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Malpractice in the New England Journal of Medicine

by John Y. Shook
February 23, 2016

Malpractice in the New England Journal of Medicine

by John Y. Shook
February 23, 2016 | Comments (76)

Two eminent physicians wrote an article, superficial and full of misconceptions, trashing lean and Toyota in the most recent issue of the most influential journal in medicine: the New England Journal of Medicine (NEJM).  I sent the following rebuttal to the NEJM; I don’t expect it to see the light of day, but here it is for your reference.

To: NEJM – Rebuttal to “Medical Taylorism” by Pamela Hartzband and Jerome Groopman

Doctors Pamela Hartzband and Jerome Groopman are renowned experts in their respective fields. I hope they practice better science on their patients than they did with their irresponsible article appearing in the January 20th edition of the NEJM.  Had the authors not been so influential and the article not published to the pages of this esteemed journal, their words wouldn’t even deserve a response.

First, to quickly debunk their argument. The authors first equate Toyota methods with efficiency and then efficiency with Taylorism. Having made one false premise on top of another, the authors attack the specter of Taylorism being applied to medicine, efficiency applied to patient care.

Lean thinkers and other management scientists going back to Peter Drucker have long considered the relationship between effectiveness and efficiency. To the extent that they are distinct characteristics, healthcare, like any complex social-technical system, benefits from achieving effectiveness first, efficiency later. The Toyota methods known as lean (think of “Lean” as the generic brand, to Toyota’s proprietary brand of thinking and practice to improve organizations and work) to which the authors refer, start with building effectiveness (recall techniques from the quality movement), and, having stabilized the system, then pursue efficiency.  In the real world, of course, steps and sequence are highly iterative, depending on the problem to be solved.  And, in the end, efficiency without effectiveness is a nonsensical concept.

Toyota identifies two main “pillars” that define its thinking and methods: continuous improvement and respect for people. This focus on continually improving the way work is done to create value by focusing on the needs and work of the people who do the work leads to starting all improvement by clearly identifying the problem to be solved.  Then, move quickly from there to the needs of the people in the system, to the work and the human doing it.  And you first make it possible for the human doing the work to do it with effectiveness (properly, with required quality), and then with efficiency. That’s the evil Toyota/lean method in a nutshell. Not so evil. Certainly not, as the authors fear, single-mindedly chasing Taylorist efficiency. 

(Having said that, there is an elephant in the waiting room that no one in the healthcare improvement community – where informed, thoughtful criticism is welcome – likes to discuss: the matter of cost. The US healthcare system costs twice that of almost any other system, yet does not produce better results.) 

As Toyota – and others – have proven, a more effective system is a more stable system and a more stable system can indeed achieve outcomes with lower costs, made possible merely through that stability. But with stable effectiveness also come opportunities for efficiency which results in better care, lower costs, healthier patients and less-stressed providers.

So authors Hartzband and Groopman need not fear; Toyota-inspired lean experts will only pull out their stopwatches in order to diagnose the patient (the healthcare system), just as you pull out your stethoscope –to not inflict damage. Do no harm. Understand the patient. Conduct causal analysis, recommend a treatment plan to be run as an experiment, carefully observing the organization-as-patient to evaluate remedies for effectiveness.  Every organization is evaluated individually, just as is every patient.

Physicians (I am not one) are notoriously defensive of any suggestion that their craft might benefit from the rigors of standards, expectations, transparency, or anything that might interfere with the physician’s discretion. Give me, as a patient, perfect care at a cost I can afford, and perhaps I will grant you the endless discretion you crave. Until then, let’s agree to let objective science carry the day: science for your work as a clinician; science for deep understanding and improvement of all the work of our healthcare providers and organizations. 

The NEJM would have served both readers and the authors better by declining to print such an unworthy article. Serious debate is welcomed regarding means by which lean and other methods of “continuous improvement” are introduced effectively in healthcare. The Hartzband-Groopman article does not represent serious debate. Upon submission, the NEJM should have conferred with experienced lean practitioners, just as you would confer with experts in any discipline. Would you print an opinion piece about heart surgery that was submitted by a dermatologist without consulting the expert opinion of a cardiologist?  Of course not. 

Much like medicine, the practice of lean is a singularly empirical discipline. The authors have never taken part in a lean (Toyota-inspired) initiative at any level, whether small improvement activity or major organizational transformation. As they have watched from the sidelines, choosing not to get directly involved themselves, they make casual, misinformed observations, just as I might were I to observe them practice their craft in medicine. But, in this case, they diagnose and prescribe without confirming the facts of the situation, akin to prescribing treatment relying only on hearsay of the patient’s condition.

It is true that simple-minded, bone-headed applications of efficiency tools to healthcare situations are all too common. It is unfortunate that the doctors mistakenly associate these misapplications with lean thinking or Toyota. Indeed, there is much malpractice in the continuous improvement industry, with healthcare consultants peddling 12-step programs to be like Toyota.

Dr. Groopman wrote “How Doctors Think,” one of my favorite books about the healthcare profession. How disappointing that he didn’t think like a doctor when he wrote this piece.

 

John Shook
Chairman and CEO
Lean Enterprise Institute
Cambridge, Mass.

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
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Dan Cashman February 23, 2016
10 People AGREE with this comment

Great post, John. In leading improvement teams within healthcare, I often find myself constantly reiterating Shingo's, "Easier, Better, Faster, Cheaper, in that order!" to help get through to clinical staff. It's hard to convince such a naturally skeptical group but I've seen time and again that when they see and feel the effect of making work easier and improving quality has on outcomes, they become ardent supporters.

I've also always made it clear to the senior teams who I've worked with that the day we free up FTEs and they get fired instead of reinvested in the organization is the day I put in my notice. That helps too :)



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Jan Sierpe February 25, 2016
3 People AGREE with this reply

Congratulations! Well done.

Regards, Jan 



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Rick Rantilla February 26, 2016
1 Person AGREES with this reply

Repeating John Shoock: "Toyota identifies two main “pillars” that define its thinking and methods: continuous improvement and respect for people."

The people who create and/or execute the continuous improvement are the ones that need to be respect.  No respect... no improvement.  So simple.

As Dan Cashman says, firing people who have participated in continuous improvement is not respecting them.



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Boris Achramenko February 23, 2016
4 People AGREE with this comment

It's unfortunate that many times very honorable and influential people give the lean methodology terrible reputation without first trying to understand it properly, and by doing so cause even more objections in organizations with fixation problems as if it's not bad enough.

What do you think is the most effective way to fight fixation in senior management thinking which is caused by bad reputation to encourage continues improvement in their company?



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Thomas Warda February 24, 2016
6 People AGREE with this reply

Many in healthcare are firmly stuck in the methods of Craft Production as described in The Machine that Changed the World. And since the method used defines the results achieved, one can see at least part of why healthcare is such a costly mess.

 

More enlightened healthcare professionals have embraced Lean for what it truly is – a comprehensive business methodology based on continuous improvement and respect for the individual. The authors of the New England Journal of Medicine obviously understand neither of these concepts. And if one looks at the results those properly embracing Lean have achieved, it is very hard to argue with the methodology used.

 

Remember when Lexus (Toyota’s luxury division) used to employ “The relentless pursuit of perfection” in their advertising? That pretty well sums up the goal of Lean / TPS. I wonder what the goal of healthcare really is?



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Michael Smiles February 29, 2016

Thomas makes some very valid points here. 

I believe that good judgement can be clouded at the prospect and opportunity of  earning more money. If I can control my income flow based solely on efficiency then effectiveness will go out the window. 

I believe that in some countries (UK comes to mind) medical staff are paid a salary and are judged on the health outcome of patients. This model helps to drive a better outcome for patients at a lower overall cost. 

 

Establishing clear and objective measures of success in healthcare is really not that hard to do, putting them into action seems to be the stumbling block. Maybe I'm jaded by my view of the healthcare system but I can't help but think that certain compensation methods, can drive bad behavors.  

 



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JimB April 08, 2016

My family has been gong to a medical practice group for over twenty years because of the reasons put forward in Michael's post. The founders of the group tried to replicate the structure of the Mayo Clinic.

The doctors are salaried with a typical corporate bonus structure. With this in mind, we have seen that people from other cities come to this practice for treatment and surgical procedures due to the reputation of the doctors.

This group started the transition to digital records long before it became a requirement.

We have stayed with them because of the standards of care. We have had the same primary care physician for the entire time we have been patients of the group.

 



Bella Englebach February 24, 2016
5 People AGREE with this comment

John, thank you for submitting this response to NEJM. I noted that there were many cogent and well-informed comments from  lean thinkers and healthcare practitioners made to the online version of the article. I would hope that there will be additional formal correspondence to the journal...I hope the editors will publish some of those responses!



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Bob Emiliani February 25, 2016
15 People AGREE with this comment

I am deeply disheartened by the extensive criticism Drs. Hartzband and Groopman have received for their article "Medical Taylorism" from esteemed members of the Lean community. A better more and productive respose to would have been to acknowledge the key concerns raised in the article and elist their help in identifying the root causes of the problems and effective countermeasures.

