more needs to be said given healthcare’s need for transformation and the powerful solution that Lean offers in this transformation.
Principles
Doctors Hartzband and Groopman are feeling pain due to their experiences. We sympathize with their pain. Too often, whether in healthcare or other settings, we see poor implementations of Lean. These poor implementations are almost always due to failure to follow the principles of operational excellence.
In this discussion about Lean in healthcare, there are some specific principles that deserve emphasis. In citing these principles, we will adopt the terminology used in the Shingo Model.™[2]
It is unfortunate that many who implement Lean seem to forget these core principles. It is hard to imagine any set of principles which would more closely align with the needs of healthcare and commitment to the population’s well-being than these principles.
Seek Perfection
American healthcare is in dire need for transformation. American healthcare has significant issues with cost, waste, access/coverage, quality, disparity, geographic variation, and employee burnout. These issues affect everyone—every American business and their employees. All of us. These problems cannot be ignored. These problems cannot be fixed by merely wishing for improvement. Nor will these problems be solved solely by government actions. Individual healthcare systems must transform the way they deliver care. This requires a robust and disciplined approach that uses the talents of the entire workforce—exactly what Lean does.
“Perfection is an aspiration not likely to be achieved but the pursuit of which creates a mindset and culture of continuous improvement. The realization of what is possible is only limited by the paradigms through which we see and understand the world.”[3]
Womack, Jones, and Roos first adopted the term Lean to describe manufacturing systems that are based on the principles employed in the Toyota Production System. Quoting them, “Lean … is ‘lean’ because it uses less of everything compared with mass production – half the human effort in the factory, half the manufacturing space, half the investment in tools, half the engineering hours to develop a new product in half the time. Also, it requires keeping far less than half the inventory on site, results in many fewer defects, and produces a greater and ever growing variety of products.”[4] We use Lean in the meaning that was intended when it was first coined. Unfortunately, “lean”[5] has subsequently been misused, abused, and confused, as appears to be the case in Doctors Hartzband’s and Groopman’s experience.
Toyota captures the essence of this principle in their slogan used for their Lexus automobile line – “The Relentless Pursuit of Perfection” – a pursuit worthy of healthcare. Through its Lean transformation, Denver Health made substantial progress in addressing the problem afflicting American healthcare. In the most important metric of all, lives saved, Denver Health estimates that 247 people walked out of the hospital in 2011 that otherwise may not have survived in other healthcare institutions. This was a reflection of the fact that in 2011 Denver Health achieved the lowest observed-to-expected mortality rate of all the hospitals in the University Healthsystem Consortium.[6] The pursuit of perfection saves lives.
Respect Every Individual
Respect for everyone is foundational for Lean. For those in healthcare this respect encompasses the patients, their families, the employees at every level of the healthcare organization, the suppliers, the communities, and the nation. As Toyota states, “We build people, before we build cars.”[7] Hardly the motto of a stopwatch approach as Hartzband and Groopman see it.
Many people, even those with only a little exposure to Lean, know that Lean in healthcare is about removing waste from the patient’s perspective. Waste creates useless work, waste impairs quality, waste adds chaos to the work environment, and waste adds costs. Healthcare is filled with wastes from waiting, wastes due to defects in the healthcare process, and wastes related to unused/misused human talent. Waste in providing healthcare is not beneficial. In the correct application of an improvement process, every employee from the physician to the housekeeper becomes a problem solver that removes waste.
What is often not known is that Toyota’s philosophy of removing waste is tightly tied to respect for people. “Respect must become something that is deeply felt for and by every person in an organization. When people feel respected, they give far more than their hands—they give their minds and hearts as well.”[8] The people become the problem solvers.
When Denver Health launched its Lean journey, this relationship of waste and disrespect was clearly and often articulated. We quoted two sayings of Toyota leadership on waste, and added two sayings of our own:
Toyota Leadership:
Denver Health:
This key concept of respect for people is also manifested in the Lean tool set which is robust but simple to understand and use. An example would be a spaghetti diagram. One does not need a college degree to understand a spaghetti diagram! Tools such as these enable every employee, from housekeeper to physician, to be a problem solver. The tools democratize problem solving. What is more respectful than democratizing work?
We agree with Doctors Hartzband and Groopman when they write, “When it comes to medicine, … ‘man’ must be first, not the system.” However, if the system is wasteful, every person suffers the consequences and no person is respected. It is unfortunate that their “lean” experience appears to have ignored this foundational principle of respect for every individual.
Control Quality at the Source
Every physician, healthcare worker, or patient wants quality healthcare. Unfortunately, our current healthcare system cannot guarantee quality. A recent article dramatically illustrates this by determining there are approximately 251,000 deaths in American hospitals every year due to medical errors making it the third leading cause of death.[10] Thus, an approach that fosters quality at the source is critically important.
