Featured Product
This Week in Quality Digest Live
Quality Insider Features
Jeremy L. Boerger
To keep your business running, you need visibility into your IT assets
Elizabeth Gasiorowski Denis
An inclusive approach to designing products and services guarantees accessibility to as many consumers as possible
Naresh Pandit
Enter the custom recovery plan
Anton Ovchinnikov
In competitive environments, operational innovation could well be the answer to inventory risk
Brian A. Weiss
Tech transfer can be more efficient

More Features

Quality Insider News
Serving the needs of employers and educators
Powder reuse schemes affect medical device performance
MIT course focuses on the impact of increased longevity on systems and markets
Upgraded with blue laser technology
Delivers time, cost, and efficiency savings while streamlining compliance activity
First responders may benefit from NIST contest to reward high-quality incident command dashboards
The Ring Dex 2 filling and capping system is designed to simplify production.
Enhances clinical data management for medtech companies
Demonstrating fast, accurate wireless measurement data acquisition

More News

Mark Graban

Quality Insider

Can’t Always Believe Somebody Saying, ‘Toyota Would Tell You To...’

Quality should come before maintaining takt time

Published: Wednesday, June 19, 2013 - 11:38

From my experience, you have to be cautious when somebody says either, “Lean says you should...” or “Toyota would tell you to...” because those statements, even if stated authoritatively, can be wrong.

At a recent speaking engagement (I won’t disclose where), a professor (one who teaches about lean) made a curious comment that I’d put in the Lean As Misguidedly Explained (or LAME) category.

The professor made a point that, when working in healthcare, we have to be careful about applying all methods and tools from Toyota. I agreed with that part of his statement. We’re not literally hanging andon cords or putting tape around every piece of equipment just because a factory does it. We have to be solving hospital problems and not just copying tools. I get that.

His example, though, was a bit off base.

The prof talked about takt time (or the rate of customer demand), and how we balance the service or production time to match up with takt. Again, that’s correct.

In his hypothetical, he said let’s assume that a doctor’s office is supposed to be seeing a patient every 20 minutes. What if the patient has been in the room for 19:59 already?

The prof said, “Toyota would tell you to kick the patient out of the room at 19:59 because you have to keep on takt time.”


I think we were in agreement that you shouldn’t kick a patient out of the room as if a timer bell went off. There’s going to be variation in healthcare, and we have to plan for that and make sure patient care comes first. We need to have a reaction plan for how to try to get back on schedule (and part of that approach could be to have buffer times for charting during the day instead of doing all of the charting at the end of the day).

I explained to the professor and the audience that Toyota would do no such thing, and there’s no lean principle that says kicking the patient out of the room would be appropriate.

Even on a Toyota assembly line, with relatively low variation and highly engineered, repetitive jobs, a worker might have 60 seconds to complete his work (based on takt and balancing the “cycle time” of the line to that).

If, in a particular job cycle, there’s a problem with a part or the worker drops a bolt—let’s say he can’t get his work done in the scheduled 60 seconds—he is expected to reach up and pull the cord. The team leader comes to help. And, if the problem cannot be resolved, the line stops. You don’t kick the car out because its time is up.

If the work really took 90 seconds for that particular car, you’d take 90 seconds. Quality comes first.

Interestingly, a tour guide at a Toyota plant I visited said they sometimes let a problem move ahead in the line to be fixed later, that this is sometimes a judgment call depending on the problem and how it would get fixed for a particular car. This is certainly not the Toyota orthodoxy on “quality at the source.”

Now, if a problem is occurring frequently, I think it’s safe to say the team leader and production worker would try to fix the root cause of the problem using the kaizen approach. It’s important to understand why the problem occurred so you can prevent it from happening again.

Either way, you wouldn’t kick the patient out of the room.


About The Author

Mark Graban’s picture

Mark Graban

Mark Graban is an author, educator, and speaker in lean health care, through his company Constancy Inc. He is a faculty member for the Lean Enterprise Institute (LEI) and vice president of improvement and innovation services at KaiNexus, a technology company that helps organizations spread continuous improvement. He is founder of the Lean Blog and is author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition (Productivity Press, 2011) and, with Joseph E. Swartz, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements (Productivity Press, 2012), both recipients of the Shingo Professional Publication and Research Award.


Cycle time


You added up the times of the steps.. the total time of 51 minutes is irrelevant. All we need is for each step to be faster than takt since the steps are sequential and flow from one into another. 


I'm glad to stuck to your guns with the professor.... My response to the professor would have been "SQDC".  After working for JTEKT, the fourth largest supplier to Toyota, who is 20% owned by Toyota, the priorty is Safety first, then Quality (take care of the patient), then Delivery (takt time) and finally Cost. Whenever we made improvements to the bottleneck operations, we had to get "Chokko" (First Time Thorugh) up to accepatable levels of 98%, them 99% then 99.6% before we could focus on Bekido (OEE).

