Two correspondents with noteworthy conflicts of interest have objected to Drs Hartzband and Groopman’s earlier opinion criticising Taylorism in medicine. Many medical leaders remain slow to catch on about “the toxic effects of obsessive standardisation”. However, Hartzband and Groopman correctly perceive the inappropriateness of using standards for the manufacture of inanimate objects in a factory to managing the behaviour of human workers.
This correspondence illustrates how dependent vested interests arise in those who derive income and career advancement from inspectionism even if they are not part of the more formal cartel organisations listed in the sidebar.
And remember: this is about milder inspectionism than ISO accreditation!
There is no accountability for leaders who continue to make gullible decisions to sell their staff and patients to the inspection cartel members.
Read the full text and comments here in the NEJM.
To the Editor:
In over 15 years of our Lean journey at Seattle Children’s Hospital,1 we have repeatedly heard the perspective on the Toyota Production System (TPS) offered by Hartzband and Groopman in their Perspective article in the January 14 issue.2 “Work harder and faster” is the usual response by the uninvolved, uninitiated observers.
A core principle of the TPS is to show respect to your people by engaging them in improvements using the scientific method with ideas generated by them, often validated with time measures. Through provider and staff feedback, we seek to reduce variation and wait times for both patients and staff. Thus, we create a system in which we “work smarter” by removing waste and complexity. This engaged, bottom-up approach of standardizing processes allows each provider to deliver his or her best possible care for every patient. Ultimately, the provider is working in such a way that the only variable in the system should be the patient’s condition.
Joe Rutledge, M.D.
Lynn Martin, M.D., M.B.A.
Seattle Children’s Hospital, Seattle, WA
Drs. Rutledge and Martin report receiving fees and expenses from various institutions for teaching the concepts of the TPS in health care. No other potential conflict of interest relevant to this letter was reported.
To the Editor:
Hartzband and Groopman distort Lean management and incorrectly conflate Taylorism with the TPS. This is disappointing and unfortunate. True Lean enterprises are centered on the core principles of respect — which includes not asking people to perform valueless work — and continuous improvement, and they foster an environment in which creativity flourishes while maximum value is delivered to patients.
Quite the opposite, Taylor focused on making the fastest worker the standard. Lean seeks what is reasonable and adds value to a process. Improvements are made by people who do the work, not by “efficiency experts.” Lean standard work does not replace the art of medicine. It serves to reduce unnecessary variation in repetitive processes — not to standardize necessary variation in individualized patient care. Using the scientific method, Lean results in predictability and a path to meet patient needs without overburdening clinicians and staff.
When deeply understood and authentically adopted, Lean improves quality and safety for patients and staff and balances work at a sustainable pace.1-5 We see the extraordinary results of its application every day.
Samuel Carlson, M.D.
Thomas L. Jackson, M.B.A., Ph.D.
Joanna Omi, M.P.H.
Rona Consulting Group, Mercer Island, WA
Drs. Carlson and Jackson and Ms. Omi report being principals in Rona Consulting Group, a Lean health care consultancy. No other potential conflict of interest relevant to this letter was reported.
The authors reply: The TPS is a set of principles designed for the manufacture of inanimate objects in a factory. We accurately depict two essential elements of this system that are directly derived from Taylorism: standardization and time efficiency. In his classic study of the application of Toyota principles to the manufacture of cars in the United States, Paul Adler describes how “Each job was analyzed down to its constituent gestures, and the sequence of movements was refined and optimized for maximum performance. Every task was planned in great detail, and each worker was expected to perform that task in the prescribed manner.”1 Adler refers to “the intelligent interpretation and application of Taylor’s time and motion studies” as key to its success. He states, “The reference to Taylor may be jarring, but it fits.”2
In the above letters, despite claims of science, we are struck by highly subjective terms used by Lean consultants including “unnecessary variation,”“best possible care,”and eliminating “complexity.” In much of patient care, there is no standard regarding what is “best.”As opposed to a factory assembly line, medicine necessarily involves considerable complexity and uncertainty. The patient’s “condition” will never be the only variable in the system, nor should it be, because both patients and medical professionals are people — individuals with diverse goals, preferences, and personal styles that matter.
Other medical professionals who, like us, have experienced the toxic effects of obsessive standardization and time efficiency in the care of patients have expressed concerns similar to ours.3-5 In an era of accountability, we believe that those who advocate the application of Lean principles to medical care must take responsibility for the unintended consequences resulting from these elements shared by Taylorism and Toyota practices.
Pamela Hartzband, M.D.
Jerome Groopman, M.D.
Harvard Medical School, Boston, MA
Since publication of their article, the authors report no further potential conflict of interest.
For a broader perspective on what people think Taylorism and Lean are try Mark Graban’s Leanblog here: