This was prompted by Kim Sullivan’s review of Jerry Muller’s The Tyranny of Metrics at The Healthcare Blog. Drs. Accad and Koka also had Mr. Muller on their podcast. Both are worth going through.

It’s always been unironically fascinating to me how primitive systems thinking is in healthcare. Frederick Taylor was a turn of the 19th century industrial engineer credited with the development of scientific management, known as Taylorism colloquially. Taylor’s main idea as described in his Principles of Scientific Management was to apply the scientific method and experimentation as a management tool to figure out what’s really going on inside the organization and what processes work best instead of relying on impulse, intuition, and habit. This on its own should not be controversial. Discord about Taylor arises from the way Taylorism has been applied in practice, through the meticulous measurement of employees in order to justify the creation of onerous compensation structures and unrealistic performance expectations. As Mr. Sullivan and Mr. Muller point out, this is increasingly a problem in healthcare through the rise of pay-for-performance measures and evidence-based medicine requirements that are detached from reality. Taylor himself is not entirely guilt-free of this association, as he did have a consulting business through which he showed a willingness to advise exactly this type of tyrannical measurement as long as it would sell his consulting product.  Unfortunately villains in the real world are rarely straightforward. In addition to proposing the scientific method and measurement as management tools, Principes of Scientific Management also instructs managers to treat employees as human beings by considering employee capabilities and motivations when assigning work  and for managers to be actively engaged in the training and development of their employees.

That being said, although Taylor was instrumental in introducing the scientific method to the practice of management, industrial engineering theory was already evolving beyond Taylorism and its flaws at the time of his death in 1915, and has made significant advances in both theory and practice since then. This is to say that Taylorism in industry has been out of fashion for 100 years already, so it’s both interesting and frustrating to see it so earnestly adopted in healthcare only now and in such a chimeric form. The work of W. Edwards Deming, Peter Drucker, Taiichi Ohno, and even Taylor’s contemporary Henry Ford made great strides to humanize and correct the errors of Taylorism. This work remains unknown and misunderstood in the healthcare field, but of course everybody must start somewhere.

However, although healthcare systems engineering is still in its nascent stage, there is little reason for optimism or hope for actual clinicians that the situation in general will change for the better, regardless of their attempts to fight this problem of tyrannical measurement. While industrial engineering advanced significantly beyond Taylorism, most of this knowledge is not being put in practice widely despite being around for quite some time. Bob Emiliani dives into the question of why this is the case in “The Triumph of Classical Management over Lean Management“. Mr. Muller is correct to point out that manager expertise is an issue, but this is only a symptom of the problem. Low level managers are less affected to do this problem insofar as they are directly engaged with the work, so even if they were not previously experienced or taught they are bound to learn quickly. The root of the problem lies in the scale of organizations and the implications that this has for increasingly higher levels of management. As you go up the levels of management, the managers are paradoxically vested with increasingly greater levels of resources while at the same time increasingly less knowledgeable of how to properly utilize those resources due to being more removed from the actual work. As the Russian proverb wisely says, God is high above and the Tsar is far away. This is compounded by the fact that high ranking management needs to justify its existence to their employees and the organizations funders (whether public or private), needs to manage conflict between different departments vying for the same resources, and has a perfectly human (surprisingly, managers appear to have limbic systems) need to minimize risk to the self from mistakes made downstream. Is it surprising then that the solution management uses to negotiate all these stresses are dumb, objective measurements that they can point to when something goes wrong? Downstream employees say they were following instructions to explain why a mistake is not their fault, upstream managers say they were following best practices.

This is all colorfully illustrated in Eli Goldratt’s “The Goal“, a delightful book that I highly recommend. It’s a cult hit among industrial engineers and operations consultants, butit’s also a good bridge for clinicians who have a visceral reaction to the specter of  Cheesecake Factory management insofar it shows that their frustrations with administration are shared in other industries and explains what good scientific management can look like. The book itself is a novel and not especially well written, the characters are blunt and the events can feel conveniently orchestrated, but the plot moves along at a rapid pace making one always wonder what happens next. In many ways it reminded me of a Dan Brown novel. The story follows Alex Rogo, an industrial engineer who is the head manager of a struggling factory producing a variety of widgets. Alex is a humane character in that it’s obvious he cares deeply about his factory and the employees that work there, but he is also limited in his ability to be patient, to keep promises, and to fully understand his situation. These challenges extend to his personal life. Alex’s main challenge in the story is that he did everything that he was supposed to: he went to the right schools, got the right internships, and once he became manager made sure that his factory did well on all the metrics that the central corporate offices believe to be important. Why, then, is his factory failing? Why are his costs always increasing? Why are his orders always overdue? All this should be a familiar setting to healthcare professionals.

Without spoiling the novel itself, and leaving Alex’s adventure for you to discover for yourself, the main point of the book is that blind measurement is not only ineffectively, but actively harmful to organizations’ ability to achieve their eponymous Goal. Measurement has to be intelligent and strategic, designed to analyze and solve specific problems in the organization rather than be applied haphazardly trying to use the measurement to find problems to solve. For frontline practitioners the book implies two key pieces of advice. The first is that although the Tsar is far away and measuring foolishly, this does not mean that you can’t use measurement appropriately within your local context to help you solve problems that you as a person immediately affected by these problems, the person with that dasein to use Heidegger’s term, are facing. The second piece of advice is to stop trying to convince whoever is making you do ineffective measurement to change, because the odds are that they are incompetent and won’t change until proven wrong. To that effect, rather than asking for permission, the frontline practitioner needs to take the initiative (and responsibility) to make the necessary change and then let the results speak for themselves.

I recommend reading Mrs. Muller, Emiliani, and Goldratt’s books for the rest.