“Cheaper By The Dozen” Efficiency Gurus Meet EMR Workflow Systems–Usability Results

Short Link: http://j.mp/6uIHXX

Last week’s post (A White Paper About EMR Workflow, Usability, and Productivity in Pediatric and Primary Care) was *so* serious, and 5000 words to boot (including the white paper). This post is compensatorily on the lighter side.


A Metaphorical Depiction of an Assistant
Handing a Physician the Right Data or
Order Entry Tool at the Right Time

So, have you ever heard of the movie or the book “Cheaper By The Dozen”?

Whenever I talk about industrial engineering approaches to healthcare in general, or pediatric and primary care in particular, I usually mention Frank and Lillian Gilbreth, Ph.D., the founding father and mother of industrial engineering techniques applied to healthcare. They invented the Therblig (”Gilbreth” backwards–almost), a unit of work.  (The PowerPoint slides I usually use to introduce this topic are below.)


The Gilbreth’s family life was recounted by two of their children in the memoir “Cheaper by the Dozen” (the 1950 movie, not the 2003 version with Steve Martin). They ran their household of twelve children as an experiment in the application of modern efficiency principles (many of which they invented)–hilarity results.

Dr. Gilbreth received the first Ph.D. in Industrial Psychology (from Brown) and was the first woman member of the American Society of Mechanical Engineers and the National Academy of Engineering.

“Lillian Gilbreth is best known for her work to help workers in industry with her classic Time & Motion Studies, which supported work simplification and industrial efficiency. Lillian Gilbreth was one of the first scientists to recognize the effects of stress and lack of sleep on the worker.”  Lillian Gilbreth and Frank Gilbreth - The Birth of Ergonomics

The previous quote uncannily describes both the plight of a physician *and* the positive benefits of an EMR workflow system–stress and lack of sleep versus simplicity and efficiency. Ergonomics is the science of designing the job, equipment, and workplace to fit the worker. Computers didn’t exist when the Gilbreths founded the science of ergonomics, but the direct descendent of ergonomics today is usability. If Frank and Lillian Gilbreth are the founding father and mother of ergonomics, it would not be too much of a metaphorical stretch to say that they are also the founding grandparents of usability.

“Doctors to this day owe a debt to them, since it was Frank who first came up with the idea that surgeons should use a nurse as “a caddy” to hand them their instruments as and when they were needed. Previously surgeons had searched for and fetched their own instruments while operating.” Gurus: Frank and Lillian Gilbreth

The key? Without the surgeon being required to remove his eyes from the task at hand, at the right time and right place the right tool should be passed to the surgeon in its most “usable orientation.” (Patient Safety in Emergency Medicine, page 98) Again, this presages the use of EMR workflow systems to “hand” a physician the right data or order entry tool at the right time and place during a patient encounter.


I usually then move on to review typical topics of industrial engineering study and application–decision science/operations research, human factors and ergonomics, manufacturing and production systems, and quality engineering–and then point out that modern IE departments often have an optional health systems concentration as well. I’ll definitely turn that material into a future post; but here I’d do something more fun: plumb Cheaper By The Dozen for parallels to improving pediatric and primary care workflow systems.

The following are some quotes from 152  reviews of Cheaper By The Dozen on Amazon (many of these charming essays were lovingly written by children: “A review from a 6th grade reader”, “Honors English fifth period!”, “Ross Middle School 6th Grader“, “Sarah from fifth period”):

“How can you afford so many kids?”, a stranger would ask. Frank would say, “They come cheaper by the dozen, I guess.” (Complete review on Amazon, by the way I don’t get a commission from Amazon.)

