Design rules, metaroutines, and boundary objects : a framework for improving healthcare delivery systems

Abstract

The healthcare industry in the United States has been fraught with medical errors, rising costs, and wastes for many years. Despite widespread adoption of Total Quality Management and Six Sigma programs, healthcare's woes continue unabated. The Toyota Production System (TPS), progenitor of lean manufacturing, is widely regarded as the most effective production system ever devised. It has been successfully adopted by manufacturing firms worldwide resulting in significant gains in efficiency and quality in companies of all sizes. The goal of this research is to determine whether principles from the Toyota Production System could be applied to a healthcare environment to improve its delivery systems. Following an action research methodology, the work reported here describes how TPS principles were adapted and applied to generate sustainable improvements to hospital work processes. Using a combination of qualitative and quantitative research methods, the results of the intervention were scrutinized, resulting in several important contributions to the existing body of knowledge on TPS and organizational problem solving.

First, the design rules to construct work processes were found applicable to healthcare and were associated with better process outcome. Second, the systematic problem solving methodology adapted from Toyota, a metaroutine, prompted individuals to jointly validate and create knowledge to improve work processes and adopt long-term, instead of a short-term, solutions. Third, a problem-solving tool (also adapted from Toyota) provided a common language of solving problems in a cross-departmental setting and thus acted as an effective boundary object by members from different functional disciplines. These three elements were tightly interwoven during the problem-solving process, suggesting a framework for the design of any quality or process improvement program for helping organizations make efficient use of resources while improving quality of service. The implications of this work are significant not only for hospitals, but for many other non-manufacturing sectors where improved work processes are desirable.