You probably saw my blog post and the debate on the recent NEJM article on “Medical Taylorism” that falsely equated “Taylorism” (pressuring people to speed up and telling them how to do their job) with “Toyota Lean” (a very progressive, modern, and engaging management system).
Many of the complaints being directed at Lean or Toyota should really be directed at Taylorism.
Other possible headlines for this post today could have been:
“The Confusion Between Taylor and Toyota”
“Your Hospital's Management System is More Likely like the GM of 1990 than the Toyota of Today.”
I believe it's freely available (or at least it was to me after Googling the title).
The article describes the NUMMI plant, a joint venture between GM and Toyota, that was open from 1984 to 2010 in California. Read my posts about visiting the plant and check out the “This American Life” episode on the plant and why the lessons learned there weren't spread more widely throughout GM.
The discussion at the time reminds me of some of the discussion and debate about Lean in healthcare… a debate that's often fueled by one side not really understanding what Lean or the Toyota Production System are about.
The HBR piece starts with the types of misconceptions we hear from some in healthcare today:
“Standardization is the death of creativity.
Time-and-motion regimentation prevents continuous improvement.
Hierarchy suffocates learning.”
The next paragraph could easily be re-written to be about healthcare today, instead of manufacturing 25 years ago.
“U.S. manufacturing is in the throes of revolution, and assumptions like these are becoming the new conventional wisdom about work. This new gospel sets up Frederick Winslow Taylor and his time-and-motion studies as the villain. It asserts that quality, productivity, and learning depend on management's ability to free workers from the coercive constraints of bureaucracy. It insists that detailed standards, implemented with great discipline in a hierarchical organization, will inevitably alienate employees, poison labor relations, stifle initiative and innovation, and hobble an organization's capacity to change and to learn.”
“But what if, as I believe, this new creed is wrong? What if bureaucracy can actually be designed to encourage innovation and commitment? What if standardization, properly understood and practiced, should prove itself a wellspring of continuous learning and motivation?”
But, the NUMMI plant proved those counterintuitive things. And some healthcare organizations are proving out, today, the standardized work doesn't have to be coercive, inflexible, or permanent. Lean hospitals and clinics (or those that “practice Lean”) create a culture of continuous improvement that doesn't alienate people, as we see in complaints or statements like these on Twitter:
— Justin Marley 😷 (@TAWOP) January 17, 2016
I'm not sure why improving the relationship with the patient wouldn't be the focus of Lean and Kaizen activities. The Kaizen work at Franciscan St. Francis improves patient care and patient relations (see these videos). Any organization that thinks there is a tradeoff between Lean and customer/patient focus doesn't get it.
@MarkGraban I have the same experience – people using only the “remove waste” part of lean as an excuse to cut costs and ppl
— Gitte Klitgaard – no to war, yes to love (@NativeWired) January 18, 2016
One doctor said, in a comment on Paul Levy's post:
“And for that matter, many a consultant has misrepresented Lean into meaning that doctors should simply see more patients in less time because thats how it is at the hospital down the road!”
Many a consultant and many a hospital executive, unfortunately. But it's not really Lean. Instead of relying blindly on benchmarks to set staffing levels (which can create a “race to the bottom”), Lean organizations look at their own workloads (and types of patients) and their own systems to determine what pace of work is possible and what staffing levels are required.
@MarkGraban Not enough time for a proper evaluation of the patient. Welcome to the new healthcare world.
— Vassyl Lonchyna (@lonchyna) January 19, 2016
@MarkGraban Docs now run by management types who treat people like widgets, and docs have to produce, just like on Toyota floor
— Vassyl Lonchyna (@lonchyna) January 19, 2016
What Dr. Lochyna is describing is “bad management,” not Lean. He's basically complaining about “mass production” or Sloan-style management practices.
— Mark Graban (@MarkGraban) January 20, 2016
Toyota doesn't treat people like widgets who “have to produce.” That was the old, bad pre-Lean culture at GM, where management didn't respect employees and put quantity before quality. At GM, the primary goal was to “hit the numbers.” At GM, the mindset was “don't stop the line.”
Toyota puts quality first and emphasizes stopping the line to ensure quality rather than mindlessly plowing ahead to hit your productivity goal no matter what.
From the article, again:
“In Fremont, California, a GM-Toyota joint venture called New United Motor Manufacturing Inc., NUMMI, for short, has succeeded in employing an innovative form of Taylor's time-and-motion regimentation on the factory floor not only to create world-class productivity and quality but also to increase worker motivation and satisfaction. What's more, NUMMI's intensely Taylorist procedures appear to encourage rather than discourage organizational learning and, therefore, continuous improvement.”
