Medical Taylorism, Lean, and Toyota | P.Hartzband and J. Groopman | New England Journal of Medicine

Seen today in the New England Journal of Medicine, under the signature of Harvard Medical School professors Pamela Hartzband and Jerome Groopman:

“The TPS is a set of principles designed for the manufacture of inanimate objects in a factory. We accurately depict two essential elements of this system that are directly derived from Taylorism: standardization and time efficiency. In his classic study of the application of Toyota principles to the manufacture of cars in the United States, Paul Adler describes how ‘Each job was analyzed down to its constituent gestures, and the sequence of movements was refined and optimized for maximum performance. Every task was planned in great detail, and each worker was expected to perform that task in the prescribed manner.’ Adler refers to ‘the intelligent interpretation and application of Taylor’s time and motion studies’ as key to its success. He states, ‘The reference to Taylor may be jarring, but it fits.’

[…] Other medical professionals who, like us, have experienced the toxic effects of obsessive standardization and time efficiency in the care of patients have expressed concerns similar to ours. In an era of accountability, we believe that those who advocate the application of Lean principles to medical care must take responsibility for the unintended consequences resulting from these elements shared by Taylorism and Toyota practices.”

Michel Baudin‘s comments:

The authors base their claim that the Toyota Production System (TPS) is “derived from Taylorism” from the writings of Paul Adler, a business school professor at USC who has written many papers over the past 40 years, a few of which touched on TPS and NUMMI, the first plant to apply this system in the US and now operated by Tesla. I met Paul Adler at Stanford in the late 1980s, and found his insights on NUMMI quite valuable. It was also clear to me that Paul Adler was not an engineer, that TPS, to him was one interest out of many, and that his knowledge of the subject was only at the business school level, as reflected, for example in an expression like “Taylor’s time and motion studies.” Taylor did time studies; Frank and Lilian Gilbreth, motion studies with, as stated in other posts, very different objectives.

This distinction, perhaps too subtle for business schools, is of paramount importance to anyone who wants to understand TPS, which owes much more to the Gilbreth’s work than to Taylor’s. Taylor wanted to prevent workers from slacking off; the Gilbreths, to observe the way work was being done and make it easier. And the medical profession has a good reason to remember Frank and Lilian Gilbreth: the way operating rooms function today is based on the analysis and recommendations they made 100 years ago.

Lean’s Midlife Crisis | Bob Emiliani

“It seems to be common knowledge that the Lean movement is now suffering from a midlife crisis. Lean movement leaders are perplexed at the widespread continuing emphasis on Lean tools, narrow focus on cost cutting, and the slow uptake of the “Respect for People” principle over the last 15 years. This is the outcome, despite determined efforts to inform people otherwise. I’m not surprised.”

Sourced through from:


Michel Baudin‘s comments:

While I agree with Bob’s overall diagnosis of a midlife crisis for Lean, I object to a few details, the main one being his assertion that Lean descends directly from “Scientific Management,” the brand under which Frederick Taylor sold his consulting services.

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Organize for learning to make kaizen stick | Michael Ballé

“[…]the Quality Director would ask the nursing supervisor to track the time of first incision in each theater every day and share the results with surgeons. This simple measure increased OR usage by 20% in the first month. It also led to heated discussions among surgeons (why were some late and others on time?) and paved the way for further kaizen. But then one of the crises hospitals are so accustomed to came, and the practice was abandoned. Theater usage went back to what it was before.[…]”


Michel Baudin‘s comments:

The author is missing an essential point: changes that add labor are unsustainable. They will be reversed at the first emergency and rarely if ever reinstated once the emergency is over. Asking a nursing supervisor to track the time of first incision in each operating room meant adding to his or her work, without reducing anybody else’s. It was a change all right, but not a Kaizen.

Surgeons in front of Gilbreth's grid

Surgeons with grid used  by Gilbreth to track motion on film

100 years ago, Frank Gilbreth improved the performance of operating rooms by, among other things, having nurses supply tools and instruments to surgeons rather than having the surgeons leave the patient to fetch them. Work previously done by the surgeon was offloaded to nurses for the benefit of the patient, without any net addition of labor. It was a genuine improvement and became standard practice.

The author quotes Ohno as  saying  “Why not make the work easier and more interesting so that people do not have to sweat?” Adding record-keeping tasks does not fit that bill.

See on Scoop.itlean manufacturing

Using videos to improve operations | Part 1 – Overview and Motivation

This is the first in a series of posts about  the use of video technology to improve operations. This technology is now so pervasive that it is nearly impossible to buy a phone that does not include a camera capable or recording footage that is good enough for broadcast news. Journalists use amateur videos to show storm damage or expose human brutality. We use it to identify improvement opportunities in operations.

