Is Healthcare Like Manufacturing?

By Gerrit Van Wyk.

A lean, mean, motor machine.

In 2010, the government of a Canadian province announced they will lean health care following Toyota manufacturing principles. To do so, they contracted a consultant for $40 million, and it didn’t end well.

As much as Toyota claim they run a bottom-up system, in practice it is micromanaged from the top down, which is not surprising; they learned from Ford, General Motors, and quality management gurus in the US, where that is the default. The basic model is one assuming an organization is a thing or entity, that thing or entity is predictable, measurable, and stable, and that it can be controlled and managed by trained managers. In fact, it needs managers. In short, organizations work like clocks or machines.

But what if that is wrong and organizations aren’t predictable, measurable, and stable, and cannot be controlled? If our world and social world specifically is complex, that would be the case, and then organizations are not things, but emerge from the interconnections, interactions, and conversations of people. It means similar interactions and interconnections will lead to similar organizations, but no two organizations are exact replicas of each other, and they constantly change in small and sometimes big ways. They stabilize around processes that work, but change when they don’t, often without being planned. It means there is no right or wrong way to organize, and what works depends on a context. Organizations don’t work because of cleverly designed rules, protocols, and regulations, but despite them; people on the ground adapt to and change them to make things work. If employees want to bring an organization to its knees, just follow the rules and regulations to the letter.

There are examples of organizations working perfectly well without or with very little management, so managers and management structures are not a requirement, some value their employees as much as their customers, committing the sacrilege of not only paying attention to customers but also to their employees, some allow differences of opinion to foster innovation and creativity, and don’t stagnate because thinking is not allowed, some evolve without plans or control, which means strategic planning is not a necessity, some have few rules and regulations, which means people don’t have to be policed all the time, some don’t manage performance, which means you can trust people, and some trust people on the ground to make decisions and mistakes and learn from them, which prevents them from stagnating. An organization doesn’t have to be a machine bureaucracy to work.

Peter Drucker said health care is socially, biologically, and technologically the most complex industry on earth, which is why it is surprising that in Canada the only sheriff in town is machine bureaucracy, which must be managed. As examples, lean production and single health regions are games of the same kind played with the same rules. There are widespread reports this model is failing all over the country which begs the question, why hold on fanatically to it? If an alternative perspective already exists, what prevents us from trying it?

The idea that health care must be managed by professional managers became fashionable in the 1970’s, and managers did what managers do, they built vast bureaucracies. The template for bureaucracies is the Industrial Revolution and Taylor’s management practices, in terms of which organizations are machines, and humans components within it. But in practice, organizations are complex social entities, which makes them difficult to govern, to which bureaucracies respond by imposing constraints on how we should behave.

What matters within them is not ability, talent, and service, what matters is politics, communication, connections, luck, and self-promotion. There are visible and invisible rules for how to interact, supporting a framework of authority, hierarchy, and stories justifying it. Rules at the same time create stability and stifle creativity, innovation, and growth. Those above us make the rules and therefore determine what is right or wrong. You make progress by kissing up and kicking down. One consequence is curating messages going up the ladder to please our bosses, which places them in a fictional world hidden from reality and bad news, where they can engage in planning strategies. Another is, such systems promote and encourage patronage. As an employee you must be a “team player”, “fit in”, and “get along” which means not being different nor asking tough questions.

Because bureaucracies stifle creativity and innovation, they are obliged to buy new ideas from outside consultants. Jackson describes the game that follows as like a drama production. A consultant writes a playbook which actors (employees) perform in front of an audience, and if the play fails, the consultant blames the audience or bad acting; the playbook is always perfect and cannot be changed. Which is what happened to the lean initiative.

The audience, or voters, disliked the play and booed the production, and the actors, or employees, were blamed for not playing according to the script. The play host, or government, widely advertised the play, and when the theater remained empty, pressured the actors to perform better, it sold tickets at a discount, and doctored reviews to show what a great play it was, all to no effect. When the playwright was eventually dismissed, he stomped away blaming the actors, and the host quickly found a new guru with a different playbook to replace him. The show must continue.

All management playbooks are of the same kind; we play in a rational, predictable world that can be controlled by smart people with knowledge others lack. But the fact is, people don’t make rational decisions, our human social world is unpredictable, and no-one can control it. A playbook written in America for Americans based on Japanese culture doesn’t automatically apply to Canada and Canadians, and pruning out and discarding actors not going along with you grows resistance, not compliance. Professional workers don’t want managers who never come to the shop-floor to tell them what to do. Had the consultant and managers approached the actors and audience differently, patients may have been rolling off a production line today, but they didn’t. The purpose of the initiative was to reduce cost by reducing waste, and if you treat humans like waste they will resist.

If we want to meaningfully change health care, we must quit playing politics and change the playbook.  We must acknowledge the complexity of the industry, that managers and consultants and political players can’t keep writing the same script, that change must be about changing processes and systems, not reduce cost, and that the actors can contribute to solutions and a successful play when they participate in writing the script.