Drs. Hartzband and Groopman's views and experiences reflect the coninued existence of significant defects in the process used to convert an organization from conventional management to Lean management, and therefore should ignite intense curiosity rather than criticism. Lean people should know better, and have failed to follow their many maxims, about learning, improvng, and asking "Why?"

Rather than defend Lean or attempt to separate themsleves from Taylorism, Lean advocates should acknowledge that there is much wrong with the currrent understanding and practice of Lean such that it results in the outcomes that Drs. Hartzband and Groopman identify - which, by the way, have been among the same concerns expressed by workers since the dawn of progressive management over 130 years ago.

Rather than criticize Drs. Hartzband and Groopman, Lean advocates should thank them, as I do, for helping us undersand their concerns and frustrations. Their views and experiences are value inputs for helping us do our job better.



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Ken Hunt February 25, 2016
7 People AGREE with this reply

Bob,

First off, I completely agree with John's post. When 2 authors are so off base criticism is warranted.

Might I suggest that you go to the Forums page and under Healthcare read Tom Warda's post asking if Healthcare is stuck in Craft Production. It's quite enlightening and accurate, and of course you have the chance to comment.

Ken



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Bob Emiliani February 25, 2016
4 People AGREE with this reply

I kindly suggest that one not sneer at craft production and instead learn why craft production (in some form) is a necessity in human evolution http://wp.me/p3kI3Y-2XV.



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Paul Critchley February 25, 2016
6 People AGREE with this reply

Bob,

You make a point relative to "seeking first to understand", and as Lean practitioners, it is our job to do so in an effort to change the hearts and minds of the Lean naysayers. It's a battle we've been at for decades, and no doubt will continue for decades to come...

However, considering the tone and the platform of the article, the backlash from the Lean community (albeit unsatisfying to some) was deserved. The good doctors did not take up a position of trying to see any of the benefits that Lean can provide; instead, they railed against it blindly, with no real facts or data to back them up. As medical (and scientific) professionals, they should know better. It's no different than the scores of others who have arrogantly dismissed Lean because "it just doesn't work here". Perhaps the most disappointing thing for me in this whole thing is that a prestigious publication like the NEJM published such a one-sided, misguided article without seeking input from any Lean professionals.



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Lev Ono February 25, 2016
3 People AGREE with this comment

The doctors stop short of grasping the real situation and therefore they obfuscate the situation. There is rampant malpractice in the healthcare improvement consulting industry, with consultants peddling rapid improvement events that they call kaizen and that just cut costs without building the capability. Those methods might be Taylorist, but they have little to do with lean or the Toyota Way. This was lost on the doctors, a missed opportunity.  There are many successful examples of lean, of application or in healthcare. 



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Thomas Warda February 25, 2016
4 People AGREE with this reply

Bob,

This may come as some surprise to you, but I absolutely agree that there is still a place for Craft Production, even today. However, I do not think healthcare should embrace it as strongly as it has. Craft Production (and craftsmen and women) has produced some of the true wonders of the world. It can also be credited with - or blamed for - high costs and highly variable quality. Can healthcare tolerate high costs and highly variable outcomes in this day and age? I think not.

The problem with Craft Production – as practiced by some in healthcare today – is that it propagates the myth that nothing can be standardized (or improved) and all methods are a deep secret held by a select few. Furthermore, no outsider is capable of offering advice on how to improve these secret processes.

The truth is that some parts of healthcare should support some aspects of Craft Production. For instance, some aspects of reconstructive surgery. Since by definition no two reconstructive surgeries are exactly the same, some parts of the process are by definition Craft Production. However, many aspects of reconstructive surgery can and should be standardized and continuously improved. Take for instance the preparation of the Operating Room, the sterilization of the instruments, the preparation of both the patient and the OR staff - and much more. I can’t tell you how many times when I’ve asked healthcare professionals what the standard is for something, I’ve gotten the reply, “I know what the standard says, but I do it this way.” Wrong answer – unless you embrace Craft Production.

Many in healthcare shrug off Lean by saying “You don’t understand. We’re not making cars.” If you look at the most successful practitioners of Lean in healthcare (Virginia Mason in Seattle for instance), you will find that they very quickly got over that issue. They learned Lean / TPS from the true masters of it – Toyota – and their results speak for themselves.

Tom



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Ken Hunt February 25, 2016
2 People AGREE with this reply

And to add to Tom's example of "You don't understand, we're not making cars". I heard something similar when we at Boeing embraced TPS. What I heard was "It'll never work, we're not building cars, we're building airplanes".

Look at what we are doing today compared to 15 years ago....

 

 



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Lester Sutherland February 25, 2016
3 People AGREE with this comment

Ouch,  what a brouhaha about misunderstanding of process improvement  from the very beginning of their statements of what Frederick Taylor actually wrote and said.  They paint the standard cartoon of Frederick Taylor as a boogieman.  Then they state that Toyota is just about time-study (the Taylor Boogieman). As if there were no Hawthorne Studies, Socio-technical studies, TQM, or other learnings between Craft production and where we are now.  As you read the original article (Medical Taylorism) by Pamela Hartzband, M.D., and Jerome Groopman, M.D.; you wonder why they felt required to author a document in which they obviously betray their lack of depth.  Reading the comments in The New England Journal of Medicine, we find they are criticized by the Journal readers also.  Unfortunately the journal must have had reviewers who were unfamiliar with the Lean topic. 



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Bob Emiliani February 25, 2016
1 Person AGREES with this comment

In my comment, above, I did not say that medicine should be practiced as a craft. This link http://wp.me/p3kI3Y-2XV clearly identifes Toyota-style kaizen as the form of craft for people to practice within the context of Lean management. Simply put, people need to practice a craft in order to satisfy human evolutionary needs. Kazien is the craft. What's why kaizen is so important.



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Lester Sutherland February 25, 2016
1 Person AGREES with this reply

Bob, Your comment of Lean as a craft is right on. If you are in fact indicating that the Master Craftsman should know the process from beginning to end, with successful products and appreciation from the customers (a real craftsman). Unfortunately there are many more practitioners than true craftsmen.  The underlying message of the New England Journal Article was the poor implementation (and apparently university training) of what you call Real Lean.



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Bob Emiliani February 25, 2016
1 Person AGREES with this reply

No, I'm not indicating that the Master Craftsman should know the process from beginning to end. I am simply saying that craft is important to people in an evolutionary sense, and that Toyota-style kaizen is a method of craft than can satisfy human needs. Please see http://wp.me/p3kI3Y-2XV.



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Lester Sutherland February 25, 2016
1 Person AGREES with this reply

You also say the kaizen craftsman is like Nakao-san, saying: “What I learned from Mr. Nakao about kaizen, processes, people, creativity, innovation, motivation, and business is almost indescribable. Mr. Nakao is an amazing sensei – the best there is. He is also a generous man, happy to share his profound knowledge with all whom he comes into contact with. I took copious notes and hundreds of photos. (http://www.bobemiliani.com/nakao-san-and-shingijutsu-kaizen/).

 

I would suggest master craftsmen like Nakao-san are necessary (critically so in the medical area) to bring the enlightenment of how the system works. A real Craftsman who knows the process from beginning to end.

I am not disagreeing that kaizen is important to people in an evolutionary sense. I am simply stating that the proliferation of Lean through partial knowledge is not helpful.

 



Ronnalea Hamman February 25, 2016
6 People AGREE with this comment

Great rebuttal to an all too common response to lean application in healthcare.  I spent six years learning about lean while working with an ambitious but ill-informed lean implementation in a large Canadian health authority.  There were successes, but there were also the common failures of an ambitious implementation of rapid improvement events complete with stopwatches, time observations sheets without the fundamental knowledge and support behind it.  This is but one example of what is a common mantra of "tried lean - didn't work."  So while this NEJM editorial is misinformed (and unfortunate as it is an influential journal), it is the result of these trials of 'lean as a quick fix' for long standing complex problems in healthcare.

As a lean/continuous improvement practitioner working with large scale provincial system improvements, I have ceased using any of the terminology associated with lean because of the wide variation and often incorrect interpretation of people's experience with it.  This is unfortunate, but in too many cases there is just so much resistance to it.  I go back to the principles behind lean - scientific problem solving (7 steps of PDCA), defining problems with metrics and aligning them with higher level KPIs, using a value stream map (or whatever they want to call it) to define value and understand waste from the patients' perspective.  It is not total lean transformation, but it is the continual pushing the edge of what people are willing to learn.  I just did a presentation yesterday of why we should not solve problems with high level outcomes data (that is over one year old) and how we should break this problem down in order to get to root cause.  After walking through this demonstration, I had a group of Physicians nod in agreement and state that this is how we should be approaching all of these problems.  Go figure.  One small step at a time.



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Paul E. Cary February 25, 2016

Great post John, I spent three day per week for nine months at a local hospital attenpting to influence a cultural transformation. I emphasised and encourage leadership involvement at every level with little success. I discoverd four identifyable independant cultures working in isolation of each other: doctors, nurses, admin., and third party. Doctors for the most part insulated themselves with intelectual superiority and arogance. Nurses were most receptive but had little time or encouragement to participate in learnig how to "think lean". Administrator were so bogged down with burocratic reporting that they seemed quarentined and hardly ever ween at the gemba. Third parties seemed to have different goals and motivations. The result was that these four cultures were following seperate paths with different directions. It always boils down to leadership and it takes a motivated passionate leader to transform a hospital.

