Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition / Edition 2

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Building on the success of the Shingo Prize-Winning first edition, Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition explains how to use the Lean management system to improve safety, quality, access, and morale while reducing costs. Lean healthcare expert Mark Graban examines the challenges facing today’s health systems, including rising costs, falling reimbursement rates, employee retention, and patient safety.

The new edition of this international bestseller begins with an overview of Lean methods. It explains how Lean practices such as value stream mapping and process observation can help reduce wasted motion for caregivers, prevent delays for patients, and improve the long-term health of your organization. In addition to a new introduction from John Toussaint, this updated edition includes:

  • New and updated material on identifying waste, A3 problem solving, employee suggestion management, and strategy deployment
  • New case studies—including a new Kanban case study (Northampton General Hospital) and another that ties together the themes of standardized work, Kanban, 5S, visual management, and Lean leadership for the prevention of patient harm
  • New examples and updated data throughout, including revised chapters on patient safety and preventing medical errors

Detailing the steps needed for a successful transition to a Lean culture, the book provides the understanding of Lean practices—including standardized work, error proofing, root cause problem solving, and daily improvement processes—needed to reduce common hospital errors. The balanced approach outlined in this book will guide you through the process of improving quality of service while reducing costs in your hospital.

*The Lean Certification and Oversight Appeals committee has approved Lean Hospitals as recommended reading for those in pursuit of Lean Bronze Certification from SME, AME, Shingo Prize, and ASQ.

Check out a video of Mark Graban discussing the new edition of his Shingo Prize-Winning Book.


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Editorial Reviews

From the Publisher
Praise for the New Edition of this Shingo Prize Winner:

Whether it is the ThedaCare story … Seattle Children’s … or Virginia Mason, the answer is in: Lean works. The question now for all of you is how are you going to do it? What is the leadership model required? … There will be many questions, and I believe starting with Mark Graban’s updated book Lean Hospitals is a good first step. … This book lays out the nuts and bolts of the Lean methodology and describes the more difficult challenges, which have to do with managing change. … I wish I could have read this in 2004, as it might have prevented some of the mistakes we made in our Lean transformation journey.
John Toussaint, MD, CEO, ThedaCare Center for Healthcare Value

Praise for the First Edition:

Leaders of today’s healthcare organizations are on a continuous journey to improve results, requiring a relentless focus on improving the underlying process of care delivery and leadership practices. Mark has written a book that provides compelling ideas to help create better places to work, practice medicine and receive safe, high quality care.
—Quint Studer, Founder and CEO of Studer Group, a 2010 recipient of the Malcolm Baldrige National Quality Award, Author of Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference and Results That Last: Hardwiring Behaviors That Will Take Your Company to the Top

Mark Graban is the consummate translator of the vernacular of the Toyota Production System into the everyday parlance of health care. With each concept and its application, the reader is challenged to consider what is truly possible in the delivery of health care if only standardized systems borrowed from reliable industries, were implemented. Graban provides those trade secrets in an understandable and transparent fashion.
—Richard P. Shannon, MD, Frank Wister Thomas Professor of Medicine, Chairman Department of Medicine, University of Pennsylvania School of Medicine

There is an enormous shortfall between the healthcare we receive and what we actually get. Mark Graban explains how those in the system can make care delivery better for everyone –patients, providers, and payors.
—Steven Spear, Sr. Lecturer at MIT Sloan School of Management and Sr. Fellow at IHI, Author of The High Velocity Edge

Mark Graban has been tirelessly studying the application of LEAN to health care, with an emphasis on respect for the people served by the system as well as the people who provide excellent care. He has an accurate sense of how things work in health systems, which makes his work more meaningful for people who want to make them better.
—Ted Eytan, MD

The concepts outlined in this book are the most powerful tools that I have ever encountered to foster innovation, ownership, and accountability at the front line staff level. This is a must-read for any leader in today’s increasingly complex healthcare industry.
—Brett Lee, PhD, FACHE, SVP of Health System Operations at Children's Healthcare of Atlanta

The Lean approach to healthcare, including a strong emphasis on culture, is the best way to ensure the optimal patient experience. The multiple examples of the application of Lean given in this book provide a wealth of information to draw from for a hospital that is venturing into Lean principles for the first time. In addition, this book emphasizes not only methodology, but also the cultural changes that must occur for sustainability - something often forgotten in change management.
—Beverly B. Rogers, MD, Chief of Pathology, Children’s Healthcare of Atlanta, Clinical Professor of Pathology, Emory University School of Medicine