For long-time followers of this blog, this is closely based on comments I posted 18 months ago about a news article on the application of a sports video analysis package to manufacturing. The forthcoming installments, on the other hand, are completely new. 


1. Frank and Lillian Gilbreth did it 100 years ago

Motion pictures have a long history in manufacturing. In 1895, the first film ever publicly projected onto a screen showed women leaving the Lumière Brothers factory in Lyon. In 1904, the American Mutoscope and Biograph Company shot several scenes in Westinghouse factories. In 1913, Frank and Lillian Gilbreth were probably the first to use this new technology to analyze operations, and a compilation of their films is available on line, which shows that, from the very beginning, the camera was much more than a substitute for the stopwatches used by Taylor. As is obvious from watching the Gilbreth films, where Taylor measured in order to control, the Gilbreths observed in order to improve. Taylor’s greater fame or notoriety, however, obscured this fundamental difference in the public mind, and made workers as wary of cameras as of stopwatches.

According to psychologist Arlie Belliveau:

The Gilbreths used workers’ interest in film to their advantage, and encouraged employees to participate in the production and study of work through film. Participants could learn to use the equipment, star in a film, and evaluate any resulting changes to work practices by viewing the projected films in the labs or at foremen’s meetings. Time measurements were made public, and decisions regarding best methods were negotiated. By engaging the workers as participants, the Gilbreths overcame some of the doubt that followed Taylor’s time studies.”

In other words, these pioneers already understood that, unlike the stopwatch, this technology enabled the operators to participate in the analysis and improvement of their own operations.

Until recently, however, the process of recording motion was too cumbersome and expensive, and required too much skill, to be massively practiced either in manufacturing or in other types of business operations. In addition, most managements failed to use it in as enlightened a way as the Gilbreths, and manufacturing workers had a frequently well-founded fear that recordings would be used against them. As a consequence, they were less than enthusiastic in their support of such efforts.

2. Use in Setup Time Reduction

Setup time reduction is probably the first type of project in which it was systematically used, first because the high stakes justified the cost, even in the 1950s and second because its objective was clearly to make drastic changes in activities that were not production and not to nibble a few seconds out of a repetitive task by pressuring a worker to move faster.

3. The Vanishing Cost of Shooting Videos

Technically, the cost of shooting videos has not been an issue since the advent of the VCR in the 1980s. Analyzing a video by moving forward and backwards on a cassette tape, while it appears cumbersome today, was far easier than dealing with film. The collection of data on electronic spreadsheets also eliminated the need to use counterintuitive time units like “decimal minutes.” Adding columns of times in hours, minutes and seconds was impractical manually but not a problem for the electronic spreadsheet.

With videos now recorded on and played back from flash memory, and free media-players as software, not only is moving back and forth in a video recording is easier, but the software maps video frames to the time elapsed since the beginning. We could manually transfer timestamps read from the bottom of the video player software window into electronic spreadsheets and have the spreadsheet software automatically calculate task times as the differences between consecutive timestamps.

Analyzing Data in Video Form

While this approach has been a common practice for the past 15 years, video annotation software is available today, which helps break down the video into segments for steps, label them, categorize them, and analyze them.

You can also use it to structure the data and generate a variety of analytics to drive improvements or document the improved process through, for example, work instructions. Over the previous approach, video annotation has the following advantages:It automates the collection of timestamps. Reading times on the video screen and typing hem into an Excel spreadsheet is tedious and error-prone. Plowing through the details of a 30-minute is tedious enough already.

  1. Within the annotation software, each video segment remains attached to the text, numeric or categorical data you attach to it. One click on the data brings up the matching video segment.
  2. Using parallel tracks, you can simultaneously record what several people and machines do. Of course, you can do that without annotation software too, but it is more difficult.
  3. You can still export the data you collect and analyze it in Excel, but you can also take advantage of the software’s built-in analytics.

“Video time studies” is too restrictive a name for what we do with videos. It implies that they are just a replacement for a stopwatch in setting time standards. But what we really do with videos is analyze processes for the purpose of improving them, and this involves more than just capturing times. The primary pupose of the measurements is to quantify the improvement potential to justify changes, and to validate that they have actually occurred.

4. Remaining Challenges

Putting this technology to use is not without challenges. Video files are larger than just about any other type we may use, be they rich text, databases, or photographs. And they come in a variety of formats and compression methods that make the old VHS versus Betamax dilemma of the VCR age look simple. More standardization would help, and will eventually come but, in the meantime, we have to learn more than we want to know about these issues. Functionally, the next technical challenge is the organization of libraries or databases for storage and retrieval of data captured in the form of videos. The human issues of video recording and analysis of business operations, on the other hand, remain as thorny as ever.