I wonder how the autors would see things if a lean practitioner wrote an article about heath-care referencing outdated early 2oth century methods?



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Thomas Warda February 25, 2016

Paul,

 

My experience exactly. In fact the Docs were the worst practitioners of Craft Production - and damned proud of it to boot!



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Tom Lane February 25, 2016
1 Person AGREES with this comment

I began doing total system (Toyota) in 1983 before we could spell Kaizen, and the parade of people selling the watered down version and easy as 1-2-3, began soon after. After all this time, it still amazes me that educated people jump to the conclusion that the "tool" is the essence.  I wrote my book, "The Way of Quality" in  94 laying out the shift in consciousness to do Kaizen/Toyota Production and my colleagues still in the business are still battling that old mindset of "results only" and "fragmented/functional" thinking.  Excellent rebuttal.. tom lane



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Don Peven, MD February 25, 2016

Would be a compelling rebuttal except for the gratuitous inclusion of the standard trope "The US healthcare system costs twice that of almost any other system, yet does not produce better results." By throwing this unsubstantiated and out-of-context accusation into your essay, you do the same thing that you accuse the authors of the NEJM article of doing.

For someone who insists on accurate evaluation of a process, you have to admit that "does not produce better results" is a vapid and meaningless statement in the context of evaluating the quality and effectiveness of a health care system. Much of what people talk about when they say that the US health care system (as if it really was a system, but that's another issue) doesn't produce better results is essentially blaming the health care system for the country's wide disparities in income, education, population density, (un)healthy lifestyle choices, social status, and government effectiveness. Aside from maybe China, India, and Russia, there is no other place so diverse in population and geography, and I don't think you would want to seek health care in any of those venues. When you compare various countries with regards to the best available health care the US will always win, and most people who have the choice (and, admittedly, the money) will prefer to come here for treatment rather than go anywhere else.

Cost is relatively objective to measure, but again there is a lot of context involved. You can buy a $30K Toyota and get perfectly good transportation, but if you want to go 200 mph you will probably need to fork over $200K for the Ferrari. People in the US are willing to spend more to get better service, faster and more comprehensive access to care, and the latest and greatest in diagnostics and treatments. There is also the inconvenient fact that the US subsidizes the rest of the world in some aspects of medical care. Much of the reason that drug prices are so much higher here than in other countries is that government price controls elsewhere force drug companies to cover most of their development costs and profits with revenue from patients in the US. This isn't to say that there is no waste here, but as somebody who advocates Lean thinking and processes, you must appreciate that cost can only be judged in the context of value received, and the proper way to reduce costs is to Lean out the system to improve the value.



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Lester Sutherland February 25, 2016
1 Person AGREES with this reply

Well, I personally would go for the Ford Mustang GT350R at around $70K. A lot of your arguments seem to be saying that there would be no flow of medical tourism to other countries, but we all know that is happening. Money is a factor and offshoring of medical treatment for some and lack for others is a problem.



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Mark Graban February 25, 2016
2 People AGREE with this reply

It would be more accurate to say the U.S. system costs "almost twice as much" as other developed countries.

Here is the data:

http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=desc

The Netherlands, for example, is creeping up toward U.S. spending levels. Other countries have lower costs, but are still mired in "cost cutting" mode, using layoffs and service cuts (which means less care and less value).

It's hard to argue the U.S. gets better results in terms of life expectancy, and other measures, but as Dr. Peven points out, this is all very complicated and complex.

Patient safety (harm and death caused by preventable medical error) is a huge problem around the world. A health system (a country or an organization) that "puts patients first" would work to address that problem... otherwise it's "unsafe at any cost," to tweak the old Ralph Nader book title.

There's a lot of work to do to fix our different health care systems.



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Tom Gormley March 02, 2016

Dr. Peven may be right about the common claim that the US doesn't produce any better results...as Mark Graban said below, that's very complex. But Dr. Peven's method of assessing the US's quality of care also seems very narrowly defined -- those who can afford it (our high costs) will get the best care available. But this doesn't meet the IOM's vision of equitable and accessible care, and it seems to also minimize any responsibility for the serious quality issues we continue to face, in the high volume of medical errors and resulting preventable mortality. 

It seems from my past 6 years in lean healthcare that there's a northeastern (Boston) view of quality that focuses mostly on the very bleeding edge of innovations in diagnosis and treatment - we have the first or most xyz transplants, the best specialists worldwide. And these do attract patients from around the world as Peven says. But those who hold this view of quality seem willing to sacrifice continuous improvement in the core, basic, patient-centered processes in healthcare delivery that are in some systems dramatically reducing patient wait times and medical errors.

I have no doubt that if anyone wants to go see the very latest innovation in surgical techniques or bio-pharmaceutical application, they do well to come to Boston. But I've noticed in the 3 northeastern systems where I've worked, when we want to go learn from the best in continuous improvement in quality, cost, value, and staff satisfaction, we all get on planes to the mid-west (Thedacare) and west (Virginia Mason, Intermountain, Denver). So the fact that the article's authors are from Boston systems didn't surprise me at all. I hope they'll get on a plane west soon to see the real lean and its results. 



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Tony Zalucki February 25, 2016

After over 30 years of Lean practice in almost every market I'm not surprised by the attempt to categorize Lean with old disciplines. I've been able to double output at both healthcare and industrial institutions. The key is will the process owners listen and support improvement. The Doctors should hide there heads in shame because they just don't understand how the Lean culture of continuos improvement can grow beyond the obvious. 

I find Healthcare to be very supportive until you ask some doctors to participate in an improvement process. I've been told but I like the way I've always done operations, or the drugs they continue to push, talk about a dogmatic attitude. So it goes, but one truth remains, there is always a better way. 



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Chris Turner February 25, 2016

Hi John, 

I can only support you in your rebuttal to this article. I have owrked in both manufacturing and healthcare and heard the same language being presented as fact.

Your response corrects many of the misguided concepts and misinformation about lean principles that are often touted as fact!

Chris Turner

Senior Lean Consultant

Radical Transformation LLC



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Jay Bitsack February 25, 2016

Hi All,


Very interesting discussion… I must say that I’m pleased that it was catalyzed from within a community that - over its evolutionary/emergent history – has been eminently transformed/molded into what is universally recognized as being one of humanity’s highest-order forms of THINKING AND BEHAVING. In fact, that transformation has been so well-perfected that to practice the craft of medicine, one must now be subject to years of concentrated education and hands-on practice (typically in a controlled and highly-structured environment) under the watchful eye of a degreed, experienced, and licensed PROFESSIONAL. In fact, not far behind the practice of medicine in its evolutionary maturity and sophistication is the practice of engineering. Both – based on their respective evolutionary progress beyond their earliest manifestations as true crafts being practiced by “artisans.” [Note: Had a codified comprehensive body of knowledge been standardized for the purpose of measuring a practitioner’s level of competency and capability, the earliest crafts people might well have been able to refer to themselves as “PROFESSIONALS.]


Without this progressive evolutionary emergence of a more disciplined and replicable standard for a higher-order form of THINKING AND BEGHAVING, the likelihood that humanity would have been able to progress much further than the stone or bronze age should be in serious question. But given that humanity has managed to elevate its overall condition to what it is today, it should be obvious that the natural, biologically-endowed (and possibly even chemically encoded) tendencies for human beings to be “CREATIVE” in their THINKING AND BEHAVING would also be subject to evolutionary progress and adaptation.


Ergo, when it comes to likening what could or should represent the pinnacle of contemporary man’s THINKING AND BEHAVING abilities – particularly in the arenas of medicine and engineering and continuous improvement (aka “DISCIPLINES” and for good reason)- the pure notion of practicing a “CRAFT” (as a genetically-inherited right-of-being) should give way to the notion of practicing a TRUE PROFESSION; one which subscribes to and rests upon adherence to a set of recognized and accepted standards against which a practitioner’s on-going competency and performance quality might be gauged. After all, the progress that humanity has made over the past two centuries – based on the disciplined/systematic and improvable/evolvable practices of recognized PROFESSIONALS - has been greater than the progress made since the dawn of humanity and the ever present need/inclination to practice CRAFTSMANSHIP (aka being creative as in making things mostly by hand).


Bottom line: CREATIVITY, INNOVATION, and OUT-OF-THE-BOX PROBLEM-SOLVING, will ALWAYS serve as the foundation for CONTINUOUS IMPROVEMENT. HOWEVER, the extent to which those natural human tendencies are able to be applied against the need for building and sustaining SYSTEMS that are capable of serving the greater well-being of mankind is NOT something that can be left to individual whim and fancy. Rather, the on-going development, codification, application/use and evolution of standards become the real basis for making progress. In this context, craftsmanship has given was to professionalism as a better way of THINKING AND BEHAVING…. LET US NOT DIGRESS!!!



