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National Association for Healthcare Quality

Health Care

Learning from Toyota’s Snafu

Rapid growth can leave employees’ skills behind.

Published: Wednesday, June 2, 2010 - 05:00

The Toyota Production System and U.S. health care improvement share a long history. What lessons can health care leaders learn from Toyota’s recent production troubles? A few experts recently discussed this on WIHI, an audio program sponsored by the Institute for Healthcare Improvement (IHI). Here are some highlights from the May 6 broadcast.

“Toyota has set the direction for all of us who are on the lean journey,” observes John Toussaint, M.D., founder and president of ThedaCare Center for Healthcare Value, in Appleton, Wisconsin. “We all try to watch and emulate them. There’s a lot to be learned from this latest snafu.” Toussaint adds that Toyota has promised a return to basics after having lost sight of two of its fundamental principles—continuous improvement and respect for the customer. “It just proves that the lean journey is an [ongoing] challenge to implement for all of us, even Toyota.”

At Seattle-based Virginia Mason Health System (VHMS), whose own production system is heavily modeled on lean management, leaders came together quickly to discuss the media frenzy surrounding Toyota’s troubles, according to Gary Kaplan, M.D., VMHS chairman and CEO. “The first thing we did in our minds was separate the Toyota Production System from the Toyota Motor Company,” says Kaplan.  “Many successful companies around the world that employ [lean management] principles remain sound.”

Still, Toyota’s recent troubles provide “a wonderful learning opportunity” for health care organizations, Kaplan adds. At VMHS, leaders are pondering the answers to several questions. How did Toyota take the eye off the ball? Did the company expand too fast? What was it in the culture that allowed this to happen? “In effect, they strayed from the core principles of the Toyota Production System, and that has heightened the vigilance at Virginia Mason,” Kaplan notes.

Many speculate that Toyota simply grew too fast. “Experts [on] Toyota were concerned that the company couldn’t keep up with the growth as it relates to quality,” Kaplan explains. “They didn’t have enough people who understood the Toyota Production System as they opened plants throughout North America and all over the world.”

Indeed, Toyota grew rapidly worldwide a decade ago, according to Steven J. Spear, senior lecturer at the Massachusetts Institute of Technology and a senior fellow at IHI. “With that, probably inadvertently, [Toyota] overtaxed its internal capacity to develop people,” says Spear. That may well have occurred three to five years ago when the cars being recalled today were under design.

“This brings us to the lesson to be learned,” adds Spear. “If you run a health care organization, it’s fundamentally important to have great skills in orthopedics, radiology, and other medical professions. In addition, if you really want to succeed and achieve breakthrough quality assets and affordability, skills in the basic science of systems are absolutely fundamental.”

Kaplan agreed that Toyota’s rapid expansion affected its ability to keep up with employee training. “Not having trained talent available at the genba to respond to workers’ concerns really ran up against [Toyota’s] own philosophy and principles,” he says. “This was minimized and swept underground.” [Editor's note: Genba (or gemba) is the actual place in the organization where value-added work is done, e.g., the shop floor.]

At ThedaCare, senior executives are at the genba at least once a week—which, as Toussaint explains, is a place at work where value is created for the patient, and barriers faced by staff are deeply understood. “Sometimes we get excited about the new, shiny object, and we lose focus on what’s most important,” he says. “What problems are staff facing? How do we remove the barriers for them to solve those problems? How do we ensure defects are being identified and processes are being continuously improved? We need to be at the bedside trying to understand how to improve the process.”

Perhaps if Toyota had picked up on alarm signals earlier, it may have circumvented current problems, suggests Kaplan. “Data are critically important,” he says. “One of the ways to spot early warning signs is by looking for early trends. Having data-collection techniques—in real time—help us see emerging trends very quickly and deploy mistake-proofing or other types of solutions to stop the trend.”

