In their recent Perspective piece in the New England Journal of Medicine entitled “Medical Taylorism”, Drs. Pamela Hartzband and Jerome Groopman make a fundamental attribution error. They equate Lean as practiced according to the principles of the Toyota Production System that empowers workers to solve problems, with the approach used by Frederick Taylor over 100 years ago that minimized worker engagement in job design and problem solving.
While the case they present is riddled with errors, they do make two important points:
- The current practice environment is unsustainable, leading to physician discontent and burnout.
- Ample time for physician-patient interactions must be enhanced and protected.
Unfortunately, they completely misunderstand the role of Lean. It is the solution to, not the cause of, their frustrations.
Burnout’s drivers permeate medicine today: chaotic work environments, overburden, loss of control, and loss of professionalism. Root causes include: fee for service reimbursement,, directives to do more with less, inefficient EHRs, and burdensome regulations.
In some ways I don’t blame them for misunderstanding Lean. In far too many hospitals Lean is treated as a “tool” that is the “solution to a problem.” (Although not in Beth Israel Deaconess Medical Center where they both practice.) As a result, Taylorism devotees who misunderstand Lean misapply it with a top-down push for productivity and efficiency, exacerbating our problems in many ways:
- They put physicians, nurses, and support staff under further stress and thus increase burnout.
- They then fail to achieve their desired goals.
- Ultimately, they waste the resources they are devoting to Lean by approaching it incorrectly.
- Lean at Toyota is based on the principles of Respect for People and Continuous Improvement, not the century-old principles of Taylorism. By definition, Standard Work is designed by the people who do the work, not “managers with stopwatches.”
- Appropriate Lean leadership requires that the leaders understand the work and the challenges that their workers face every day. Ideally, this is achieved by creating a management system and culture in which the leaders:
- leave the boardroom and go to the bedside,
- respectfully learn from the caregivers about the barriers and frustrations that they experience regularly, and
- develop a process by which the caregivers identify and solve their own problems, with coaching and support from their leaders
Such an approach will empower physicians and their support staff to solve the problems they encounter every day, reduce the impact of regulatory and EHR-induced inefficiencies and frustrations, and increase time for physician-patient interactions.
Physicians should demand nothing less.
What is your experience with Lean in your workplace?
If it looks more like Taylorism than Toyota, how can you help change your culture?