“Perfect quality can only be achieved when every element of work is done right the first time. If an error should occur, it must be detected and corrected at the point and time of its creation.”[11]
The improvement approach taught by Dr. Shigeo Shingo to control quality at the source is often referred to as pokayoke[12] or error-proofing. Truly controlling quality at the source in healthcare would involve a focus on preventive care and population health. It certainly would involve more of a discussion about public health policies. We need to focus both on how to prevent health issues from occurring and how to treat health issues after they have occurred.
Application of this principle in the process of caring for someone who is ill is exemplified in the Lean concept of “stopping the line.” Healthcare uses this in many places including “time outs” for a procedure in which if some part of the process is not right—wrong patient, wrong procedure, or wrong equipment – the process is stopped. It is also part of a computerized order entry in which a drug and its dosage are checked by an algorithm and by a pharmacist stopping the wrong medication or drug dosage from reaching a patient.
The experience at Denver Health is instructive in a common corollary to this principle – that is, that quality saves money. This corollary emphasizes that when quality in healthcare is controlled earlier in the process, not only does healthcare improve, but also tremendous cost savings are realized.
During the Denver Health Lean journey, the system achieved remarkable quality outcomes in preventive care and management of chronic and acute disease.[13] Approximately 80% of all children were fully immunized, over 70% of patients with high blood pressure had their blood pressure controlled, and hospital-observed expected mortality was less than one every year.[14] These are amazing accomplishments for any healthcare system, but even more impressive for one that cares for a highly vulnerable population.
During this same period the system achieved approximately $195 million of hard financial benefit through reduced costs, increased productivity, and improved revenue cycle processes.[15]
Embrace Scientific Thinking
“Innovation and improvement are the consequence of repeated cycles of experimentation, direct observation and learning. A relentless and systematic exploration of new ideas, including failures, enables us to constantly refine our understanding of reality.”[16]
Doctors Hartzband and Groopman write, “We believe that the standardization integral to Taylorism and the Toyota manufacturing process cannot be applied to many vital aspects of medicine.” Once again, this statement comes from a misunderstanding of the principles of improvement. If processes are random, it is not possible to assess what is working and what is not working. The Toyota Way states, “Standardized tasks and processes are the foundation for kaizen.” In a correct improvement process, which embraces the scientific method, standards are the control. Without standards, then what can physicians test to make healthcare better?
We praise Doctors Hartzband and Groopman for recognizing some of the contributions of standards. As they state, “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.”
Many people, particularly those who are not directly involved in healthcare, may think that standardization is present throughout all of healthcare delivery. This is far from the case. There is variation within an organization, within a discipline, and across geographies. In the more than 400 rapid improvement events at Denver Health, the most common insight of the teams at the end of these week-long events was, “We have no standard work.” As physicians, we must not confuse standardizing a process to create a baseline from which to judge outcome, with the inability to respond to patient differences or patients’ choices.
Standards empower the scientific method. Lean exemplifies the scientific method which demands that experiments be based on a hypothesis that compares an idea against a control. The Lean tools also embrace the experimentation part of the scientific method. Anyone who has participated in a rapid improvement event has seen how critical it is to have rapid experiments to test the solutions which move the process from the current state to the target state. Also Lean communication follows a scientific model. Any healthcare professional who has submitted an abstract to a scientific meeting or a scientific journal realizes the abstract mimics perfectly the Lean tool of A3 in which it articulates the reason for action, the current state, the target state, the gaps between the two, the solution approach, and the rapid experiments.[17]
One particularly impressive and life-saving example of the power of standard work in healthcare was a Denver Heath rapid improvement event that focused on deep venous thrombosis (blood clots in the legs) which is a potentially life threatening post-operative complication.[18] This complication can be substantially prevented by appropriate anticoagulation. At Denver Health, the occurrence rate significantly exceeded the national benchmark. There was no standard approach to post-operative anticoagulation – surgeons, orthopedists, obstetricians – all had different approaches. Many committees failed to solve the problem. A four-day rapid improvement event involved five physicians, a nurse, and a pharmacist using Lean tools to tackle this problem. One standard approach emerged and was implemented. This reduced the rate of post-operative deep venous thrombosis to at or below the benchmark. In addition, the standardization prevented misuse of expensive drugs, saving $15,000 per month.
These examples demonstrate that a correct implementation of an improvement process embraces the scientific method, and leads to improvements in the care provided.
