Blog: NEJM writers confuse 'Medical Taylorism' with 'Lean'

The latest New England Journal of Medicine has launched a frontal attack on the application of Toyota's Lean manufacturing techniques to healthcare settings, which was the subject of a Modern Healthcare cover story last September.

The NEJM Perspective by Drs. Pamela Hartzband and Jerome Groopman has already come under attack from Lean experts.

"Toyota-ism and Taylor-ism are not the same thing. Toyota operates in a far different way," writes Mark Graban, a frequent consultant to hospitals in instituting Lean techniques.

Hartzband and Groopman argued in their piece that Lean advocates think "patient care should follow standardized systems like those deployed in manufacturing automobiles. Colleagues have told us, for example, that managers with stopwatches have been placed in their clinics and emergency departments to measure the duration of patient visits."

"This is wrong headed and insulting toward Toyota," counters Graban. "I'm pretty sure Toyota would not alienate physicians or other healthcare professionals this way."

It is easy to understand why Graban is upset. Frederick Taylor, an early 20th century industrial engineer, is the father of scientific management. At the dawn of the mass production era, industrialists like Henry Ford used his time-study techniques to break up industrial processes into their constituent parts. Each worker in the first assembly lines was given a small and repetitive role, whose demeaning nature was best portrayed by Charlie Chaplin in his 1937 movie "Modern Times."

Toyota's Lean manufacturing system, on the other hand, was invented in Japan after World War II with the help of an Iowan, W. Edward Deming, who believed improved productivity and quality came from working in teams, breaking down silos of activity, and applying tools like measurement and statistics to foster steady, small improvements in work processes. "Lean manufacturing and Deming focused on the importance of treating employees with respect and creating systems that allow employees to think and drive improvement," a blogger on the Deming Institute website wrote a few years ago.

There probably are some hospitals or large physician practices that have time-study engineers running around with stop watches and calling it an application of "Lean" techniques, as Hartzband and Groopman assert. But process improvement malpractice shouldn't be used to condemn an entire approach to enhancing quality and productivity.

The editors at NEJM might want to go back and read this 1989 article by Dr. Donald Berwick, who later launched the Institute for Healthcare Improvement and became the head of the Centers for Medicare and Medicaid Services. Its title: "Continuous Improvement as an Ideal in Health Care."