By MARK GRABAN

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, how those concepts would be helpful in healthcare. Dr. Berwick realizes, as he talks about in that article, 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 this week, 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.”

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.

As I’ve written about before, some hospitals or engineers working within them have taking 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 my 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 appropriate 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 cdreating 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
• 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“).

The doctors also say:

“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.”

Mark Graban is a consultant, author, and speaker in the “Lean healthcare” methodology. He blogs at Mark Graban’s Lean Blog where this post first appeared. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.