Finally! The healthcare industry has needed this book for many years. Informative, understandable, and timely, Mark Graban’s book will leave you with an appreciation for what lean is and what it can do for your hospital. After you read this book, I’ll be surprised if you don’t make implementing lean your highest strategic priority.
—Jim Adams, Senior Director, Laboratory Operations, Children’s Medical Center, Dallas

It’s obvious that Mark Graban has spent time in the trenches of healthcare and understands the complexities of applying the Lean philosophy and tools to that environment. If you want to improve your chances of surviving in today’s healthcare system (both literally and figuratively), read this book.
—Dean Bliss, Senior Lean Coach, Altarum Institute.

Graban provides a helpful translation of the terms, practices, and tools of Lean thinking into hospitals’ everyday situations and challenges. His book illustrates Lean’s elements with many actual examples of Lean applications in typical hospital practices and procedures. Graban’s book should definitely be on the reading list for those who want to bring the benefits of lean thinking to healthcare.
—David Mann, Principal, David Mann Lean Consulting

Lean health care is becoming a global movement. The reasons given are overrun costs, errors that compromise patient safety, time of patients wasted, and general bureaucratic inefficiency. In Lean terms the problem is how to eliminate waste. Health care is different than car making. This is true but many, many hospitals are finding the principles of the Toyota Production System apply well and are making remarkable improvements. Unfortunately the remarkable improvements are in specific areas and challenging to sustain because of a mysterious ingredient which the folks at Toyota seem to understand quite well—humans. The humans that health care exists to help also operate the system and are far from perfect. Toyota's system is actually designed to support the development of people, not to provide a quick fix set of technical solutions, and this takes time and patience. Many health care consultants have rebadged themselves as lean consultants and do not understand the real thinking behind the Toyota Production System. Mark Graban is an exception. He has worked hard to study the philosophy and stay true to the thinking of Toyota. His book is a welcome translation of the Toyota Production System into language any health care professional can understand.
—Professor Jeffrey K. Liker, University of Michigan & Bestselling Author of The Toyota Way

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Product Details

  • ISBN-13: 9781439870433
  • Publisher: Taylor & Francis
  • Publication date: 11/28/2011
  • Edition number: 2
  • Pages: 268
  • Sales rank: 165,175
  • Product dimensions: 6.90 (w) x 9.90 (h) x 0.80 (d)

Meet the Author

Mark Graban is a consultant, author, keynote speaker, and blogger in the world of Lean healthcare. Mark is an experienced consultant and change agent, with a background in industrial and mechanical engineering and an MBA from the MIT Sloan Leaders for Global Operations Program. Prior to healthcare, Mark worked in multiple industries, including automotive (General Motors), electronics (Dell), and industrial products (Honeywell). At Honeywell, Mark was certified as a Lean Expert (Lean Black Belt).

Since August 2005, Mark has worked exclusively in healthcare, where he has coached Lean teams at client sites in North America and the United Kingdom, including medical laboratories, hospitals, and primary care clinics. Mark’s motivation is to apply Lean and Toyota Production System principles to improve quality of care and patient safety, to improve the customer/patient experience, to help the development of medical professionals and employees, and to help build strong organizations for the long term.

From June 2009 to June 2011, Mark was a Senior Fellow with the Lean Enterprise Institute (LEI), a not-for-profit educational organization that is a leading voice in the Lean world. In this role, Mark also served as the Director of Communication & Technology for the Healthcare Value Network, a collaboration of healthcare organizations from across North America, a partnership between LEI and the ThedaCare Center for Healthcare Value. Mark continues as an LEI faculty member.

In June 2011, Mark joined the software company KaiNexus as their Chief Improvement Officer, to help further their mission of "making improvement easier" in healthcare organizations, while continuing his other consulting and speaking activities. Mark was raised in Livonia, Michigan and currently resides in Keller, Texas with his wife, Amy. To interact with Mark and the Lean healthcare community, visit www.LeanHospitalsBook.com.

