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  • Satyan

Standardisation in healthcare: A cruel master and capable servant

(An article I first published on Linkedin a few years ago)

North Wall of the Detroit Institute of Arts: 'Factory'​ by Diego Rivera | photo credit:

In 1996, Dr Donald Berwick, a giant of the modern healthcare quality movement, wrote an article for the British Medical Journal - a short opinion piece modestly titled 'A primer on leading the improvement of systems'. Berwick, a soft-spoken paediatrician with rare ability to communicate complex forward thinking ideas in accessible language, mapped out a grand vision for healthcare transformation and wrapped these around a set of pithy improvement laws. His central law was this: "Every system is perfectly designed to achieve the results it achieves." The law offered no caveat or qualification. The paper went on to elaborate that "Real change comes from changing systems not changing within systems". As clear as Berwick's message was, healthcare wandered down a lesser path for the next thirty years - one fenced in by standardisation and 'protocolisation' of clinical care processes, whilst mostly neglecting the systems from which these processes arise.

From Berwick's vantage as President of the Institute for Healthcare Improvement (IHI), he would have noted the early portents of derailment of the nascent healthcare quality movement. Perhaps for this reason, Berwick revisited his core thesis in 2004, this time in a paper published in Quality and Safety in Healthcare. Berwick patiently reiterated "...performance improvement, to put it mildly, is difficult. If it were easy, we would not suffer from the serious quality problems that continue to plague medicine in America, the United Kingdom, and elsewhere." His pointed commentary went on: "At present, prevailing strategies rely largely on outmoded theories of control and standardisation of work". His concluding paragraph delivered a stinging diagnosis of the problem: "...while health care was discovering Taylorism, other industries were moving beyond it, into more effective terrain."

Taylorism and more modern ideas of quality

"Standardization does not mean that we all wear the same color and weave of cloth, eat standard sandwiches, or live in standard rooms with standard furnishings. Homes of infinite variety of design are built with a few types of bricks, and with lumber of standard sizes, and with water and heating pipes and fittings of standard dimensions."
Edwards Deming 1951

It would come as a surprise to many that Berwick made early distinctions between indiscriminate attempts to standardise work and the sensible application of systems engineering principles - repeatedly cautioning against the first while encouraging wide application of the second. As conveyed by Berwick, healthcare's doctrine of standardisation (as an all-encompassing improvement philosophy) has more in common with the outmoded ideas of Frederick Winslow Taylor than the systems engineering mindset he sought to encourage. Both make fundamentally different assumptions about variability in systems and how it should be tackled (if at all) and potentially lead to vastly different endpoints - yet these salient differences seem to have been poorly assimilated within healthcare improvement practice and become a cause for rising concern among informed observers.

'Taylorism' describes the philosophy and core precepts on organisational management and improvement advanced by Frederick Winslow Taylor in the early 1900s - at a time when work was more sequential, products were simpler, and most industries were transitioning from a master-apprentice model to large scale coordinated work and invariably reliant on an under-skilled workforce. Against this backdrop of inconsistent production quality, frequent stoppages and injuries, Taylor (and contemporaries, most notably Lilian Gilbreth) pioneered the idea of applying empirical measurement principles to the study of work, distilling out the 'one best way' through painstaking time and motion studies, against which all subsequent recruitment, training, and monitoring could be framed. While this might all seem quite unremarkable to the modern observer, it was nothing short of revolutionary in its impact at the time. The heavy hammer of standardisation built the manufacturing behemoth that was America in the inter-war years.

Taylor effectively transformed the landscape of American industrial production - bringing about unprecedented levels of efficiency and setting the stage for several decades of American industrial dominance. Yet some saw the seeds of more sinister effects from this doctrine of standardisation even at the height of its popularity. Charlie Chaplin's offered a dark interpretation in his 1936 film 'Modern Times' - capturing the essential criticism of the modern industrialisation movement (and Taylor's influence on 'modern' industry) through the eyes of a character that epitomised the times - the hapless process worker. Whilst Taylor's intentions were likely noble, it seems the unbridled application of Taylorist principles became associated with disenfranchisement of the front line and a demonisation of variability in all its forms. These pernicious effects of the Taylorist mindset would be what Berwick would have wished to see avoided in our quest for increasing healthcare quality.

The quality reformation

Taylorism's societal impact was broad and deep - steadily seeping into the substrate of Western consciousness, shaping modernist thought and the world views of many applied disciplines - nowhere more so than in organisational management. Even though Taylor's idea would persist for another century, new industrial improvement challenges in the inter-war years were forcing a re-examination of the paradigm, causing many thought leaders like Walter Shewart, W. Edwards Deming and Joseph Juran (the triumvirate of the modern quality movement) to begin challenging the sufficiency of Taylor's ideas. Work was becoming less sequential, more complex, more prone to externalities and increasingly reliant on specialised workers. Routine problem solving was again a necessity in many industries and managers could no longer afford to assume superior expertise over their subordinates. Perhaps most importantly, the inter-dependant nature of many sectors (like transportation and power generation) meant that organisations could no longer afford to design whole systems as per a linearised 'one best way' doctrine. As a result, variability could not be eliminated as easily as it could in Taylor's era but instead had to be tolerated in a multitude of situations.

In the post-Taylorist era, a more nuanced understanding of standardisation and its role in improvement was taking shape. Deming saw standardisation as a means of creating an environment of consistency and relative predictability within which skilled humans could make creative contributions to society. Building on work by Shewart, Deming taught that only some kinds of variability could be managed through standardisation - delineating two forms of variation. That which could be seen in stable systems and could be plotted around a central tendency he labelled as 'common cause' variation. Here, process-level standardisation could contribute to increasing stability. The other form of variation he saw as arising from 'special causes' as they generally pertained to unexpected factors, usually external to the system. Deming recognised that a system's ability to respond to novel variability was not a function of how standardised its processes were but much more to do with its ability to quickly identify the special cause and to mobilise a suitable response to it - possibly foreshadowing the contemporary idea of systems resilience. In the New Economics, Deming spoke positively of variation, saying "life is variation, and variation there will always be." The probing of variability to understand it, ascertain its cause and then to choose from a range of possible organisational responses stood in stark contrast with positions rooted in Taylorism. A reformer at heart, Deming sought to rehabilitate the role of the worker in the modern organisation. Along with several contemporaries, Deming framed a new view of management where the frontline was not a problem to be controlled but a valuable asset to be developed and tapped into as ever-more complex problems arose.

The persisting challenge

Despite the nuanced writings of Berwick, Deming, Juran and Russell Ackoff and the many attempts at course correction in more recent years, popular management fads have re-injected a fondue of Taylorist principles into contemporary healthcare improvement practice and continue to retard efforts aimed at rediscovering its more nuanced, systems-oriented foundations. Perhaps most worrying is the recent trend to repackage the same deficient thinking as something new and transformative. In fact, the neo-Taylorist narrative is already upon us - utopian promises to 'fix' healthcare and constrain error-prone clinicians through artificial intelligence, big data, automation and 'digital industrialisation'. All the while the performance of our national health systems continue to decline in critical areas. It seems the Taylorist doctrine of standardisation holds a deep and unshakeable appeal for health system leaders and many practitioners. Yet, a rapidly advancing evidence base gives us a multitude of reasons to side-step the seductive simplicity of the standardisation doctrine, but we mustn't consign nearly fifty years of systems knowledge to the rubbish pile because newer ideas have emerged. A nuanced understanding of the promise and pitfalls of standardisation is vital in the pursuit of improvement in socio-technical systems like healthcare.

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