May 5 2018
French TV Show Blames Nurse Suicides On “Lean Management” In Hospitals
On September 7, 2017, France2’s Envoyé Spécial (“Special Correspondent”) had a feature about a suicide epidemic among nurses at French public hospitals and blamed it on the adoption of management practices from the private sector, and singled out “Lean Management” as a method from the car industry that resulted in treating patients like cars and nurses like assembly line workers. It went on to explain that it was Ford’s system “from the 1930s,” dressed up by Toyota with a few Japanese words.
Besides the reporters’ inability to get basic facts — Ford’s system is not from the 1930s and Toyota’s is not a copy of it — I don’t recognize here any of the approaches I have heard from colleagues involved in health care, like Mark Graban, Pascal Dennis, or Katie Anderson, and it doesn’t match my experience as a patient in a healthcare network that has had an active Lean program for four years. Mostly, what I have noticed is less waiting when I show up for appointments, friendlier staff, and enhanced online services, including communications with doctors.
Are management practices from the private sector necessarily worse for health care workers and patients than those of the public sector? There is no single answer to this question. It depends which public sector and which companies. It’s not a foregone conclusion. If life expectancy is a measure of the effectiveness of a health care system, by the time the Soviet Union dissolved in 1991, with its Semashko state-run health system, Soviet citizens had a life expectancy of 69 years, compared to 75 for the mostly privately-run American system. On the other hand, in 2017, British citizens, with their government-run National Health Service, have a life expectancy of 81 years, which is 2 years more than Americans.
Regarding Lean Management, we could argue that increasing the number of patients per nurse and pressuring the nurses for speed is not true Lean but the hospitals were probably sold on this approach by consultants who used the “Lean” label, which isn’t protected.
And the reporters didn’t bother to check any details. For example, they show a Toyota sign with “Muri, Mura, Muda” on it but don’t seem to realize that eliminating “Muri” means eliminating tasks that overburden or stress employees, and that making nurses rush through their tasks with patients is the opposite, adding “Muri.”
From a broader perspective, I think it’s more useful to focus on the issue of whether hospitals have anything to learn from manufacturing, and the fact is that they already have, for a long time. The practice of having surgical instruments lined up at the start of an operation with the nurse ready to hand the right one on request to the surgeon is the result of an analysis of this work done 100 years ago by Frank and Lillian Gilbreth, the same industrial engineers who came up with the rising shelves to deliver bricks to bricklayers within arm’s reach and the rotisserie fixture for engine assembly.
Today, there are many workflows in hospitals whose improvement stands to enhance rather than degrade the patients’ experience and their interactions with the staff, ranging from the intake and discharge procedure to the delivery of food and medication, and I don’t see why these areas shouldn’t borrow ideas from manufacturing as well as other business activities, particularly in mistake-proofing.
That nurses have been led to suicide by management actions is a tragedy. The blame for it lies with the managers who took these actions, and these actions have nothing to do with Toyota, its production system, or its management practices.
In the report, a pediatric surgeon explained that, to increase the productivity of his operating room, surgeries were scheduled for fixed durations, like from 8:00 to 8:30 AM, with the next patient being put under anesthesia while the first patient was still being operated on. What could possibly go wrong? If the first surgery took longer than expected, the next patient was given an extra dose of anesthetics to keep him from waking up too early, and this had consequences…
It sort of looks like the sort of things you do on a factory floor, for example doing much of the setup for the next product while the machine is working on the previous one. However, it shouldn’t take a surgeon to see that this logic does not apply to hospital patients.
#LeanHealthCare, #FrankGilbreth, #LillianGilbreth
May 6, 2018 @ 10:52 am
“It went on to explain that it was Ford’s system “from the 1930s,” dressed up by Toyota with a few Japanese words.”
Yeah, the producers of that piece clearly didn’t do much to understand Toyota or Lean.
I wonder if there is a transcript online that could be Google-translated from French into English?
Healthcare certainly can learn from manufacturing (as well as learn from aviation and other settings). In the case of the Gilbreths, there was a 19 year lag… time elapsed between Gilbreth presenting these ideas and the time when the AMA endorsed this practice of having a “surgical caddy” hand instruments to surgeons, which meant surgeons could focus on the patient and their work instead of digging around searching for instruments.
An engineer having the “right” answer often ends up turning people off because, well, people are complicated. It’s more complicated than calling healthcare professionals “resistant to change.”
The one way Lean gives us, I think, a fighting chance is that modern Lean is about engaging people and helping them figure out how to improve their work. Imagine if the Gilbreths had helped surgeons discover these opportunities instead of telling them a better way?
May 6, 2018 @ 10:54 am
Also, do you have a link to the specific segment in question? The 3 May episode on the YouTube page you linked to seems to be a lot about frogs and nature.
