In a previous post on the burden of measurement in healthcare and education, I mentioned in passing an opinion piece by Pamela Hartzband and Jerome Groopman, “Medical Taylorism”, NEngl J Med 374;2, January 14, 2016, 106-108, http://www.nejm.org/doi/full/10.1056/NEJMp1512402.
Hartzband and Groopman challenged the universal application of Toyota-inspired Lean methods to improve health care.
As I noted in the measurement blog post, spirited rebuttals that describe a people-centered application of scientific management in general and the Toyota Production System perspective specifically may be found in the comments to the NEJM paper on the NEJM site, as well as more extensively here, here , here and here.
I agree with the critics that Hartzband and Groopman failed to adequately differentiate the attitude and practice of so-called scientific management developed by Frederick Taylor from the modern philosophy and methods of the Toyota Production System and the Lean systems derived from TPS. TPS/Lean is certainly not identical with Taylor’s search for a fixed “one best way” in a given clinical service, to be imposed by managers on unthinking staff.
Along with the critics, I am convinced that the philosophy and methods of Lean provide a way for managers and clinicians to improve quality and reduce costs, especially by removing waste in the host of activities that support the clinical interaction between provider and patient.
Hartzband and Groopman in fact note that scientific management in medicine, in particular the “one best way” method, has improved performance in applications like reduced infection rates in hospitals and treatment of stroke patients.
Here’s a key point of their perspective: they question whether scientific management applies to all areas of medicine, for example “…to such cognitive tasks as eliciting an accurate history, synthesizing clinical and laboratory data to make a diagnosis, and weighing the risks and benefits of a given treatment for an individual patient.”
I think Hartzband and Groopman raise a fair question, which was asked more calmly by Bataldan et al. in a discussion of the coproduction of healthcare (our blog post about the Bataldan article is here ).
Hartzband and Groopman go on to say: “Good thinking takes time, and the time pressure of Taylorism creates a fertile field for the sorts of cognitive errors that result in medical mistakes. Moreover, rushed clinicians are likely to take actions that ignore patients’ preferences.”
I’m open to the possibility that aspects of medicine (and education) characterized by coproduction of value will not benefit from application of Lean methods, without important adaptations.
On the other hand, improvement of support systems to reduce waiting time, errors and duplication of effort certainly makes sense no matter what the answer to the general question about Lean’s range of application.
Improved support systems, managed intelligently and scientifically, have the potential to provide the time and resources for the great care and rewarding work that Hartzband and Groopman fear is slipping away.
Real Numbers: Management Accounting in a Lean Organization (http://www.lean.org/BookStore/ProductDetails.cfm?SelectedProductId=139) published 13 years ago, discusses concepts of management accounting for organizations deploying a version of the Toyota Production System.
Cunningham and Fiume distill useful advice and experience; this short book is worth your time.
Based on the authors’ experience in the first wave of Lean application in the United States in the 1980s and 1990s, Cunningham and Fiume outline how standard accounting systems mislead or prevent understanding of organization performance. Information that could be useful typically arrives in reports that are hard to understand and too late to matter.
As Cunningham and Fiore say: “We believed we had more to offer than incomprehensible monthly reports; we could provide the information that give businesses a more complete picture of reality.” (p. 4).
While part of the discussion applies only to manufacturing companies—e.g. valuation of inventory and warranty reserves—Cunningham and Fiore offer practical advice for accounting and, more generally, measures and measurement for operations management.
The authors start with the basic pillars of accounting as they lay the foundation to contrast traditional accounting with accounting relevant to a Lean organization:
These four pillars offer insights for all organization measurement as you develop measures and measurements that people can use to control and improve their organization’s performance.
Materiality addresses two features. First, what is the relevance of a proposed measure—do you need to know this information to control or improve the business? Second, how precisely do you need to know a particular number? If your action won’t change given a 10% range in a reported number, then an effort to report a more precise value is immaterial (and in Lean language, waste.) For my clients, this is what I mean when I ask them if a proposed measure is “good enough” for use.
Conservatism “…means you should not overemphasize the good news or under-emphasize the bad news.” (p. 32) The use of run chart and control chart rules for any measures can help avoid claiming existence of for trends where the evidence is weak.
Consistency “guides us to present facts in the same manner each time they occur.” (p. 34). Two recent client examples illustrate this pillar. First example: a project to improve performance of primary care practices found it difficult to align measure definitions across clinics, in different health systems. In many efforts to improve performance and understanding, it suffices to have the measures and measurements consistent within each clinic. “Constant bias” makes it possible to see changes over time within each clinic and provides enough consistency to gauge performance.
Second example: colleagues developing a system of patient reported measures (http://www.ihi.org/resources/Pages/Publications/PatientReportedMeasures.aspx) have to wrestle with defining a regular time interval of surveys. They aim to have a fixed interval (e.g. 12 months between screening for depression using the PHQ-2 or PHQ-9 surveys) so that any changes in measures are comparable between individuals and among groups of patients.