Create Constancy of Purpose
“An unwavering clarity of why the organization exists, where it is going, and how it will get there enables people to align their actions, as well as to innovate, adapt, and take risks with greater confidence.”[19]
Too often, “lean” methods are applied for the sole purpose of reducing costs. It is, after all, a process that results in the elimination of waste so, of course, costs are reduced. However, we suggest that the reduction of costs cannot be the driving purpose in healthcare. The true north for any healthcare organization must be a noble and inspiring purpose, important, and a stretch.
Unfortunately, Doctors Hartzband and Groopman paint a picture where healthcare is sacrificed for the sake of efficiency. The need felt by Doctors Hartzband and Groopman to write such an article suggest either no true north was articulated or communicated throughout the organization; or it was not noble, important, and a stretch. An appropriate, well-communicated true north will be embraced by the healthcare workforce, including physicians, and will create a constancy of purpose and bring continuous improvement to the goal.
At Denver Health, the true north cause, which inspired everyone in the Lean transformation, was to “create a mature culture committed to reducing waste to perfect the patient’s experience and become a model for the nation.”
Conclusion
We encourage readers to look at the impressive results that a correctly understood and implemented Lean journey can have on patient care quality, costs, and employee engagement. There are well-documented examples at Thedacare,[20] Virginia Mason,[21] and Denver Health[22] to name a few.
We believe that understanding the Lean principles coupled with an implementation which utilizes Lean tools offers healthcare an opportunity to improve quality, lower costs, empower all the workforce, and ultimately enable better health for all Americans.
About the Authors
Dr. Patricia Gabow, MD, MACP, is an academic nephrologist, physician administrator, contributor to national health policy, and senior adviser to Simpler Consulting. During her tenure as CEO of Denver Health, a large integrated public healthcare system, Denver Health started its Lean transformation in 2007, and received the Shingo Bronze Medallion in 2012.
Ken Snyder is the Executive Director of the Shingo Institute, Home of the Shingo Prize, and the Executive Dean of the Jon M. Huntsman School of Business at Utah State University. Based on the work of Dr. Shigeo Shingo, one of the key developers of the Toyota Production System, the Shingo Prize is an internationally recognized standard of operational excellence.
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[1] Pamela Hartzband, Jerome Groopman, “Medical Taylorism,” The New England Journal of Medicine 374 (January 14, 2016): 106-108.
[2] Shingo Institute, Shingo Model™, http://www.shingoprize.org/model.html (May 27, 2016). Note: Similar articulations of these principles are available from other sources, such as Jeffrey K. Liker’s, The Toyota Way: 14 Management Principles From the World’s Greatest Manufacturer.
[4] James P. Womack, Daniel T. Jones, Daniel Roos, The Machine That Changed the World: The Story of Lean Production: Toyota’s Secret Weapon in the Global Car Wars That Is Now Revolutionizing World Industry (New York, NY: Simon & Schuster, Inc., 1990), 14. Note: To our knowledge, Toyota has never used the term Lean but always uses the term kaizen, which means “improve,” and implies that the sought improvement is constant or continuous.
[5] For the purpose of this article, all references to Lean use the same meaning as intended by Womack, Jones and Roos in The Machine That Changed the World. All references to “lean” (with quotation marks) are based on the experience of Hartzband and Groopman where we contend the term was misused, abused, or confused.
[6] Patricia A. Gabow, Philip L. Goodman, The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System (Boca Raton, Florida: CRC Press, 2014), 137.
[7] George Koenigsaecker, Leading the Lean Enterprise Transformation (Boca Raton, FL: CRC Press, 2009), 101.
[9] Gabow and Goodman, 19.
[10] Martin Makary and Michael Daniel, “Medical error—the third leading cause of death in the U.S.,” BMJ (May 03, 2016): 353 i2139.
[12] ポカヨケin Japanese. This term was introduced in Shingo’s book, A Study of the Toyota Production System: From an Industrial Engineering Viewpoint first published in the 1950s, and was developed further in his book Zero Quality Control: Source Inspection and the Poka-Yoke System.
[13] Gabow and Goodman, 138-140, Ch. 9.
[14] Gabow and Goodman, 138-140.
[15] Gabow and Goodman, xix.
[17] Gabow and Goodman, 88.
[18] Ida Martinelli, Paolo Bucciarelli, Pier Mannuccio Mannucci, “Thrombotic risk factors: Basic pathophysiology,” Critical Care Medicine 38 (February 2010): S3–S9.
[20] John Toussaint, Roger A. Gerard, with Emily Adams, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (Cambridge, MA: Lean Enterprise Institute, 2010).
[21] Charles Kenney, Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience (New York: CRC Press, 2011).
[22] Gabow and Goodman, 95.