This book is the story of an unusual family at the turn of the century, with twelve children. The father is an efficiency expert who runs the family like it is a factory assembly line, with everything timed down to the minute. Even the times for bathing are scheduled, so that the household runs smoothly. Mr. Gilbreth practices all of his ideas on how to run an efficient business on his family; they are the guinea pigs for new ideas…Both of the parents were  professionals, as the mom was also a psychologist and industrial engineer. They applied  their professional ideas on raising the 12 kids. (Complete review on Amazon)

The amazing Gilbreth family shares hilarious and heartwarming stories about growing up with parents who basically began motion-study (figuring out how businesses could do things in less time). This is one to read out loud to the kids. They will laugh and laugh…and so will you. :^) (Complete review on Amazon)

When Frank and Lillian Gilbreth married, he said he wanted to have an even dozen children and Lillian was happy to oblige, having six boys and six girls. Frank and Lillian worked as efficiency experts and Frank employed efficiency techniques at home including figuring out how to shave in the quickest amount of time; how to dress as quickly as possible; having everyone in the family get their tonsils removed at the same time; and holding an Assembly Call in which he whistled and timed how long it took the family to gather together…Together they had all kinds of adventures, some on land, some at sea, many of them hilarious. (Complete review on Amazon)

Mr. and Mrs. Gilbreth, experts in motion-studies and industrial efficiency, apply their skills to managing their enormous family. Love, goodwill, and humor spill off the pages. (Complete review on Amazon)

Gilbreth is a father of 12 during the early 1900’s. He is a white collar professional whose specialty is “efficiency”. In order to run this large household smoothly, Gilbreth introduces systems of operation similar to a factory within his home. This book is funny as we watch the children go through their daily grind using Father’s grand plans for organization. I thoroughly enjoyed reading this novel and highly recommend for a quick read. (Complete review on Amazon)

The Gilbreth family of 12 kids, parented by efficiency experts Lillian and Frank, were a bit eccentric and very funny…The Gilbreths were actually serious innovators of efficiency for the new factory assembly lines, figuring out the number of movements needed to complete a task and establishing a unit of work movement called the Therblig. (Complete review from Amazon)

This is a story about family. It is funny in a gentle way. Family values, respect , and good-natured fun are featured in this period piece. Both mother and father are efficiency experts who believe that having a dozen children is most efficient. The humor comes from the situation of having twelve children and all that it entails. (Complete review on Amazon)

What I really liked about it was how they were always trying to find new ways to make their lives more efficient, by doing two things at once, like brushing their teeth while learning a language or shaving with two razors. (Complete review on Amazon)

A famous effiency expert who believes a family can be run just like a factory, has charts all over the house so that he can make sure that chores are being done. He has the older children in charge of the younger children to learn “responsibility.” (Complete review on Amazon)

I found this charming story to be captivating, motivational, heartwarming, and humorous. The story was coiled around the father of twelve children, Frank Gilbreth Sr., who was in the business of “motion study” which he was very good at. Motion study was said to be finding the way to make-work quicker and more efficient. (Complete review on Amazon)

A reporter asked Frank Gilbreth Sr. why he wanted to save time and what he used his spare time for…This is what Frank Gilbreth Sr. said in reply to the reporter’s question: “For work, if you love that best…For education, for beauty, for art, for pleasure…For mumblety-peg, if that’s where your heart lies.” (Complete review on Amazon)

Some final thoughts:

  1. As an only child who grew up on a farm, I’m a bit envious how much fun a large family apparently can be.
  2. The emotional tenor and potential for chaos inherent to a large family reminds me of just about a every pediatric clinic I’ve experienced.
  3. The efforts to impose order and efficiency reminds me of the effects of a pediatric EMR workflow system: “everything timed down to the minute,” “how businesses [can] do things in less time,” “how to do [X] in the quickest amount of time”, “always trying to find new ways to make their lives more efficient,” “doing two things at once,” “finding the way to make work quicker and more efficient,” as well as the systematic delegation of responsibility amongst family members.
  4. If Frank and Lillian Gilbreth were alive today, I believe they would be early enthusiastic proponents of EMR workflow systems, which achieve through workflow automation many of the same goals emphasized in Cheaper By The Dozen. In fact, just as I noted in an earlier post, an EMR workflow system is similar by analogy to a hyper-competent operating room nurse who automatically hands you the right data entry or order entry tool at the right time and place in the patient encounter.
  5. The question the reporter asked Frank Gilbreth, “why he wanted to save time and what he used his spare time for” reminds me of a question we sometimes ask potential customers, “If you had more time, what would you do with it? See more patients? Spend more time with each patient? Go home on time? Some combination? Something else?”

“For work, if you love that best…
For education, for beauty, for art, for pleasure…
For mumblety-peg, if that’s where your heart lies.”

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