Matching at first view looks like it is a purely accounting concept relevant to manufacturing because it is based on an accounting rule: “All costs to manufacture the good you sell must be recognized as an expense in the month you recognize revenue.” (p. 35) On the other hand, usually costs are recognized in the period in which they are incurred. The authors point out that the interplay of these two recognition rules generates a lot of accounting discussion and transactional activity. (Of course in Lean manufacturing organizations, as cycle times from production to sale decrease dramatically and inventories shrink, most costs will just be incurred in the current month.)
Matching in fact relates to a general measurement principle that applies broadly: a measured quantity should align with the time period that spans the actions that generate the numbers. That’s so you can match patterns in the time series with the actions. For example, tracking and displaying “near miss” incidents in time order in an ambulatory surgical center is far more informative than looking at an annual summary of these incidents and then attempting to understand potential causes.
Dr Maren Batalden and co-authors in “Coproduction of healthcare services” (BMJ Quality and Safety, published online16 September 2015) (http://qualitysafety.bmj.com/content/early/2015/09/16/bmjqs-2015-004315.full) remind readers that production and delivery of products and services are different.
In particular, “[h]ealthcare is not a product manufactured by the healthcare system, but rather a service, which is cocreated by healthcare professionals in relationship with one another and with people seeking help to restore or maintain health for themselves and their families.” (p. 7).
The authors cite with approval three defining features of services (Osborne SP, Radnor Z, Nasi G. “A new theory for public service management? Toward a (public) service-dominant approach”, Am Rev Pub Adm 2012; 43,135–58) :
“(1) a product is invariably concrete, while a service is an intangible process; (2) unlike goods, services are produced and consumed simultaneously and (3) in services, users are obligate coproducers of service outcomes.”
Dr Batalden explores her perspective on a March 24 2016 WIHI podcast.
While health outcomes are always produced by provider and patient working together, Dr Batalden notes that there is a range of relative contribution over time and across patients. On the WIHI podcast, she used the blue and green pictures at the top of this post to show schematically the degree of agency of the two participants: blue for patient agency and green for health professional agency, with the horizontal dimension representing time.
As Dr Batalden says, “You can play with the shapes over time to imagine the way in which the agency and dynamics might change over time or in different situations.”
For example the middle stripe could represent a patient who mostly operates without assistance from the health care professional, with occasional acute events in which the patient has little agency, e.g. in emergency surgery events.
Once you accept that products and services are different, you’re ready to consider a key point raised by the authors:
Should we expect theory and methods of management and improvement developed and deployed in the world of product manufacturing to apply directly to management and improvement of services?
One literature review article suggests the answer is “No.” (D. Arfmann et al. (2014), “The Value of Lean in the Service Sector: A Critique of Theory and Practice”, International Journal of Business and Social Science, 5, No. 2, 18-24) (http://ijbssnet.com/journals/Vol_5_No_2_February_2014/3.pdf)
Nonetheless, there are numerous examples of Toyota Production System applications in healthcare, with strong advocates and compelling stories. Interestingly, many of the most compelling examples I’ve learned about involve application of TPS methods in hospitals, diagnostic laboratories, and pharmacies.
Dr. Bataldan’s green and blue pictures hold a clue that may explain why.
For episodes or events in which healthcare professionals have most of the agency, over a short period of time, health services behave less like pure services. For example, specific interventions like hip or knee joint replacements, cataract surgery, or implant of ear tubes in children might be called “product-like” services.
In particular, product-like services are dominated by a concrete procedure and may involve a specific physical item like a replacement joint or a drain tube.
For product-like services, I expect that theory and methods of operations management and improvement developed in manufacturing like the Toyota Production System will be useful.
For healthcare experiences that are far removed from products—like chronic disease experience and management involving adults with diabetes or children with irritable bowel syndrome—direct application of Toyota Production System methods seem less immediately appropriate. For example, trying to map chronic disease management into a standardized linear value stream with specific inputs and outputs and meaningful cycle time measurements can lose vital complexity and meaning.
Dr Bataldan and her co-authors conclude:
“Improving healthcare service using [the construct of coproduction] invites us to consider new ways of preparing health professionals and socialising patients, new organisational forms and structures for healthcare service delivery, and new metrics for measuring success. Like any paradigm, the construct of coproduced healthcare service is imperfect and contains its own pragmatic challenges and moral hazards, but these limitations do not negate its utility. Marcel Proust suggested that the real voyage of discovery consists not in seeking new landscapes, but in having new eyes. Perhaps this lens of coproduction will help us see healthcare service with new eyes.” (p. 9)
It’s a worthy challenge to understand how to manage and improve health services like those discussed by Bataldan and her co-authors. The lens of coproduction should indeed help us see better.