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Dan Riley February 25, 2016
3 People AGREE with this comment

Having written my own own critical book on lean (http://thenobbyworks.blogspot.com/2013/08/heres-to-continuous-improvement.html?q=Lean), I must admit that my sympathies lie with the good doctors. Like them, my experience with lean (in a non-medical envirnment) led me to conclude that it was a process over people methodology. In the course of writing my book I learned that there is good lean and bad lean, and that what I had observed and wrote about was definitely the bad. Could my book (like the NEJM article) have been more balanced and comprehensive if I had called LEI for input before I wrote it? Yes, but then it would've been a dissertation or disquisition on lean, rather than a critique. And a critique was what was called for because I, like the good doctors, saw the malpractice of lean taking a negative toll on an enterprise I cared about. My motivation was to help others from falling into the same lean trap as my company had. I felt no obligation to balance the scales, though I can maintain with an intellectually healthy endorsement from LEI's Michael Balle that my book did a reasonable job at being fair, given my stated mission. Besides, I knew there were already thousands of books out there advocating for lean. Which leads me to the crux of my response to John Shook--who I generally view as a just and reasonable man--and that is his claim that the NEJM would've "served both readers and authors better by declining to print such an unworthy article." I'm guessing that in this campaign season the communications director for every candidate running expresses that sentiment every day to news editors throughout the land. It is that baldly political...not to mention the uncharacterisic arrogance of declaring it unworthy for readers. As in politics, this is for the people to decide, and they decide in the noisy, often infuriating, back-and-forth of open debate...not by royal decree of what's worthy and what's not. John calls for a "serious debate," and presto...now he has one. The doctors used their forum to make their case. He uses his to rebut it. I rebut John. Perhaps the NEJM will print a rebuttal to the doctors' article, and so it will go. The benefciaries will be those--in medicine and out--who have to make an intelligent investment in lean...and those lean practitioners who really are interested in continous improvement.     



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Dan Riley February 25, 2016

Okay, on the Internet typos are a given...except if you self-identify as a writer...as I do. Unfortunately LEI either doesn't provide an editing feature or I can't find it...in any case, here's the cleaned up version:
Having written my own critical book on lean (http://thenobbyworks.blogspot.com/2013/08/heres-to-continuous-improvement.html?q=Lean), I must admit that my sympathies lie with the good doctors. Like them, my experience with lean (in a non-medical environment) led me to conclude that it was a process over people methodology. In the course of writing my book I learned that there is good lean and bad lean, and that what I had observed and wrote about was definitely the bad. Could my book (like the NEJM article) have been more balanced and comprehensive if I had called LEI for input before I wrote it? Yes, but then it would've been a dissertation or disquisition on lean, rather than a critique. And a critique was what was called for because I, like the good doctors, saw the malpractice of lean taking a negative toll on an enterprise I cared about. My motivation was to help others from falling into the same lean trap as my company had. I felt no obligation to balance the scales, though I can maintain with an intellectually healthy endorsement from LEI's Michael Balle that my book did a reasonable job at being fair, given my stated mission. Besides, I knew there were already thousands of books out there advocating for lean. Which leads me to the crux of my response to John Shook--who I generally view as a just and reasonable man--and that is his claim that the NEJM would've "served both readers and authors better by declining to print such an unworthy article." I'm guessing that in this campaign season the communications director for every candidate running expresses that sentiment every day to news editors throughout the land. It is that baldly political...not to mention the uncharacteristic arrogance of declaring it unworthy for readers. As in politics, this is for the people to decide, and they decide in the noisy, often infuriating, back-and-forth of open debate...not by royal decree of what's worthy and what's not. John calls for a "serious debate," and presto...now he has one. The doctors used their forum to make their case. He uses his to rebut it. I rebut John. Perhaps the NEJM will print a rebuttal to the doctors' article, and so it will go. The beneficiaries will be those--in medicine and out--who have to make an intelligent investment in lean...and those lean practitioners who really are interested in continuous improvement.  



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Michael Ballé February 26, 2016
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Oh come on! John is absolutely right to call them out ont his. The NEJM is a scientific publication, not a rag sheet, and the first commitment to science is to back up blanket assertions with convincing evidence.

This is not a matter of closing ranks or selling one approach - I'm certainly known for being equally critical of the lean movement and an advocate of evidence-based pieces, such as yours, firsthand experience, whether for or against "lean."

But willfully misinformed statements such as deliberately confusing lean and taylorim - when the entire (well, barring Bob Emiliani's odd views) lean body of lietrature is about trying to stop the reduction of lean to taylorism and trying, oh trying, against wilful, negligent, cranky, lazy resistance, to show that LEAN IS A DIFFERENT WAY - are damaging to say the least, and infuriating in the process.

"Lean" was framed as a hope that we could do better than we currently do - as John rightly says - and we've been, over the past TWENTY FIVE YEARS - been showing that a better way is possible.

So now, 25 years of proof blown away in a glib piece condoned by a scientific publication. Thank you very much.

So, yeah, everyone is entitled to his or her opinion, but please keep to to your blogs guys, or if not, produce the data to back up claims.



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Bob Emiliani February 26, 2016
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Michael - Is it not possible that the physicians' confusion between Lean and Taylorism was not willful or deliberate? Why do you dismiss such a possibility? Is that not disrespectful?

There is also 25+ years of proof of Fake Lean to recon with, as it far outweighs Real Lean. One article in a prestigious journal does not change that fact, nor does it undo the proof that Lean, understood and practices corectly, works.

I understand the frustration. We all share it. But, in my view, widespread ignorance of history of progressive management dooms all to repeat it. I know we can do better, but I'm not sure if movement leaders are up to it.



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Dan Riley February 26, 2016
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Deja vu all over again...one of the main things that doomed the lean intitiative at my former company was all the sensei talk about openness and interest in employee feedback, which turned out to be total jive. Either you want to hear what others have to say...especially others not steeped in lean, but experiencing it for the first time...or you want to demean and dismiss feedback that does not conform to your insider's view. Far more harm is done to lean by those who are out there practicing it badly than those who may be critiqueing it badly. Rather than circling the wagons, LEI might want to dedicate more effort to creating a sort of Good Housekeeping Seal of Approval which it can grant to those lean practitioners committed to an established set of lean standards. This would put the bad actors on notice, support those doing it right, and give a public more uninformed on lean than you think some valuable guidance.  



Jeffrey Liker February 25, 2016
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I was sent this  article and dismissed it as the ranting of some doctors who had some bad experience with lean and did not know what they were talking about.  John took the time to respond in a professional and scientific way.

A common misunderstanding is the difference between a philosophy and methodology as intended, and the way it is used in practice.  I also have seen many cases in which organizations use lean as another form of Taylorism. And I also rant against that.  But mistaking some person's version of lean for what Toyota does and what we can learn from Toyota is a fallacy.  

Of course for those who experience lean in a certain way it is a bit difficult to argue what the real lean is--that which was abstracted from Toyota or what actual organizations do.  If the latter then there are as many flavors of lean as there are adopted and to be scientific we should at least represent some spectrum of practice rather then the most negative and narrow interpretations as this article did.

I applaud John for taking the time to respond and for writing such a thoughtful, informative piece. 



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Bob Emiliani February 25, 2016
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Why dismiss it and why assume the physicians did not know what they were talking about? Can't improve if we don't know about problems, right? 

The same problem has been with us for more than 100 years. There seems always to be more of a desire to ignore or ridicule it than there is a desire to acknowledge the problem's existence and determine root causes and countermeasures - difficult as that may be. 

That, especially, includes looking inward to learn how the Lean community has contributed to the problem's existence (and persistence).



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Michael Codega February 25, 2016
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One of the key elements to be recognized in cultual transformation is fear of the unknown.  This fear is apparent in their book as neither have lived in a "lean" environment.  There are several examples of the successful introduction of "lean principles" in healthcare institutions and all began with consistent leadership enlightened by studying the experience of a successful change.  Leading with humility is a trait which can be difficult for some disciplines but is a fundamental characteristic of an enlightened leader.



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Bob Emiliani February 25, 2016
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I think it worthwhile to re-focus:

My reading of "Medical Taylorism" is not focused on Taylor, Lean, or Toyota. It is on the substance of the physicians' criticism. They are upset about the same things that front-line workers have long been upset about: losing their voice, standardization, etc. (see "Eliminating the Six Criticisms of Lean" http://www.bobemiliani.com/eliminating-the-six-criticisms-of-lean/).

This is a persistent defect in Lean transformation process that everyone passes through to the next in line, and which undermines both the merits of Lean and the advancement of Lean. By diminishing the physicians' concerns, we undercut our own credibility, influence, and effectiveness.

Again, I say we should thank the physicians for identifying a problem and pulling the andon cord.



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Thomas Warda February 25, 2016

Bob, you bring up a very viable concern – the concerns of the doctors. However, I think we need to differentiate between “concerns” and “willingness to change.”

Good doctors are a critical part of any healthcare team. But as with any team sport, a team is only as good as its individuals and how well they mesh as a team. In my experience, almost all of the players in healthcare are willing to change what they do in order to improve the performance of the team – except the doctors. Perhaps – as I have stated before – they are too rooted in the methods of Craft Production and see themselves as the last true remaining craftsmen?