May 6, 2018 @ 7:52 pm
Thanks for the details. Given that this is your bailiwick, I was hoping you would chime in. The story actually aired in September, 2017 but it took six months before TV5Monde, the French language channel in the US, showed it. You can see it at:
https://www.youtube.com/watch?v=u3GPZJhbdlE
but it’s in French with no subtitles.
May 8, 2018 @ 5:16 am
“treating patients like cars and nurses like assembly line workers”
Reflecting on this more, I think the people who lob this criticism have usually NEVER been in a car factory.
Of course patients have feelings and emotions that a car does not. Hospitals can never lose sight of that in the name of efficiency.
That said, many hospitals (before Lean) have nurses who are overburdened and don’t have time to be fully present with patients. So, the current state isn’t necessary good or caring.
A car on the assembly line is not left unattended. All of the parts and supplies that are needed are always right there. Nobody has to run off to find parts, leaving the car alone. If there’s a problem, somebody can call an alert and get help immediately. Quality comes first on the assembly line.
I could only hope to be treated that way if I were a patient.
As for assembly line workers… Dr. Donald M. Berwick, founder of the Institute for Healthcare Improvement, wrote this in a 1989 New England Journal of Medicine article titled “Continuous Improvement as an Ideal in Healthcare” (he was promoting Masaaki Imai-style Kaizen):
Imagine two factories (I’ve edited it slightly to be less gender specific):
“In situation factory, the supervisor walks the area, watching carefully. “I can see you all,” she warns. “I have the means to measure your work, and I will do so. I will find those among you who are unprepared or unwilling to do your jobs, and when I do there will be consequences. There are many workers available for these jobs, and you can be replaced.
In factory two, the supervisor says, “I am here to help you if I can,” she says. “We are in this together for the long haul. You and I have a common interest in a job well done. I know that most of you are trying hard, but sometimes things can go wrong. My job is to notice opportunities for improvement – skills that could be shared, lessons from the past, or experiments to try together – and to give you the means to do your work even better than you do now.”
Which of those assembly lines sounds like a better place to work? Most hospitals are more like “factory one” when healthcare workers would benefit greatly from “factory two” management styles.
May 8, 2018 @ 5:19 am
“It sort of looks like the sort of things you do on a factory floor, for example doing much of the setup for the next product while the machine is working on the previous one. However, it shouldn’t take a surgeon to see that this logic does not apply to hospital patients.”
It’s a question of what setup should be “internal.” There’s certainly some prep for the next patient that can be externalized… but externalizing anesthesia is probably a bad idea. Even if a bad Lean consultant is pushing the idea of doing anesthesia early, the doctors should push back on that, right? Unlike “factory one” assembly workers, doctors have a lot of professional power and autonomy that should be a defense against bad Lean, unless their leaders are threatening their jobs for not going along (which isn’t Lean either).
May 8, 2018 @ 5:24 am
Michel – Thank you for sharing the article and your reflections. From what you describe of the situation, it certainly is not a case of actual lean thinking being practiced, but rather “Lean” in name only. Respect for people is fundamental to Lean thinking and practice, and it sounds like that was missing in this situation.
My experience with Lean thinking and practices in healthcare settings – when done with the intention of engaging people who do the work to solve process problems that get in the way of excellent patient care – is that is is a very positive experience for people. Sadly, it sounds like this was not the case in this situation.
May 8, 2018 @ 6:36 am
The standards of French journalism are low. Whether in print or on TV, the reporters have a tendency to tell you what to think about events rather than what happened. Whenever I have had direct, personal knowledge of a topic, I found their coverage to be inaccurate.
At the heart of this story is an epidemic of nurse suicides. The exact number of nurse suicides in France in 2017 is actually hard to pin down. The video quotes 8. According to the French health ministry, there are 660,611 nurses in France, which works out to 1.2 suicides per 100,000 nurses per year. This raises a couple of cold-hearted questions that should have been asked:
I don’t know the answer to the first one but the reporters should have it. For the second one, per year, the French commit suicide at the rate of 14.7 per 100,000, which is 12 times the rate for nurses.
By comparison, this is how The San Jose Mercury reported on the suicides of Palo Alto teenagers on 3/3/2017:
Assuming the number of nurse suicides is a massive increase over the past, the report puts the blame squarely on “Lean Management” with no nuances whatsoever, and that’s what the French viewers saw.
May 8, 2018 @ 7:42 am
Michel – I think the question about suicide rates can be asked with empathy. Each sucide is a tragedy. But, like you said, is there a statistically significant increase in the number? If not, there’s no “effect” to assign a “cause” to. Are the suicide rates for nurses lower than the general population? If so, couldn’t Lean management be credited for that?
Doctors of veterinary medicine have very high suicide rates and Lean management is really nowhere to be found in veterinary medicine.