May 5 2018
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.