The Toyota Production System: What Does It Mean and What Does It Mean for Healthcare?

The Toyota Production System (TPS), also known as the Lean (Lean) Management System, is already helping healthcare organizations deliver high-quality care at low cost, and it promises to do so much more. However, the potential benefits of TPS/Lean are threatened by the 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 which described his theory of workers in the processes of manufacturing. The equating of Taylorism and TPS couldn’t be further from the truth.

Hartzband and Groopman go on to state that the principles of TPS, as applied to create near-zero manufacturing defects, do not work in patient care. Our experience and that of others points in the opposite direction. In fact, the use of TPS principles in healthcare has enabled clinical teams at ThedaCare in Wisconsin to provide zero medication reconciliation errors when measured over an 11-month period.

Taylor believed in the “science” of the manufacturing process. It meant that there was a way to accomplish a task, and it was management’s job to determine that way and ensure that all workers carried out the plan that management had devised. Workers were nothing more than cogs in a wheel and their thinking skills were not considered necessary. Henry Ford at this time asked “Why do every time I ask for a pair of hands they come with a brain attached?” This is Taylorian thinking, not Toyota thinking.

The foundations of TPS/Lean management, for their part, are based on the teaching of W. Edwards Deming. Deming taught that frontline workers should be tasked with improving processes using plan-do-study-act (PDSA) cycles. Management’s job was to coach and mentor employees to become partners in improvement. TPS is based on the fundamental principle that the people doing 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, which engages everyone’s brain in a scientific method of improvement, is used by doctors and other healthcare professionals to improve their own work. We are far from the Taylorism of 100 years ago.

The TPS/Lean management system also differs significantly from traditional healthcare management. The traditional approach is autocratic and involves “management by objectives”. This means that leadership sets the goals and managers do whatever it takes to achieve the desired results. The results determine whether the manager manages to keep her job. To get results, she can use any means necessary, including firing people or, in the case of the Phoenix VA, falsifying wait time records.

The TPS/Lean alternative is “management by process”. A term coined by Deming to describe a series of management skills and processes needed to achieve consistent results. In this system, managers cannot do whatever they want. They must learn the basics of management practices focused on teaching frontline workers to identify and solve problems on their own.

The roles and responsibilities at each level of management are clearly defined under TPS/Lean. Frontline managers teach frontline staff problem solving; they do not solve the problems themselves. Vice Presidents (VPs) spend their time in the workplace instead of sitting in their offices – they are with managers and frontline staff to ensure that improvement work is aligned with organization’s critical goals. VPs are also responsible for mentoring, facilitating and teaching, allowing everyone to see the waste and eliminate it.

Senior managers, on the other hand, create clarity for the organization. They establish the handful of metrics that guide the organization and determine the few game-changing strategies that matter to patients — not 248 strategic initiatives, which one of us (John Toussaint) recently observed at a hospital.

The application of the principles of TPS/Lean management is relatively new in the field of health, it dates back approximately 10 years. Frankly, some efforts introduced by supposed “experts” have been far from the truth. Organizations that have stayed true to the original principles of TPS have achieved remarkable results. For example, Stanford Hospitals and Clinics reduced median ER length of stay by 11% and door-to-doctor time by 43%. For admitted patients, Stanford reduced the time between the patient’s decision decision and the patient’s discharge from the service by 23%, and reduced the time to discharge by 22%. The number of patients who left without being seen fell from 2% to 0.6%.

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 provide the lowest cost and highest quality. of all Responsible Care Organizations (ACOs) in the Pioneer program. . Virginia Mason in Seattle, Washington reported similar excellent results for the cost and quality of back pain treatment.

More recently, the Centers for Medicare and Medicaid Services (CMS) decided to apply the principles of TPS/Lean management to their daily work. The agency reduced requests for major information technology (IT) system changes by 95% after implementing quality reporting programs, eliminating approximately 9,000 hours per year of employee time and money. – contractors. CMS has also reduced contract modification time by more than 50%. CMS has catalyzed interest in TPS/Lean among thousands of its suppliers, including many Quality Improvement Organizations (QIOs). The adage, “As CMS goes, so goes the industry” suggests that we will see an increasing number of healthcare organizations applying the principles of TPS.

It is true that what used to be called TPS may have failed in some health facilities. This is where the problem lies. National standards for the application of TPS in healthcare have not been established. However, the large number of organizations and physicians seeking to understand this methodology and the notable success that has been achieved with it suggest that it has merit.

What is needed now is research comparing the results achieved with TPS/Lean management to what the traditional healthcare management system offers. Early evidence is encouraging, but there is still work to be done.

As the healthcare 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 more and more necessary. There remains too much unwarranted waste and undue complexity in the delivery of patient care, 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 safe, efficient, effective, personalized, timely and equitable care.

Author’s note

John Toussaint is the CEO of Thedacare Center for Healthcare Value. The Center meets the learning needs of some of the organizations mentioned or linked in the blog.