Can we “Toyota” heathcare?

Can Quality Healthcare be Created Using Industrial Methods?  

In the pursuit of quality in healthcare, many hospitals and physician groups have adopted methods that have been successful in industrial settings. The most famous and popular of these methods are the Toyota Production System (TPS), also called “Lean Management” because the TPS emphasizes the elimination of waste in all its forms, and Six Sigma, which was popularized by General Electric (GE) and Motorola. An organization operating at Six Sigma levels will make on 3.4 errors or have only 3.4 “defects” per one million opportunities for error. These methods have in common a specific formula for process improvement and a focus on continuous improvement. Using its system, Toyota has become the most successful car company on the planet and using Six Sigma, GE is able to build aircraft engines that are, for all intents and purposes, perfect. Given what we know about the high rates of error in healthcare settings,  it is easy to see why hospitals and provider organizations would be interested in TPS and Six Sigma.

And, the influence of industry has not stopped with industrial process improvement methods. If quality is a problem in healthcare, many would argue that customer service is even worse. Patients not uncommonly complain about long waits, surly staff, and entitled and self-centered physicians. Small wonder, then, that many healthcare organizations have sought customer service training from the Ritz Carlton and Disney. The question is, however, can these methods, which have been so successful for their parent organizations, achieve similar results in hospitals and physician practices and if they cannot, what methods should be used to drive quality?

In order to answer these questions, we first must think about how process improvement systems work. In a factory or production setting, process improvement is generally aimed at reducing defects, costs, or both. Costs can be reduced by simplifying systems (e.g. eliminating unnecessary steps), using fewer raw materials or people in a process, or reducing processing time without adding more personnel. Reduction of defects is often more complex because it can require workers to take two completely different kinds of actions. First, they must invent a new or better way of doing something (so called “re-engineering”) which means abandoning or significantly changing a process that is (or seems to be) functioning perfectly well. Then, once the new process has been designed and seems to be achieving the sought-after results, it must be standardized so that its steps can be reliably repeated again and again, for it is only through repeating known steps with precision that excellent results can be repeatedly achieved. This process of re-engineering followed by standardization is sometimes called “unfreezing” and “refreezing”. TPS is the benchmark by which all other similar systems are measured. A typical Toyota plant will receive hundreds of suggestions for improvement every year, most of these from line employees. Toyota allows its workers the freedom to experiment with redesigning processes. But once a process has proven itself and is implemented on the production line, Toyota insists on consistency in performance. Each person performing the same task performs that task in the same manner as much as humanly possible.

As one might guess, it is much easier to take chances with process improvement and re-engineering when the only victim of a failed attempt is the right rear door on a Camry. Experimentation with actual patients is a bit more risky and that is the first limitation of industrial improvement methods in the healthcare setting. It is much harder for those in healthcare to safely alter processes in order to improve them. The second limitation is, however, the most important. Modern production methods have made products components nearly identical. That right rear door could be placed on any Camry and it would fit and function as designed. On the other hand, human beings are dramatically different from one another. Healthcare outcomes are determined by many factors, the most important of which is likely to be each individual’s genetic make-up. Modern science is only beginning to understand how the genetic code influences health and disease and we are still far from being able to use genetic information to tailor treatments to individuals. So, unlike the workers in the Toyota plant, we cannot count on consistency.

To my way of thinking, this should leave us with two slogans when we think about the application of factory techniques to the arena of healthcare. The first is one that my friend (and the author of UT Matters), Kevin Dillon, is fond of quoting: “individual results may vary”. No matter how consistent the practice, for reasons that we do not currently understand some people will respond better than others. This may not mean that our new process has failed to improve the care for most patients; it just means that the differences between people are impossible to control.

The second slogan is sometimes attributed to the great psychologist Abraham Maslow. It is: “If the only tool you have is a hammer, you tend to see every problem as a nail”. These methods can be incredibly powerful tools, but they are only tools. They are likely to help us the most when we apply them to processes similar to those for which they were designed; things that require multiple coordinated steps. So, for example, we know that blood stream infections caused by central line insertions can be reduced when the team performing the procedure adheres to an insertion protocol. But TPS and Six Sigma are likely to fail when we try to apply them to the more complex processes of medical diagnosis.

In an upcoming posting, I would like to extend these thoughts to the arena of “customer” service but until then, I welcome your comments.

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Dr. Brent King

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