The best athletes in the world all have coaches to help them change and continuously improve their game. If healthcare wants to improve its game, the way all of the individuals on the team play needs to change – including the doctors. And so I come back to the difference between some doctor’s “concerns” and their “willingness to change.” If they are not willing to change, what should we do with their concerns?



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Bob Emiliani February 25, 2016
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We all know it is wrong to blame the workers.



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Mike Rother February 25, 2016
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I can understand the thoughts and feelings all around. Of course, when we try to figure out why something seemingly irrational happens, the answer is always that it is rational in a different way than we imagine. Some people call a refuted hypothesis the 'learning edge.' (Am adding this comment for all sides of the discussion.)

 



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Steven Leuschel February 29, 2016

I agree completely, Mike. A hypothesis or refuting hypothesis is never "correct," but should push us toward the "learning edge" to expand knowledge and thinking.

House (1996) states that many researchers are "trapped in our own paradigms" (p. 347). We need to all admit we are all "trapped in our own paradigms" (myself included) as we push each other towards the "learning edge."

Kudos to John for being the great leader that he is and defending the Lean community. But now it's time to step back and reflect our approach to improvement thus far. If we can't reflect on failures, slow success stories, and even better ways of the best success stories, the lean community will never be able accelerate at the pace that is necessary.

 



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Lev Ono February 25, 2016
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Isn't the problem one of semantics? The MD authors thought they were speaking about Toyota methods when actually they were talking only about efficiency programs. this kind of misinterpretation should always be corrected. 



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John Shook February 25, 2016
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Thanks to all and, to quote Les Sutherland above, what a brouhaha. This is an outstanding dialogue; I am grateful to you all for taking the time to contribute.

I wrote it immediately after reading the original piece in NEJM, a few days after it appeared. As it happened, I had an appointment that day in the office of my personal doctor which happens to be in the same medical facility where Doctors Groopman and Hartzband also practice their craft. My personal physician joined after I was first examined by an intern. As it also happens, my personal physician is a colleague and personal friend of the authors. So, for fun, I read aloud for them my first draft of my rebuttal. So, there we were, the three of us – my PCP, the intern, and myself – sitting in the exam room, having a fine time reading the rebuttal and musing about whether it was perhaps a bit too…attacking. We got so distracted he forgot to give me a referral for a specialist I needed to see.  Anyway, I decided to move forward with submitting the piece to the big NEJM. Comments to the Groopman piece had already been closed by NEJM editors, so I submitted it as a rebuttal. The NEJM editors informed me they don’t usually print “rebuttals” like this but they were going to compile the many letters to the editor that they had received. So, I asked them to consider my rebuttal as a letter to the editor. But, turned out I had been too long-winded; letters are limited to 175 words. So, I edited it down to 174 words and sent as a letter to the editor. Then they told me letters to the editor were already closed. So, okay.

I think each of your comments is valid and makes a positive contribution, even those that are contradictory. My only real “complaint” about the authors and the NEJM editors is that the authors really didn’t do their homework and their argument suffers as a result. The NEJM would never print something so sloppy about the medical matters that are their wheelhouse.  

There is much – MUCH – to say regarding the malpractice being committed by consultants of all stripes, including those professing to be preaching “lean”. But, the Groopman piece was superficial, misinformed, and misleading. I would have ordinarily ignored it. But, since it was in the NEJM…

The authors, readers and NEJM itself would have been better served had the editors reached outside their usual circles. The NEJM would never publish something by me about anesthesia; they shouldn’t publish something about “improvement” without sending the piece out for appropriate peer review. Any of you would be fine reviewers for a piece such as this. Instead, the editors judged that this topic isn’t serious enough to be treated with that kind of seriousness. Annoying.

And, I have it on good authority that, regarding this topic, the authors in fact do not know what they were talking about. There are many out there who DO, who do have experience and that experience may be negative. From them, we would all benefit from hearing. We should listen to them.  

I bet you’ve seen this in healthcare: physicians who would never prescribe treatment without examining the patient don’t blink an eye to prescribe solutions for their organizations without ever going to confirm the facts at the gemba.  It’s hard to be a scientist all the time about everything. So, yeah, our standards are high.    

Dr. Peven’s comment deserves direct reply. Thank you for contributing. I appreciate your view. Specifically, you argue that my statement "The US healthcare system costs twice that of almost any other system, yet does not produce better results" is unsubstantiated and out-of-context. You make a good point that “better results” is a tough blanket statement to substantiate, given the difficulty in comparing what “better” means in different contexts.

While no expert, I’ve actually been following international health comparative data for quite a few years. You may choose to argue with them, but OECD data back up my statement on both fronts. You may disagree, but totally unsubstantiated it is not (Mark added some additional sources, too). As a percent of GNP, the US spends close to 20 cents of every dollar on healthcare while only a handful of nations spend even a dime. As you point out, it may be perfectly fine for a population to decide to spend that much or more; after all, what is more important than health. But, then, yes, how to determine “results”. There are outcomes such as the ones you mention where the US fares pretty well (and I agree with you that the US is de facto subsidizing healthcare costs for the world in several respects). But, surely length of life and infant mortality are measures that matter, among others.  I don’t think the fact that we are a diverse population is a good excuse for those poor results.  

But, yes, perhaps I could have qualified my statement a little further. Trying to be cute to get the attention of the NEJM editors. Mea culpa. But, as Les hinted, be careful with those $200k (more, actually) Ferraris.

The good news is that approaching healthcare with lean thinking, with a Toyota-like approach, has gone further faster than I would have predicted.  A long way to go, to be sure.  But, that’s such a given that it, ahem, goes without saying. The good news is that people are learning to approach their work no matter the field – healthcare or not – with different lenses. The further good news is that we have a long way to go. Our challenge is how to make progress, how to facilitate progress, in that regard – starting with learning more deeply ourselves.

So, hey, we’ve come this far with this conversation, let’s continue the fun. It would be nice to hear from some more doctors.

john



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Denise Bennett February 26, 2016
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For many years John Shook thought that Lean Thinking would never make it in healthcare. We have proven him wrong. Many of us who have led this charge are doctors (not me, I am a nurse). I have the privilege of working in a children’s hospital where doctors participate daily in tiered huddles to identify and resolve problems. Where medical teams use takt to allocate cycle times on patient rounds to support delivery of family centred care, including time for teaching. Just last week I spent time talking with a cardiologist who was working on an A3 to reduce waiting times for his patients in the outpatient heart centre. I am privileged to work closely with two brilliant doctors (one physician and one surgeon) who are committed to level loading planned surgical admissions and developing a production schedule that matches inpatient bed capacity. Another is leading an improvement effort to increase the number of early discharges, so that we can move our critical care patients on to the inpatient units and in turn transfer sick children from the operating room to the critical care unit. Weekly, local improvement teams meet in many locations across the organisation. All have active medical leadership where processes and practices are improved using PDCA methodology. I am heartened daily, to work with doctors who are engaged and committed to improving healthcare by continuously removing waste and making patient care safer, more accessible and a better experience.  

So John, don’t forget (I know you haven’t) that there are many doctors who are committed to Lean Thinking as a way of life in healthcare.  We must continue to work alongside them to learn and to help where we can. Because, there is no industry that needs Lean Thinking more than healthcare, there are no customers more deserving than our patients. Now working in a children’s hospital, I believe this even more.

When our ‘lean thinking’ doctors choose to share their opinion, I hope that the editors of this prestigious journal see fit to let them do so. How can their opinion be less valuable than the unsubstantiated perspective of these authors?

 



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Bob Emiliani February 26, 2016
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John – I offer these four observations:

1) People who feel like they (or their colleagues) have been harmed by Lean don't "do their homework," and their argument, from their viewpoint, is coherent. Also, while they may not know what they are talking about, they are likely providing an accurate reflection the opinions of some (many?) physicians. So, again, I say that their feedback should not be ignored.

2) It seems you were in close proximity to the genba, yet you did not actually go there to get the facts from Drs. Hartzband and Groopman, e.g. their personal experience with Lean, etc.

3) Having written nearly 50 peer-reviewed paper, having reviewed many times more than that, and having served as an academic journal editor, I can assure you that the peer-review process does not offer any guarantee that a paper will be improved. Had I reviewed “Medical Taylorism,” I would have accepted the premise that Taylorism (i.e. “fake Lean”) is prevalent in healthcare due to its ubiquitous presence elsewhere. I would have then recommended that the authors make three improvements to the paper: a) Cite the prevalence of Taylorism in medicine, b) Specifically and clearly enumerate their grievances, and c) make some recommendations to improve the situations they describe. The peer-review process is such that the authors could have argued against my recommendation to the editor, and perhaps win, or the editor could reject my recommendations in whole or part. Being an “expert” reviewer does not assure the successful prosecution of one’s opinion of a paper or suggestions for improvement, especially in the case where two other reviewers might have found the paper to be acceptable for publication as-is.

4) This argument is not valid:

"The NEJM would never publish something by me about anesthesia; they shouldn’t publish something about “improvement” without sending the piece out for appropriate peer review.

The comparison is valid, however, if you or a loved one had been harmed by anesthesia. Then, NEJM may have published your paper.



