To the Editor: The authors of the recent MJA article “Making cars and making health care: a critical review”1 have misunderstood the importance of process design in a service as complex as health care delivery. They state that the Toyota “lean thinking” model has been “accepted somewhat uncritically” in health.1 In fact, the opposite is true. Work practices and roles in conservative institutions such as public hospitals have changed minimally over many years. Cutting-edge medical technology is delivered within an archaic work practice model that fosters inefficiency, frustration and unnecessary expense. Inefficient work practices give skilled clinicians less time with their patients — not more.

Like Winch and Henderson, let’s take an example from the surgical field. Years ago, when public hospital beds were relatively accessible, many patients were admitted for “work-up” and spent days in their pyjamas in hospital before planned surgery. The application of the “just in time” principle has led to the huge turnaround to day-of-surgery and day-only admissions — freeing up beds and saving enormous cost as well as many unproductive days for patients. This is only one small example.

Lean thinking is just one model for improving the way in which complex processes are coordinated.2 Far from being “highly stylised and simplistic”, lean thinking is about removing redundant steps and reducing duplication, waiting times and errors. It’s about investing in the talent and skill of trained staff, by maximising the value they add to whatever process they are working on and minimising the extraneous tasks they have to do.3 Managed properly, this can result in faster and better care delivered by happier staff, with more time to “cure and comfort”.1

In reply: Our article highlighted issues with the uncritical adoption of car-making processes into health care planning — specifically, the regulation and splintering of the human element of a care pathway.

While day-of-surgery admission speeds patients through the system, the capacity for error remains and relates to our original arguments. For example, one assumption commonly made is that the patient or carer has the literacy level to understand the presurgical procedures, such as fasting, taking particular preparations or completing health history forms.

Yet the Australian Bureau of Statistics reported in 2003 that 37% of the population met only the minimum literacy standard (Level 3) required to function in a complex society such as ours in Australia.1 Forty-six per cent fell below this benchmark. For health literacy specifically, 35% of the population met only Level 3 standard, with about 60% falling below this standard.

This indicates that some of the work we have happily “outsourced” to the patient may be poorly understood and cause problems further down the line. It also highlights another key difference between cars and people: baseline control of the beginning raw material is difficult to achieve.