For those who are new to the fields of industrial engineering or management engineering (as the field is often called in health care), the use of engineering methods may seem like a recent innovation in health care settings. The recent rise in the popularity of lean and Six Sigma in hospitals around the world has brought an influx of engineers into health care.
While there is a lot of innovative work taking place, it is important to note that there is a rich history of industrial engineering principles that reaches back over 100 years being applied in health care. In this article, we will look at two early practitioners-- Frank Gilbreth and Henry Ford.
Frank Gilbreth (1868 - 1924) is considered, along with Frederick Taylor, to be one of the “fathers of Industrial Engineering.” Gilbreth (along with his wife and partner, Lillian) is credited with a practice that anyone who has watched a surgery on TV would recognize – the surgeon puts his or her hand out and has the exact tool or implement placed in their hand. The surgeon does not waste time searching for the equipment. Gilbreth introduced this practice after observing wasteful motion in operating rooms (find the reference to this again). Gilbreth referred to the surgeon as having a “caddy” to assist and, today, the practice is taken for granted by those in and out of health care.
Gilbreth’s time and motion study was dramatized in the 1950 movie, “Cheaper by the Dozen” (not to be confused with the Steve Martin remake where the efficiency expert became a football coach). In the film, based on the book 1948 written by his son and daughter, Gilbreth takes advantage of 11 of his 12 children needing their tonsils taken out. Gilbreth proposes that the doctor set up an operating room in their house, where Gilbreth would film each surgery, analyzing each repetition for examples of efficiency and standardization. Gilbreth himself even volunteered to have his own tonsils taken out that same day.
Gilbreth was portrayed as showing quite a bit of arrogance in his interaction with the doctor. He bluntly proposed to the doctor that he would “study what you doctors are doing wrong. Then I could show you how you could eliminate a lot of waste motion and speed things up.” In modern times, this may not fit the model for effective change management and collaboration with a physician (yet alone any hospital staff member).
The physician, having his methods challenged in a way that wasn’t very respectful, countered by protesting, “Now all right, that system of yours might be OK in factories...” and Gilberth cut him off and said “... and medicine too!” “Oh, I’ve been looking for a chance like this!,” exclaimed Gilbreth, which might make many viewers question his priorities -- his children being used for time and motion study.
A more modern example brings us the case of Dr. John Tebbetts, a board certified plastic surgeon in Dallas, TX. Tebbetts is a living combination of Gilbreth and the doctor in the movie. Tebbetts initiated the videotaping of his own surgical methods in the 1990s and found ways to work more consistently and more effectively. By eliminating wasted motion, he not only takes less time for the standardized procedure but the results in terms of recovery time and other quality indicators are better than his peers. Tebbetts published his work and credited the time and motion study methods of the Toyota Production System as his means for process improvement.
Henry Ford (1863 - 1947), had a lifetime body of work that any IE would be proud of, including the famous innovation of using moving assembly lines to build automobiles more efficiently than the “craft” builders who proceeded him. As Toyota developed its namesake production system, they studied the early writings and work of Henry Ford, even as Ford, the company, was moving down the “mass production path.” It is argued that many of the “lean” methods were borrowed from or adapted from Ford.
In his 1922 book, My Life and Work, Henry Ford wrote about his purchase of the Detroit General Hospital in 1919, renaming it “The Ford Hospital.” Right away, Ford questioned many of the standard practices of hospital management and design. He was patient focused, stating, “it is not at certain whether hospitals as they are now managed exist for patients or for doctors.” (page 216) Ford added, “It has been an aim of our hospital to... put the interest of the patient first.”
Ford was very aware of waste in the patient care settings, surmising that, “In the ordinary hospital the nurses make many useless steps. More of their time is spent in walking than in caring for the patient.” Ford’s hospital was, of course, different and better as he claimed that, “This hospital is designed to save steps. Each floor is complete in itself, and just as in the factories we have tried to eliminate waste motion in the hospital.” (page 218).
In modern times, different studies show that only about 30% of nursing time is spent with direct patient care activities. The remaining time consists of some required activity, such as charting, but also includes a great deal of waste motion. Nurses walk and search for medications, supplies and equipment because of poorly designed physical layouts (medications being stored in one central location, for example) and because of problems with the management system (equipment not always being stored in the same location or not enough equipment being available).
Ford was optimistic that his changes would sweep the industry, stating, “There seems to be no good reason why the experiment should not be successful. Its success is purely a matter of management and mathematics. The same kind of management which permits a factory to give the fullest service will permit a hospital to give the fullest service, and at a price so low as to be within reach of everyone.” If only change was as simple as invoking logic and mathematics. Politics (both internal and governmental), pride and human emotion can sometimes interfere with the logical becoming the norm. It is probably a good lesson to learn from Henry Ford that to effectively implement change in a hospital in 2009, we need more than just the correct mathematical and engineering answers.
As the study of Frank Gilbreth and Henry Ford’s early work shows, health care has long struggled with the need for process and quality improvement. As the saying goes, “Everything old is new again,” and the same is true when applying engineering principles to health care.
About the author:Mark Graban is author of the book, “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.” He has a BSIE from Northwestern University and an MSME and MBA from the Massachusetts Institute of Technology.