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Richard Rantilla February 26, 2016

On a slightly different direction I am frustrated by people often attribuiting to Frederick Taylor ideas that were not really proposed by him.  In particular, in this case of "Medical Taylorism" it was Taylor's understanding of medical training techniques that partially inspired him to write his book "The principles of scientific management."

Here I quote from page 66 of the 1998 Dover reprint of Taylor's book:

" And it should be remembered that the training of the surgeon has been almost identical in type with the teaching and training which is given to the workman under scientific management. The surgeon, all through his early years, is under the closest supervision of more experienced men, who show him in the minutest way how each element of his work is best done. They provide him with the finest implements, each one of which has been the subject of special study and development, and then insist upon his using each of these implements in the very best way. All of his teaching, however, in no way narrows him. On the contrary he is quickly given the very best knowledge of his predecessors; and, provided (as he is, right from the start) with standard implements and methods which represent the best knowledge of the world up to date, he is able to use his own originality and ingenuity to make real additions to the world's knowledge, instead of reinventing things which are old. In a similar way the workman who is cooperating with his many teachers under scientific management has an opportunity to develop which is at least as good as and generally better than that which he had when the whole problem was "up to him" and he did his work entirely unaided."

What do the Doctors see as wrong with this practice?  Or, more exactly, what are they actually seeing that is different from this practice?

 



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John Sidaway February 26, 2016
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Firstly I would like to congratulate John on an article that summarises what "Lean" is, or at least what it is meant to be, in probably the best and most succinct way that I have ever come across.

However, concerning the medical article that initiated John's reply I have to agree with the comments from Bob Emiliani. I read that article as very much indicating that the authors have experienced, knowingly or not, the dramatic misunderstanding and misapplication in some medical professionals and institutions of what "Lean" is and the real principles and objectives involved.

I would believe that most people in the Lean community have at some point experienced situations, including back in manufacturing, where such misunderstandings and "misapplication" has happened and aspects of "Taylorism" have beed evident in its place. 

I read the medical article as a somewhat impassioned alert that this needs to get resolved. I believe however that anyone reading John's comments should be better prepared to help this happen.



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Dirk Steffan February 26, 2016
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Rather than stating opinions and attacs an analysis of the arguments and thesis of the doctors Hartzband and Groopman with proper disputes and debate would have been more helpful.



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Michael Ballé February 26, 2016
3 People AGREE with this reply

How about: some doctors (okay, and consultants and a few professors) confuse lean with taylorism doesn't logically lead to lean = taylorism.

 

We'd have to do a meta-analysis to tally up the number of experts who think "lean = taylorism" and those who think "lean is different from taylorism" to have some idea about the statement.

The ironic part is that no one disputes that taylorism applied to medicine is a really poor idea.

 

Lean is the generic name for Toyota Production System, aka The Thinking People System, aka think deeply about your pratice and work more mindfully.

 

Lean is essentially about teaching diagnostic and self-study skills to practitioners. Lean is about problem-solving based teaching. Just like medicine.

 

Oh, wait.



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Helen Jackson February 26, 2016
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A view from accross the pond - here in the UK our provision of medical care is free at the point of use, but the government budget for our healthcare is pretty much out of control.

Where it has been tried at all in healthcare, we have been largely subject to the same tick-box application of "Lean", without depth of understanding of the principles.  But, it is possible to go to any healthcare provision location in this country and after just 5 minutes observation see waste everywhere.

But daring to make this comment is seen as a personal attack on the clinicians, not an observation on the, often ridiculous, systems that they are trying to work within.

Your rebuttal, John, is crucial: it is not okay for such an important industry as healthcare to beleive that properly applied Lean thinking is not for them.  It is also not okay for such an important industry to look at a few bad applications and beleive that they understand what Lean is.



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Barry Evans February 26, 2016

I have re-read John's reply and I am amazed by his comment that

"I sent the following rebuttal to the NEJM; I don’t expect it to see the light of day, but here it is for your reference". Isn't any respectable and respected journal honour-bound to print a response from a person with a reputation like John has!!!

I am aware of great healthcare examples such as

- Huddersfield and Calderdale Hospital in UK - great "through-time" reduction improvements by adapting Triage to a more patient-focused methodology

- Boston General Hospital - I believe - where great improvement has been achieved

- Health Care examples in Steven Spears book "The High-Velocity Edge: How Market Leaders Leverage Operational Excellence to Beat the Competition"



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Paulo Sousa February 26, 2016

Its important your statement, Mr  Shook. Thanks.

And this is important for that "lean gurus" that are implementing Lean.

Unfortunatey I'm seeing to much push implementations done by those "gurus". It works? When the only salary that those people who absorbes that implementations have are about 7000 USD... of course, it works.

But when they arrive in organizations (like hospitals) where salaries rise up to 50000 and other honorably values... well, nobody wants to be pushed, no mathers how the philosofy or methodology works.



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Daniel Jones February 26, 2016
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With greatest respect I suggest everyone needs to look at the evidence for lean in healthcare as told mainly by healthcare practitioners themselves from many different countries around the world - Planet Lean already contains 27 really good case studies  - check them out at http://planet-lean.com/index.php?searchword=healthcare&searchphrase=all&areas[0]=content&Itemid=255&option=com_search



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Bob Emiliani February 26, 2016
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Dan - It is wrong to cherry-pick the data. One must look at all the data. Otherwise, analysis is tainted by confirmation bias. Planet Lean isn't the only source of data.



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Robert MacDonell February 26, 2016

John,

Your rebuttal was exceedingly well done.

Having worked in healthcare for 40 years, 20 in process/performance improvement, my experience tells me the opinions of the physicians in the referenced article in the NEJM represent a small, but sometimes very vocal, minority of their peers. The vast majority of the physicians I work with on a regular basis are much better educated and open minded about Lean and its value.  Most understand the Lean's value and, in some circumstances, are the first to acknowledge the limits of their understanding. 

It is clear that the authors in the NEJM are among those who have only a superficial knowledge of Lean, and an outdated understanding of performance improvement generally. Very few of their peers would appreciate their misguided commentary, and arrogant undertone.

Thank you for your clear and cogent response to the NEJM.

Gratefully,

Bob

 



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DAVID CLARK March 15, 2016

Bob,

Confirmation bias is not the the only error of cognition we should be concerned with.

Survivor bias is often just as misleading. Studying the only the Lean "successes" in healthcare and developing general conclusions about the reasons for their success without systematically taking into account the characteristics of the much larger number of "failed" lean implementations is likely to lead to flawed assumptions.

The medical mindset is to use evidence gained from radomised controlled trials (ideally double blinded) to draw inferences about the effectiveness of interventions. The lack of such "evidence" and the virtual impossibility of conducting such a study may have something to do with resistance to Lean among many medics.

 

David

 



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Matin Karbassioon February 26, 2016

John,

Great rebuttal. A major paradigm shift is required to move healthcare forward. It reminds me of my conversation with a physician at a Lean training session a couple years ago. We were discussing the benefits of "Batch Reduction" by reviewing some examples from Lean healthcare organizations. After a brief discussion (and not giving a good enough reason why performing certain tasks more frequently would not provide better value to his patients), he finally told me, "You are not in my world". Translation: Lean's first principle, “Understand value as defined by the customer" is really inconvenient to him and his way is more "efficient"!



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Thomas Warda February 26, 2016

I think it also might be helpful to note that many process improvements can be made to the healthcare system without or before involving doctors who might be resistant to change. If one looks at the actual amount of “hands on” time a doctor spends with a patient, it is but a tiny fraction of the total time the patient spends in a healthcare facility. That said, making improvements in that part of the value stream might be largely invisible to a doctor resistant to change. But, it might allow them to see more patients in a given time frame – or spend more time with the same amount of patients. After this is accomplished, it will be much harder to criticize possible changes / improvements to the part of the process actually involving the doctor.



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Steven Domalik February 26, 2016

Such a shame that a leading medical journal does not insist the articles they publish are supported with factual references. Why depart from the high standards of previous medical article pubilshing that have been the hallmark of NEJM?



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John Bicheno February 27, 2016
3 People AGREE with this comment

A very well written piece by John Shook.

I have concerns, however. Let us begin with a quote from the great systems thinker, West Churchman: the systems approach begins when you first see the world through the eyes of another.

What would be response of the medical community to the rebuttal? Note, not a 'response' but a 'rebuttal'. So, 'you are wrongand we know better'. I fear the danger that some would see this as intolerant to other views, or worse, arrogant. And hence do more harm than good. TWI JR's first point is, 'get the facts.'

what happened to cause the doctors to write such an article? In the spirit of continuous improvement we should seek to find out. Something certainly failed at the hospitals. There may be an inkling of truth or insight from which we as the lean community could and should learn.

Could it have been a series of poor implementations? If so, what went wrong? We all, I guess, know of poor implementations. One failed case I of know of in a hospital was led by an ex Toyota employee....

Was the problem with the 'tools' or the intervention? We should seek to find out. Home in, as per in an A3.

Or could it just be blind prejudice or ignorance on the part of the doctors and the article reviewers. If so, what led them to this, and what can be done to help overcome such views? And how can we improve? TWI again: if the worker hasn't learned the instructor hasn't taught.