Takeaway quotes

Involve senior leaders in quality improvement: “To have sustainable change in a health care organization—the magnitude required to put in place the Toyota production system—you need to have the deep commitment of senior leaders, ” says Kaplan. “I can’t emphasize that enough. The same is true of quality improvement in general. We have a whole cadre of middle management and quality improvement experts who all too often butt up against resistance, or inattention, from senior leadership. [But] that’s how resources get allocated. That’s how cultures change. That’s how signals are sent that penetrate entire organizations. I would encourage [you to] work hard to engage the most senior leaders.”

Toyota’s lag in skill training: “Starting around the early years of the new millennium, Toyota realized that a real lynch pin in skill cultivation was its group leaders,” says Spear. “Toyota realized that, to succeed, you had to figure out how to clone group leaders more quickly. Between five and eight years ago, Toyota started a process of decoding great group leaders, [but] like everything else, there’s the action and the lag until the effect takes place.”

A standard process of care: “Most processes in health care are chaotic,” says Toussaint. “Until we stabilize the process, we can’t improve it, whether it’s for a patient’s simple sore throat or multisystem organ failure.” Toussaint stresses that a standard process of care works for patients 80 percent of the time.

Patient-centered care: “Health care, in pockets, is beginning to make major gains in becoming more patient-centered,” notes Kaplan. “I would still suggest that it is not nearly as widespread as it can be. Many community hospitals across this country continue to, out of necessity perhaps, look at the referring physician and the admitting physician as the key customer.”

Getting started: “When you’re not seeing and solving problems, you end up squandering the most important resource, which is people’s time,” warns Spear. “So start small, even if it’s just a few people, and identify problems that are regularly impeding their success. When you give them back time, they can see and solve [even] more problems.”

“Get started by doing kaizen [or improvement] events, value-stream mapping, and fixing some problems that your staff and physicians have had for the last 25 years,” suggests Toussaint. “Once you fix some problems, you’re going to get engaged and want to fix more.”



About The Author

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National Association for Healthcare Quality

The National Association for Healthcare Quality (NAHQ) empowers health care quality professionals from every specialty by providing vital research, education, networking, certification and professional practice resources, and a strong voice for health care quality. NAHQ is universally recognized as the leading resource for health care quality professionals and is their essential connection for leadership, excellence and innovation in health care quality. Founded in 1976 and located in Glenview, Illinois, NAHQ comprises 5,000 individual members and 100 institutional members.




"Toussaint stresses that a standard process of care works for patients 80 percent of the time." WOW!! What a statement! Who wants to be in the other 20%?? That's one in five times the system doesn't work. I wouldn't want to "stress" this point. I would be ashamed.



There may be a misunderstanding. I believe the author intends to say that a standard process "applies" to a patient presenting with a given set of symptoms 80% of the time, and that by employing standardized work we can remove 80% of the variation in the way providers do their job. That is definitely worth emphasizing, especially to those practitioners who insist that because each patient is a unique being that treatment must also be unique.

Standardized work, if properly hardwired, can be successfully completed 100% of the time. Whether that course of treatment "works", i.e. outcomes for the patient, depends in part on the biology of the patient. Not the variation we are able to reduce and not the point.


Steve you are right on

The movement to "lean" in healthcare is a move to manufacturing tools and healthcare has different problems. A big one being the variety of demand we see in healthcare. Standardization gets to a solution before we understand the problem. It is as Russ Ackoff said "Doing the wrong thing, righter."

Theory vs. practice


I agree with your assessment that any time a solution doesn't address the root cause it doesn't fix the problem. In fact it might be termed "tampering". However, there are two points I'd like to make and see if we can discuss further.

1. Protocols and pathways have been in health care for many years and are definitely a form of standard work. They just need to be applied AFTER we know what is wrong, not before.

2. There are many processes in any health care system that have nothing to do with patient care and would greatly reduce waste (reducing costs, time and hassle) while potentially improving outcomes because they allow the providers to spend more of their time on "value added" activities (i.e. caring for the patient).