Agree that this fits the LAME category, BUT For a different reas

Looking at the example this looks to me to be confusion between TAKT and the relationship between cycle time and what manufacturing would call “operator loading”, other industries tend to describe as “staffing”. In the doctors’ office, there are likely a number of steps to the visit. Some would be performed by the doctor, some by a nurse, maybe some by a lab technician, etc. I propose a truly “lean” ways to approach this scenario is from a standard work perspective. Let’s start with a hypothetical standard work: I imagine that the standard work would follow something like:

1. office staff: greet patient, collect insurance information, collect co-pay, notify medical staff patient is ready(8 minutes);

2. nurse’s aide(maybe nurse): greet patient, take to exam room, confirm identity, confirm reason for visit, collect vital signs(time 5 minutes);

3. nurse(maybe doctor): greet patient, perform preliminary examination, collect information(7 minutes);

4. doctor: greet patient, perform examination, issue instructions (8 minutes);

5. nurse(maybe doctor): confirm patients understanding of instructions, release patient (5 minutes);

6. nurse(maybe nurse’s aide, maybe office staff): update patients chart and visit information(8 minutes);

7. office staff: prepare billing, submit to insurance, update billing records (10 minutes)

Those who are math savvy notice the “cycle time” far exceeds the Takt time of 20 minutes. From my fabrication of times, the total cycle time is 51 minutes. At this point, many “lean” practitioners are scrambling to do one of two things: 1) identify all the “waste” in the process to get the total cycle time to under 20 minutes or 2) justifying the rationale(s) that the time not spent in front of the patient doesn’t count towards Takt, by among other tactics, splitting the patient time and office time into separate “value streams” or “work flows” and showing that the time spent with the patient is under the 20 minutes and therefore OK.

I propose a slightly different viewpoint: The adjustments needed are not with the timeline, but with the number of staff involved in the process. For any given organization, there will be more people than absolutely necessary at any given point. There will be supervisors, managers, etc. and each function in a process will have varying degrees of “slack”. SO, for a given patient, the delay will happen for a given skill set. The concept of cross-training comes in here. For a number of the tasks (not all in this example and not all in many examples), the skill sets of the staff can overlap, office staff can be nurses and aides, doctors can step in and perform nurse functions, etc. As in a manufacturing realm, there are a few functions that require specialized skill and cannot be cross-trained effectively. Those functions could have “back-up” to assist if the schedule gets too far behind. At a worst case, the time line for “not patient facing” could be extended or temporary help assigned to “catch up” in “off hours”. This would be analogous to “calling in the 3rd shift” in manufacturing.

I like the suggestion of building “gap”(could be “change-over time”) into an office schedule. The time could be managed to buffer the “inventory in progress” of different patients and still meet the patients needs of a quality visit.

In reality, any way an organization decides to define “lean” or act “lean”, the bottom line: Patients (e.g. customers) are not kicked out, unless you want them to never return.

Cycle vs. Takt

You're right, I was not as precise as I should have been with my language. Takt time is calculated based on expected customer demand and the number of hours we plan to work in a day and how many people and/or machines are assigned to the work (something that's generally in our control). 

Cycle time (the pace at which we work) should be set to be somewhat faster than takt time (which is based on customer demand). I shouldn't have used the terms interchangably.

Either way, the main point is that we don't have artibitrary cut-offs where we stop working on a car or kick the patient out of the room. Safety and quality come first. 

Thanks for adding to the discussion. I agree that having gaps and buffer times in an appointment schedule is a good strategy for absorbing variation.Mark 

Now You Know What I Have Been Talking About


This is the problem. I believe LAME is too high level and providing examples like this story give more relevance. The variety that a doctor's office receives may have six patients that require 8 minutes with the doctor and One make take 60 minutes.

Understanding variation and designing systems that can absorb variety of demands has to be paramount for service. Takt time in service seems silly if you take this view. I have been writing and studying on Scientific Management. Lean folks needs to understand there is Taylorism Lean and Deming Lean. Where the former is a bad path and the latter opens new perspective to solve problems in a less tool-oriented way.

I know you have been interviewing and talking with the Deming community - this cannot be a bad thing. There is no TPS or Ohno without Deming. Tripp


Tripp -

Thanks for your comment. I like the distinction between "Deming Lean" and "Taylor Lean" and I've done my best to be a proponent of Dr. Deming's work and a detractor of Tayloristic top-down thinking that's not respectful of workers.

I've tried to give specific examples of L.A.M.E. where I can on my blog - for example, the idea of "Lean says you can't put a sweater on the back of your office chair," etc.


Much of this so-called Lean is misplaced command-and-control thinking... something I know we agree is misplaced.

I've never spent too much time focusing on takt time in healthcare. There are certainly times when understand expected average demands (and expected variation) is helpful in, say, planning how many people should be working in the emergency department in a given hour and day of the week. We also have to understand what are low-variation and high-variation settings. I think the only place we would disagree is that I think "standardized work" is helpful, even in high-variation settings, because standardized work doesn't have people shut off their brains and it certainly doesn't set time limits for patients.

I agree wholeheartedly there is no TPS without Deming. Thanks for your work in debunking outdated scientific management mindsets and promoting Deming.



Hi Mark Can you please explain the last time you worked with Toyota (paid work)? Did you observe and measure what you have claimed in your article? If we do not hear from you I would assume your article is based on your discussion with people at Toyota. Not sure that is really the lean way.

Your Point?

Kyle - you do work under the "Lean Sigma" banner. Would I expect that you have worked for Toyota, Motorola and/or GE?

I have worked for and with many former Toyota people and have worked along side (and also learned a great deal from) former Toyota people as a consultant. I'm not perfect, but I am confident that I have a good practical grounding in TPS mindsets and practices. 

What was your point?

My question is no different than yours

Mark practice what you preach. You make reference to what toyota would do. So what is it based on? You know very well you would ask the exact same question. When is the last time you worked for toyota? Be an example, can you do that? I have worked with people trained and worked with ge and toyota. I could not claim however what these companies do without well documented evidence.