As was once pointed out to me, to my embarrassment, by a Toyota employee with little formal education, learning is the most important thing. Not only what the doctors should learn, but  what we as Lean community should learn from this experience. If we don't learn but just rebut, the future is bleak.



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Tyson Ortiz February 27, 2016
2 People AGREE with this reply

I agree, John Bicheno.

I believe deeply in the potential of Lean to save Healthcare. However I've spent a lot of time in hospitals as a consumer, including hospitals that publicly tout the success of their Lean efforts in areas I've encountered, and in those places the clinicians and systems show little to no evidence of Lean thinking.  Sure, look around and you'll see evidence of Lean tools applied here and there, but talking to clinicians I hear sentiments very consistent with those expressed in the NEJM article.

Lean is trying to serve healthcare, yes?  Does this mean that we few Lean folk run around trying to make process improvements here and there, or that we run around trying to help everyone else get better at making their own improvements?

Most here seem to agree that the NEJM article reflects a mindset that doesn't understand Lean.  Given my experience these sentiments are common.   These are our customers, in some way our students.  If the student hasn't learned, then has the coach really taught?

We could blame the stopwatch-wielding consultants... blame people... but even then we're just looking at more learners that haven't learned.

I'm glad John Shook wrote this very strong rebuttal to set the record straight.  Great content from an authoritative source in the NEJM authors' backyard.  So what next???

Who knows what actually drove this article, but based on my exerience it seems to reflect a real problem -- likely a process problem -- that we could use to evolve our approach and strengthen our movement.

What do we think is wrong with our process to produce this outcome?  What is the next step to try to improve?



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Steven Leuschel February 28, 2016
1 Person AGREES with this comment

The reality is that whether we agree with the NEJM article or not, we are facing this mindset everyday. But before commenting any further, I believe it's important we gather facts.

To help facilitate the conversation, I've done a quick search of the peer reviewed literature from 1988 to 1998 based on the information and articles I had available. I used the words “toyota” and “lean” and clicked on “Peer Reviewed” and “Available,” meaning its available in the database I’m working with. I chose to pick one quote as it describes the word “lean.”

Please note all the references to Taylorism.

I chose these early years of lean, because I am assuming that many of the later peer reviewed articles are based on these early articles. Here's some quotes from the articles I retrieved from the database as they relate to the definition of lean. 

1991, 1 result.

“The practice of just-in-time or lean production (Schonberger 1982, 1986; Womack et al. 1990) has received particular attention from the early 1980s onward.” (Delbridge & Oliver, 1991, p. 2083).

 

1993, 1 result, citation below.

“Proponents of the Japanese-inspired "lean production" model, such as the MIT researchers who contributed to The Machine That Changed the World, argue that organizational learning will be maximized in a system based on specialized work tasks supplemented by modest doses of job rotation and great discipline in the definition and implementation of detailed work procedures” (Adler & Cole, 1993, p. 85).

1994, 1 result

“They [Adler & Cole from the article cited above] seem to suggest that there is only one way of organizing effective learning in labor-intensive production of relatively standardized goods, by using revamped and intensified Taylorism -- rigid standardization, minute subdivision of labor, short-cycle tasks, and narrow job roles” (Berggren, 1994, p.37).

1995, 1 result

“From Taylor to Toyota - The Development of Lean Production

The production management approaches of Japanese companies have been given many names. In Japan they were and are still known as ‘Toyota Production System’ (Sugimori et al., 1977). In the West, the term just-in-time management has been widely used. However, as it does not accurately reflect the full scope of Japanese approaches, many others have been including ‘continuous flow manufacturing,’ ‘world class manufacturing’ (Schonberger, 1987) and most recently and probably the best term, ‘lean production’ (Womack et al., 1990).” (Voss, 1995, p. S20)

1996. 6 Results. I quoted the second article, the first appeared to be in Chinese. Cited below.

“Those production techniques once broadly classed as "Japanese" are now being subsumed under the generic label "new wave manufacturing strategies"[5]. These are seen to include lean production, just-in-time, total quality management, cellular manufacturing and flexible manufacturing systems.” (Winfield & Kerrin, 1996, p. 49)

Note, the citation above for [5] is: Storey, J., New Wave Manufacturing Strategies: Organisational and Human Resource Management Dimensions, Paul Chapman, London, 1994.

 

1997. 7 Results. Quote from first result below:

“He [Price] distinguishes five significant features of lean production: Flexible mass production (utilizing the assembly line); stratified production complexes, with a small core workforce and an extended peripheral workforce; a modified Taylorism labor process; continuous waste elimination; and employee involvement (pp. 190 ,29-291). Regarding the ‘modified Taylorism labor process’, he finds that Toyota and Suzuki adopted Tayloristic approaches such as standardized jobs and job routines, and short-cycle times.” (Gronning, 1997 .p 401)

 

1998, First result below:

 

“Both types of factories are managed according to the precepts of what has come to be known as “lean production,” a system of automobile manufacturing first perfected in Japan that combines the ultimate in efficiency and quality control techniques with extensive worker involvement in the production process. In a dramatic departure from the traditional, highly authoritarian “Fordist” system, under lean production, rank-and-file workers are organized in cooperative teams, rotate jobs, and are offered incentives to mobilize their knowledge of the labor process to improve productivity and quality by reconfiguring the minute details of their work operations.” (Milkman, 1998, p. 1568) Ruth Milkman, reviewing the book Team Toyota: Transplanting the Toyota Culture to the Camry Plant in Kentucky. 

 

References:

Adler, P. S., & Cole, R. E. (1993). Designed for learning: A tale of two auto plants. Sloan Management Review, 34(3), 85. Retrieved February 27, 2016.

Berggren, C. (1994). NUMMI vs. Uddevalla. Sloan Management Review, 35(2). Retrieved February 28, 2016.

Delbridge, R., & Oliver, N. (1991). Narrowing the gap? Stock turns in the Japanese and Western car industries. International Journal of Production Research, 29(10), 2083-2095. Retrieved February 27, 2016.

Gronning, T. (1997). Review Essay : Correctives to the Lean Production Thesis - Three Monographs: Terry L. Besser: Team Toyota. Transplanting the Toyota Culture to the Camry Plant in Kentucky. Albany: State University of New York Press, 1996. Laurie Graham: On the Line at Subaru-Isuzu: The Japanese Model and the American Worker. Ithaca: ILR Press/Cornell University Press, 1995. John Price: Japan Works. Power and Paradox in Postwar Industrial Relations. Ithaca: ILR Press/Cornell University Press, 1997. Acta Sociologica, 40(4), 399-407. Retrieved February 27, 2016.

Voss, C. A. (1995). Operations management - from Taylor to Toyota - and Beyond? British Journal of Management Br J Management, 6(S1). Retrieved February 27, 2016.

Winfield, I., & Kerrin, M. (1996). Toyota Motor Manufacturing in Europe: Lessons for management development. Journal of Mgmt Development Journal of Management Development, 15(4), 49-56. Retrieved February 28, 2016.

Disclosure: Searched academic database for peer review articles with the full text available using keywords “lean” and “toyota.” Is there a better way to search? Yes, but this is a start on fact finding. Please note, I used citationmachine.net for full citation at the bottom, so excuse any technical mistakes, but you should be able the original article. This is the information I have to work with, and I understand there are better articles from the same year I do not currently and immediately have access to.



Reply »

Bob Emiliani February 28, 2016
5 People AGREE with this reply

Correct; we have been facing this mindset every day, from the beginning, decades ago. The standard work for Lean failures is to instruct people on the right way of thinking/doing. That is not sufficient; we must work to a new standard.

It is like studying why a bridge stands, yet ignoring bridge failures. We must study Lean failures and the minute details that led to the failure, just as an engineer does when conducting an analysis of bridge failure.



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jim February 29, 2016

What part of the TPS System did the doctors find themselves having a challenge to apply? Was this opinion generated from within a hands on experiment or an intellectual disagreement based upon another person(s) efforts

In the experimentation did they (or does the text indicate) spell out what they were trying to change / minimize- waste, uneveness, overburden or some combination while elevating human growth toward some target: patient volume, quality care, so on.

Interesting debate.

 

always partiall to Lilian Gilbreth myself- didnt need a watch :-)

 

Jim

 



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Mark Graban March 01, 2016
1 Person AGREES with this reply

It's true there was a progression from Taylorism to Toyota.

But, the authors in the NEJM incorrectly equated them, saying Taylorism and TPS are the same thing, which we know not to be true.



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John Seddon March 01, 2016
2 People AGREE with this comment

Two physicians had the temerity to criticise ‘lean’. Guru Shook’s ‘rebuttal’ criticised them as being ‘unworthy’ and ‘irresponsible’ and described their article as ‘superficial and full of misconceptions’. Shook added a further insult, hoping that ‘they practice better science on their patients’. The lean gang piled in as a chorus, holding Shook’s coat.

With the exception of appeals from Emiliani and Bicheno no one addressed the physicians’ issues. Their argument was that standardisation of patient visit durations and electronic health records (as checklists) had increased the clinical workload and taken the focus away from patients.

