Tuesday, December 11, 2012

La méthode Toyota pervertie

An article last month in Montreal's La Presse, entitled "Soins à domicile: tollé contre la méthode Toyota" ("Home Care: Outcry against the Toyota Way") set forth a terrible scenario in which the wrong application of the Lean approach in the home health care setting led to awful results.

Here's a rough translation of some excerpts (with thanks to Google translator and apologies for inaccuracies. Je ne parle pas français.):

The implementation of the famous Toyota Way in home care in Montreal by a private firm is currently causing nurses, social workers and occupational therapists to be on the verge of hysterics. And it is on track to cost a small fortune in the health care system in a context of budgetary restrictions. The new Minister of Health, Dr. Réjean Hébert, has also pledged to hold accountable those health centers that are in the process of implementing the method.

In Montreal, a dozen centers of health and social services centers (CSSS) recently approved contracts with a private firm for a sum of at least $12 million. Fees are up to $27,540 per week (excluding taxes) for a period up to 35 weeks, it was found.

The firm, named Proaction, was founded in 2004 and first imposed its approach in the manufacturing sector. Its founders had never set foot in a hospital or a health center before 2009.

"Currently, many employees are exhausted, emotional and in physical distress. And when we try to denounce the situation it is perceived as a sign of weakness and we are afraid of the consequences," said a social worker from CSSS Canvendish. The lady preferred anonymity for fear of reprisal, but a dozen nurses, social workers and occupational therapists with whom La Presse spoke were outraged by the situation.

According to what La Presse has seen, the Proaction method is largely based on the creation of a grid of "planning and implementation" on which all acts . . . are timed. This grid is developed by an internal committee consisting of a few handpicked employees. For example, washing one ear by a nurse should take 15 minutes. Two ears 20 minutes. A single wound care should not take more than 15 minutes. There is provided a time of 30 minutes for follow-up "post death". 

On the ground, it will even tell therapists not to intervene with patients in cases of psychological distress, and transfer the task of the social worker to save time. If an employee has not been able to perform his or her task in a timely manner, he or she shall explain the reasons.

In a follow-up article, "La méthode Toyota pervertie," ethics consultant Pierre Deschamps noted, "The correct approach would not have led home care nurses to the edge of a nervous breakdown."

In fact, what it is has nothing to do with the Toyota method, but instead is a practice of Lean, disembodied from the fundamental values of the Toyota approach.

At Toyota, the continuous improvement process is based on the respect that the company provides to its customers, suppliers and employees. Continuous improvement, yes, but never at the expense of respect for persons.

In recent years, several consulting firms who see the Toyota approach as a business opportunity have appropriated some of its processes and argued that organizations that adopt it would rapidly increase their performance and efficiency.

What these companies have forgotten is that the Toyota is successful when it is part of a corporate culture that is strong and in businesses where there is a healthy work environment. There is no success in organizations where there is a significant psychological distress and mental suffering high among employees, as appears to be the case with several employees of the health system.

In addition, the Toyota approach to be successful within an organization requires that those who want to use have an excellent knowledge of the culture and to develop a profile of the organization in terms of governance, leadership, ethics, practices, traditions, etc.

In a book called The Toyota Way to Lean Leadership, the authors make a serious warning in regard to the use of external consultants.

The traditional role of external consultants is to manage a project and produce a plan of action. Indeed, the consultants step into the customer's shoes. They claim to have expertise in Lean methods and guarantee that they will make the client organization more efficient by eliminating all unnecessary tasks and standardizing work.

However, in reality, learning new methods remains with consultants and what they leave at the end of their mandate is very fragile.

Several months ago, I declaimed:

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."

[They] leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs.

In their search to find financial savings, hospitals and health care administrators are often carried along by the latest fad.  Governments, too.  Here, the previous government health minister of Quebec opened the financial gates to support his "transformation" intentions several years ago.  But the concept was not well thought through.  The consultant community responded as you would expect.

As I have said:

You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.

Please, if you are hospital or government leader and are not prepared to adopt the overall philosophy, don't start down this path.  You will just pervert the nature of Lean.  Soon enough, la merde va frapper le ventilateur.  (Again, a Google-assisted translation.  No doubt there is a better idiomatic version, but you get the point.)


Mark Graban said...

Sadly, people can do any old stupid thing and they can call it Lean. Neither John Shook (from the Lean Enterprise Institute) nor anybody from Toyota can come with a cease and desist to force people to stop this behavior or to stop them from calling it "Lean."

I call it "L.A.M.E." (Lean As Misguidedly Executed) when people force top-down changes on people without involving them in the process. You can't claim (well you can... but you shouldn't) to be "doing Lean" when you ignore basic TPS tenets like "respect for people."

Going back in history, Toyota's Taiichi Ohno wrote that standardized work methods must be written by the people who are doing the work -- respect for people.

Having standardized times (such as 15 minutes to clean an ear) can be helpful for planning purposes (to have enough staff to properly meet patient needs and to do work in the highest quality way), but a time like 15 minutes must NEVER be a hard quota (such as it cannot take more than 15 minutes). There is variation in patient care that must be allowed for...

The top-down tyranny that's described in the Quebec piece shouldn't be called Lean. I'm glad you and the authors there can distinguish between (as Bob Emiliani calls it) "real Lean" and "fake Lean."

Bruce Ramshaw said...

I think this is so important for people to understand. It sounds like Taylorism to me (Scientific Management- published 1911, republished 2006). Boje and Winsor wrote an interesting article discussing this misapplication of Lean in the Journal of Organizational Change Management (1993). They suggest that the effort is intentional, although I believe, in most cases, it is just a lack of understanding.

I also see a lack of understanding in healthcare when applying Lean, even when done well. It seems that Lean has been applied mainly in the fragmented sub-processes- the emergency department, the OR, etc. I've not yet seen Lean applied to the most important process to be defined, measured and improved- the patient's entire cycle of care. This cannot be done within a hospital only. I believe this would be truly accountable care.

Mark Graban said...

Bruce - I agree that Lean is not Taylorism... Taylorism is about the expert telling people what to do, where Lean is about people participating and figuring it out (maybe with a coach or facilitator, not an all-knowing expert).

People with Taylorist habits tend to view Lean as a new way to tell people how to do things, sadly. They can't see what Lean really is through that old lens, sometimes.

You're right that Lean needs to help create value across the care continuum -- value being health and quality of life, not efficient delivery of treatment.

ThedaCare, a health system in Wisconsin, is using Lean to reduce admissions (which, in a fee-for-service environment, hurts them financially) and they are using Lean as part of ACO experiments.

Hear their CEO, Dean Gruner, MD talk about this here in a podcast:


Al Lewis said...

This is exactly what happened in the 1980s in the department store industry. Nordstroms was making much more money than others due to its legendary customer focus. They also happened to have (still do, I think, though since I am guy and I don’t shop, I can’t say for sure) a piano player in the lobby.

Several department stores tried to “copy” the Nordstroms model by simply putting a piano player in the lobby. What you are describing in this posting is exactly that, mangers trying to push a button rather than do the hard work of changing a process.

Bruce Ramshaw said...

Hi Mark- Thanks for the update on ThedaCare. I've read about their effort in the past, but not recently. It sounds like they are doing the right thing- disrupting themselves for the good of their customers (actually improving their chance for sustainability).
I've also appreciated reading and learning from your work with Lean.
Thanks again,