Even though this article says that Toyota's Lean system is, basically, a form of Taylorism, it's a pretty broad leap forward from classic Taylorism (or the Neo-Taylorism practiced today in far too many hospitals).
See my post from a few years ago: “Time & Motion Studies Are Not “Discredited,” Just How They Are Used.”
There's a certain philosophy and mindset in the Toyota Production System that should be present in a real Lean effort. Without the right mindsets, it's L.A.M.E. not Lean.
Taylorism, basically, thought workers were stupid and should just be quiet and do their jobs, as designed by management. Taylorism thought you could break down work into small chunks, so that labor basically became interchangeable.
The Toyota approach realizes that employees have brains and creativity and that they can be partners in improving quality and safety.
“Standardized work also has the overall benefit of giving control of each job to the people who know it best. It empowers the work force. Not surprisingly, NUMMI discovered that workers bought into the process quite readily. As one manager put it, “They understood the technique because it had been done to them for years, and they liked the idea because now they had a chance to do it for themselves.”
Here's another HBR article on this topic: “Don't Set Process Without Input from Frontline Workers.”
Instead of viewing workers as a cost, Toyota views them as an asset to invest in (and they don't lay them off, even in tough times).
“[Toyota] Management sees the no-layoff policy as a critical support for its overall production strategy not only because it reinforces the team culture, but also because it eliminates workers' fear that they are jeopardizing jobs every time they come up with an idea to improve efficiency.”
The HBR article, which I hadn't seen before this writing, makes the same case I make in my blog post:
“Formal work standards developed by industrial engineers and imposed on workers are alienating. But procedures that are designed by the workers themselves in a continuous, successful effort to improve productivity, quality, skills, and understanding can humanize even the most disciplined forms of bureaucracy. Moreover, NUMMI shows that hierarchy can provide support and expertise instead of a mere command structure.”
Many of the complaints about what's being described as “Lean” are really complaints about top-down command-and-control decision making and doctors (or others) being told how to do their work. A truly Lean culture engages doctors so the doctors can figure out how to improve doctor work after being taught Lean concepts and being helped to understand waste and opportunities for improvement. Lean hospitals that I've seen generally focus on using Lean to provide better service to physicians and staff (such as making sure surgeries start on time more often) before trying to engage doctors in improving doctor work… or engaging nurses in improving nurse work.
Again, I'll try to emphasize: It's not Lean to just bully people into hitting higher productivity numbers and it's not Lean to tell them how to do their work.
As opposed to the old “coercive bureaucracy” (which I knew well from my days at GM), NUMMI was:
“In practice, NUMMI's “learning bureaucracy” achieves three ends. First, it serves management by improving overall quality and productivity. Second, it serves workers by involving them in the design and control of their own work, increasing their motivation and job satisfaction, and altering the balance of power between labor and management. Third, it serves the interests of the entire organization–management and the work force–by creating a formal system to encourage learning, to capture and communicate innovation, and to institutionalize continuous improvement.”
It's not Lean if people are being told what to do, rather than being engaged in ongoing continuous improvement that serves everybody well, including the patients.
A NUMMI employee at the time said:
“But it's not like we're just getting squeezed to work harder, because it's the workers who are making the whole thing work–we're the ones that make the standardized work and the kaizen suggestions. We run the plant–and if it's not running right, we stop it.”
If doctors are being squeezed… if they're not involved in improving the work and the systems they are a part of… it's not Lean.
The NUMMI person continues:
“Being consistently busy without being hassled and without being overworked takes a lot of the pain out of the job. You work harder at NUMMI, but I swear it, you go home at the end of the day feeling less tired–and feeling a hell of a lot better about yourself!”
I've seen that in many healthcare settings. People aren't just squeezed to work faster and harder. They have figured out better ways to do the work… ways that are less frustrating for doctors and staff… and better for the patients…
“Doing more with less” is a phrase that draws snarls because, in a Neo-Taylorist mindset, an organization might lay off employees (creating “less”) while then just pressuring the rest to do “more.”
Through the Lean process, I've seen, for example, a hospital lab pretty quickly be able to do 20% more lab testing volume with the same staff. They're “doing more with the same” and, because they've eliminated waste and frustrations, people are happier. They're doing more “value added work” that serves patients. They don't feel like they're working harder. They wouldn't go back to the old way of doing things. That lab might have a few employees quit because they're moving… and maybe they don't get replaced.
That lab is now “doing more with less” but they came about it in a far better way.
Anyway… there's lot of great stuff in the article and I've quoted from it and commented enough. The article is a fantastic summary of Lean management and Lean thinking… as can even be applied to healthcare.
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