The physicians had stepped on what is felt by the lean community to be an essential prerequisite for improvement: standardisation. The lean religion was called into question. And they have an important case, for standardisation in any service dealing with a high variety of demand will render the service incapable of dealing with that variety. It is the very reason that every financial services company we work with throughout Europe has given up on lean.

The UK health service no longer trumpets lean as the future, it will take longer to wane as there is no rudder of profit. The claims for improvement that keep it barely alive amount to no more than process improvements and frequently these have no bearing on overall performance; but wane it will.

Listen up! A truth has been spoken.



Reply »

Ken Hunt March 01, 2016
1 Person AGREES with this reply

If it is true John that UK health service no longer trumpets Lean as the future, all I can say is good luck with that.



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Mark Graban March 01, 2016
3 People AGREE with this reply

I addressed the physician concerns in my blog post on this:

http://www.leanblog.org/2016/01/doctors-bash-taylorism-and-toyota-lean-in-the-new-england-journal-of-medicine/

The physicians in the NEJM weren't criticizing "Lean." They were either criticizing

1) what they had experienced 

or 

2) what they had been told about "Lean" (and what was described wasn't really Lean... more like a bastardization of Lean thinking)

or 

3) they were writing about what they feared Lean would be

 



Reply »

Thomas Warda March 01, 2016
5 People AGREE with this reply

It occurs to me that this subject has become somewhat of a mudslinging match with Lean practitioners facing off against healthcare professionals. Maybe it’s time to drop the mud pies and seek some common ground. In that vein, I offer the following:

  • Lean is not the only continuous improvement methodology out there. Practiced correctly though, it is one of the absolute best methodologies currently available.
  • There have been a number of misguided Lean projects / implementations in various healthcare facilities. Some of these failures were the result of misguided consultants. Some process improvement initiatives would have failed no matter what methodology was used. In these cases, it’s simply not fair to blame Lean.
  • Some Lean implementations have been much more successful than others. In my humble opinion (based on personal experience), the most successful implementations involved top leadership that was both fully involved and not afraid to say that they learned something new from the automotive industry. Those that resisted by saying “You don’t understand, we’re not making cars” were far less successful.
  • I think it is very fair to say that the healthcare system in the United States is in need of some serious process improvement. As Dr. Deming once said: “A bad system will beat a good person every time.” There are lots of good people working in the US healthcare system – and they are not (generally) the problem. What Lean strives to do is teach these good people a methodology that will allow them to continuously improve the system they work in to provide better results for not only the true customers – the patients – but the workers themselves. How can one argue against that?

And finally, neither side is 100% correct. Instead of fighting each other, both sides should seek some common ground. Healthcare professionals should accept the fact that they can indeed learn something from the automotive industry - specifically Toyota – and seize the opportunity. Lean professionals should learn that they don’t always have all the answers. Listening and learning must always come before criticizing and instructing someone on what to do. When I learned Lean / TPS from a number of very wise Shingijutsu Senseis, they always taught me by asking me tough questions and refusing to answer them for me. Maybe both sides could learn from that technique here.

Tom



Reply »

John Shook March 02, 2016
5 People AGREE with this comment

Thanks again to everyone for weighing in on this topic. The bruhaha continues :-)  

I think I need to address what seems to be a fundamental misunderstanding around the “Medical Taylorism” piece itself, and the response I wrote to it. 

I can applaud Doctors Hartzband and Groopman for raising their voices about the true cause of their concerns (as I mentioned in my rebuttal). The docs are dismayed (understandably) by the encroachment of bureaucrats imposing “efficiency” programs on their profession in the US. This means things like (starting around 25 years ago) “managed care”, Joint Commission requirements, new requirements of Obamacare,compliance with various quality standards that restrict their judgement as physicians, and so on. 

But note that the docs were NOT victims of a botched lean implementation (as exemplified, for example, by the experience of Dan Riley, in his comment above) nor where they even touched by ANY lean initiative. If they were, I would certainly applaud and want to run to their andon call. But they lack a "gemba", and any direct observation, and weren't talking with experience about "lean" or Toyota methods at all. They were lamenting "efficiency programs" and simply made a mistaken connection. 

They had HEARD about lean, or Toyota methods, being brought into healthcare and, (again, understandably) made an incorrect assumption between lean and the efficiency programs that have confounded them. The hospital they work in has never had one of the famously misguided, consultant-led, prescriptive “lean programs”. The CEO did lead a “soft” initiative, with no one ever being required to do anything, the opposite of what’s being assumed by some commenters in this thread, with no prescriptive forcing of any lean tools, processes, or even terminology.  (I know this from being familiar with their situation because they work in the hospital I’ve been attending the past years and I know people who know them well.)  Now, there are problems with THAT (very soft) approach, too – I actually agree that failures and failure modes deserve serious study, which is in fact precisely the genesis of our lean transformation framework.  Hence I saw the need to distinguish between Taylorism and Toyotaism as it was being depicted in the influential NEJM.

My real quarrel was more with the NEJM than the authors, so perhaps I was a bit harsh with them. The NEJM, upon receiving submission of a piece such as Medical Taylorism, should handle it as they would handle a submission regarding any specialty – they should send it out for expert peer review. Any of the commenters to this Post will do just fine. Instead, the NEJM editors published it as-is because they don’t think of “improvement” as a science. This is, in fact, a big concern for all of us in the improvement community. Our – LEI and the Lean Global Network – response is to continue to work with the lean community to advance the Lean Transformation Framework as a heuristic framework for both study and application.

So, in some ways, the fun bruhaha has been much ado about nothing. Words, semantics can be our friend and can be our foe. I think there's actually very little (but more than zero) disagreement of real substance.  

One thing I learned from this is to never publish a Post right before going on vacation (or TRYING to be on vacation). With this, I'm out again until next week. - best, john   

 



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James B. Couch, M.D., J.D., FACPE March 02, 2016
2 People AGREE with this comment

Dr. Shook:

Your editorial had me practically jumping up and down excited about how brilliantly you took apart the NEJM article erroneously comparing Lean (and other related disciplines such as Six Sigma) to Taylorism (i.e. Time-Study methods which date back to the early 20th Century that, unfortunately, still drive productivity processes at a lot of volume vs. value based medical practices).  The application of  Lean Six Sigma (LSS) to the monumentally wasteful (and often deadly) $3.1 trillion healthcare industry (responsible for 440,000 annual preventable deaths in American Hospitals alone)  has been one of the only bright spots in the many efforts by those like yourself to try to extract value from our "Sickness System".  

I was trained by Dr. Mikel Harry, who also personally educated Jack Welch, to be the first physician in the country to apply  Six Sigma to a healthcare organization (actually a health insurance organization) back in 1992.  We found $55 million in waste in just that organization's 487 step claims paying process, alone.  Since that time, many others have applied Lean Six Sigma to healthcare with great ROI.  One of the most notable was Patricia Gabow, M.D., long time CEO at the Denver Medical Center (and Distinguished Alumna of Penn's Medical School).   LSS turned that municipal hospital from one just barely suriving clinically and financially into one that has become a national model for superior value care delivery from the perspectives of payer, purchasers, providers, policymakers and, most importantly, patients (the 5P's). 

I can also attest that as a physician and attorney, I found that of the hundreds of malpractice cases I have reviewed (for the defense) that most were rooted in doing too much (haphazardly) for patients, not too little.  This is only logical based on the principles that drive LSS, viz.: the more steps (often unncessary) in a process (such as diagnosis and treatment), the greater the opportunities (and actualities) of errors and resultant harm (not to mention skyrocketing costs often not covered by insurance).  This finding served as one of the major themes in my recently published book:  "Achieving the Quadruple Aim in a Technology-Driven Transformed Health System:  Better Care, Improved Health, Lower Costs and Decreased Medical Liability."

Keep up your great work!

Sincerely,

Jim

James B. Couch, M.D., J.D., FACPE

Senior Physician Executive

JHD Healthcare Partners, LLC

Fellow, Benjamin Franklin Society

University of Pennsylvania

908 642 6224

JCouch@jhdhp.com



Reply »

Jack Billi March 03, 2016
4 People AGREE with this comment

What Drs Hartzband and Groopman object to (appropriately) is the mindless pursuit of time efficiency to the detriment of individual patient care and disempowerment of physicians and staff. I basically agree with that. What I disagree with is their labeling this mindless pursuit as “lean”. That’s the biggest error in the article. As John Shook once said, "You can do any old crap and call it lean." 

Dave LaHote describes lean as "creating the most value for the customer (patient, for one) consuming the fewest resources through the creativiy of the workers (doctors, nurses, staff)". (The parentheses are my translating into healthcare.) Managers and leaders do a huge disservice to the community striving to use scientific problem-solving at the front lines when they use the term "lean" to describe cost cutting, cookie cutter approaches, and copy-pasting solutions delivered by consultants to improve efficiency. But think of a healthcare organization in which every worker takes the initiative daily to find and fix the root cause of the most important problem he/she faces, while their leader help them - that's what I want in a healthcare organization, and in my organization we call that "lean".



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Dave Wakeman April 08, 2016

As another great communicator wrote, way back in 1596 and repeated many times since, "... truth will out"

Shakespeare - The Merchant of Venice



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