The Toyota Production System (TPS), also known as the Lean management system (Lean), is already helping health care organizations provide high-quality, low-cost care, and it promises to do far more. However, the potential benefits of TPS/Lean are endangered by a failure of many to understand it. For example, Pamela Hartzband and Jerome Groopman claimed in a recent article that TPS/Lean was a direct descendant of “The Principles of Scientific Management,” a monograph published by Frederick Winslow Taylor in 1911 that described his theory of workers in manufacturing processes. Equating Taylorism and TPS could not be further from the truth.
Hartzband and Groopman go on to state that the principles of TPS, as applied to create near zero defects in manufacturing, don’t work when caring for patients. Our experience and that of others is to the contrary. In fact using TPS principles in health care allowed ThedaCare clinical teams in Wisconsin to deliver zero medication reconciliation errors when measured over a period of 11 months.
Distinguishing TPS/Lean From Taylorism
Taylor believed in the “science” of the manufacturing process. This meant there was one way to accomplish a task, and it was management’s job to determine that one way and make sure all workers executed the plan that management had designed. Workers were nothing more than cogs in a wheel and their thinking skills were not considered necessary. Henry Ford, in that era, asked “Why is it every time I ask for a pair of hands, they come with a brain attached?” That’s Taylorist thinking, not Toyota’s thinking.
The underpinnings of TPS/Lean management, on the other hand, are based on the teaching of W. Edwards Deming. Deming taught that front line workers should be in charge of improving processes using plan-do-study-act (PDSA) cycles. Management’s job was to coach and mentor employees to be partners in improvement. TPS is based on the fundamental principle that the people who do the work know the work best and are therefore in the best position to improve it. As Don Berwick advocated in The New England Journal of Medicine in 1989, the “kaizen” approach to continuous improvement, one that engages everybody’s brains in a scientific method of improvement, is being used by physicians and other health care professionals to improve their own work. This is far from the Taylorism of 100 years ago.
Distinguishing TPS/Lean From Traditional Health Care Management
The TPS/Lean management system also differs significantly from traditional health care management. The traditional approach is autocratic and involves “management by objectives.” This means leadership establishes the objectives and managers do whatever it takes to achieve the desired results. The results determine whether the manager gets to keep her job. In achieving results she can utilize any means necessary including firing people, or in the case of the Phoenix VA, falsifying the wait time records.
The TPS/Lean alternative is “management by process.” A term coined by Deming to describe a series of management competencies and processes required to deliver consistent results. In this system managers can’t do whatever they please. They must learn core elements of management practices that are focused on teaching front line workers to identify and solve problems for themselves.
The roles and responsibilities at each level of management are clearly defined under TPS/Lean. Front line managers teach problem-solving to front line staff; they don’t solve problems themselves. Vice Presidents (VPs) spend their time at the place of work instead of sitting in their offices — they are out with front line managers and staff to assure the work of improvement is aligned with the critical goals of the organization. VPs are also responsible for mentoring, facilitating, and teaching, enabling each person to see waste and remove it.
Senior executives, on the other hand, create clarity for the organization. They establish the handful of metrics that guide the organization and determine the few breakthrough strategies that matter to patients — not 248 strategic initiatives, which one of us (John Toussaint) observed at a hospital recently.
Applying the principles of TPS/Lean management is relatively new in health care, approximately 10 years old. Frankly, some efforts introduced by supposed “experts” have been far off the mark. Organizations that have stayed true to the original principles of TPS have achieved remarkable results. For instance, Stanford Hospitals and Clinics reduced the median length of stay in the Emergency Room by 11 percent and door-to-doctor time by 43 percent. For admitted patients, Stanford reduced the time between decision of patient disposition and the patient departing the department by 23 percent, and reduced the time until discharge by 22 percent. The number of patients who left without being seen dropped from 2 percent to 0.6 percent.
And as mentioned earlier, ThedaCare has had success with TPS/Lean: In Appleton, Wisconsin an entire population of 15,000 Medicare beneficiaries was managed using TPS principles to deliver the lowest cost and highest quality of all accountable care organizations (ACOs) in the Pioneer program. Virginia Mason in Seattle, Washington has reported similar excellent results for back pain treatment cost and quality.
More recently, the Centers for Medicare and Medicaid Services (CMS) has been on a journey to apply the principles of TPS/Lean management to its daily work. The agency has reduced requests for major information technology (IT) system changes after the implementation of quality reporting programs by 95 percent, eliminating approximately 9,000 hours per year of employee and contractor time. CMS has also reduced contract modification time by more than 50 percent. CMS has catalyzed interest in TPS/Lean among thousands of its vendors, including many of the Quality Improvement Organizations (QIOs). The adage, “As CMS goes so goes so goes the industry” suggests we will see increasing numbers of health care organizations applying the TPS principles.
It is true that what has been called TPS in the past may have failed at some health care institutions. Therein lies the problem. National standards for applying TPS in health care have not been established. However, the sheer number of organizations and physicians that are seeking to understand this methodology and the notable success that have been achieved with it suggest that it has merit.
What is needed now is research that compares the outcomes achieved with TPS/Lean management to what the traditional health care management system is delivering. Early evidence is encouraging but there is more work to do.
As the health care payer, policy, and provider communities continue to develop new patient care delivery models to align with new payment models, the TPS/Lean management system and tools are increasingly needed. There remains too much unjustified waste and unwarranted complexity in delivering care to patients, exposing them to errors and complications. It is time to marry the science of management systems as embodied in TPS/Lean with the science of medicine to achieve care that is safe, efficient, effective, personalized, timely, and equitable.
John Toussaint is the CEO of the Thedacare Center for Healthcare Value. The Center supports the learning needs of some of the organizations mentioned or linked to in the blog.