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Table of Contents

The Case for Lean Hospitals
Why Do Hospitals Need Lean?
A Renewed Sense of Purpose
Lean Methods Are Not New to Healthcare
Toyota’s Role in Popularizing Lean
Origins of the Term Lean
Lean Is Proven to Work Outside Automotive Factories
Lean Is Helping Hospitals Improve
Problems in Healthcare
Price Pressures and Cost Challenges
Coping with Employee Shortages
Poor Quality of Care
Good Quality Costs Less
A Snapshot of Department Success: Laboratory, Children’s Medical Center Dallas
From Departmental to Hospital-Wide Success
Lean Lessons
Points for Group Discussion

Overview of Lean for Hospitals
What Is Lean?
Ohno’s Definition of Lean
Lean Thinking
The Toyota Triangle: Tools, Culture, and Management System
Human Development
Technical Tools
Managerial Methods
The "Toyota Way" Philosophy
Continuous Improvement
Respect for People
Four Organizational Capabilities for Lean
Capability 1: Work Is Designed as a Series of Ongoing Experiments that Immediately Reveal Problems
Capability 2: Problems Are Addressed Immediately through Rapid Experimentation
Capability 3: Solutions Are Disseminated Adaptively through Collaborative Experimentation
Capability 4: People at All Levels of the Organization Are Taught to Become Experimentalists
Lean Lessons
Points for Group Discussion

Value and Waste
Waste Is Not the Same as Cost
What Is Waste?
What Is Value? Start with the Customer
How Do We Define Value?
Rule 1: The Customer Must Be Willing to Pay for the Activity
Rule 2: The Activity Must Transform the Product or Service in Some Way
Rule 3: The Activity Must Be Done Correctly the First Time
Examples of Value-Added and Non-Value-Added Activities
Learning to Identify and Describe Waste
Waste of Defects
Waste of Overproduction
Waste of Transportation
Waste of Waiting
Patients and Products Waiting
Employees Waiting
Waste of Inventory
Waste of Motion
Waste of Nursing Motion
Waste of Overprocessing
Waste of Talent
What Non-Value-Added Activities Are Required?
Non-Value-Added, Pure Waste
Lean Lessons
Points for Group Discussion

Observing the Process and Value Streams
How Do We Find Waste? Go and See
What Is a Value Stream?
Value Stream Mapping
Creating a Current-State Value Stream Map
The Future-State Maps
Breaking Down Silos and Reducing Suboptimization
Observing the Process
Activity of the Product
Activity of the Product—Laboratory
Activity of the Employee
Activity of the Employee—Nursing
Activity of the Employee—Primary Care
Activity of the Employee—Perioperative Services
Lean Lessons
Points for Group Discussion

Standardized Work as a Foundation of Lean
The Need for Standardized Work
The Toyota House Metaphor
Overview of the Lean Foundations
Lean Foundations: Standardized Work
Definition of Standardized Work
Proper Outcome and the Highest Quality
To Safely Complete
One Best Way
Fewest Possible Resources
Standardized, Not Identical
Written by Those Who Do the Work
Considering How Long Tasks Take
Staffing Based on Data
Types of Standardized Work Documents
Standardizing Daily Routines
Defining Roles and Responsibilities
Quick Changeover as Standardized Work
Explaining Why through Standardized Work
Standardized Work Documents and the Standardized Work System
Measuring and Observing for Standardized Work Adherence
"Resistance" to Standardized Work?
Asking Why When Standardized Work Is Not Followed
Standardized Work Can Apply to Physicians
Lean and Checklists
Standardized Work Can Apply to Managers
Training through Standardized Work
Lean Lessons
Points for Group Discussion

Lean Methods: Visual Management, 5S, and Kanban
Lean Is More than Tools, but Tools Can Help
Reducing Waste through Visual Management
Examples of Visual Management for Patient Flow
Examples of Visual Management to Prevent Process Problems
5S: Sort, Store, Shine, Standardize, and Sustain
First S: Sort
Second S: Store
Third S: Shine
Fourth S: Standardize
Fifth S: Sustain
Safety as a Sixth S?
Kanban: A Lean Approach to Managing Materials
Problems with Traditional Materials Systems
Trade-offs with Inventory
Using Kanban to Replenish Supplies
Lean Lessons
Points for Group Discussion

Proactive Root Cause Problem Solving
The Mary McClinton Story
Improving Quality and Patient Safety
Cultural Obstacles to Quality Improvement
Why Do Errors Occur?
Violations and Errors, Lapses, and Slips
Examples of Quality Improvement
Finding Root Causes and Preventing Errors
Workarounds and the Need for Fixing Root Causes
Asking Why Instead of Who
Start at the Gemba
Find Root Causes Using Simple Methods
A3 Problem Solving
Be Proactive and Use Failure Modes and Effects Analysis
Proactive Resolution of Near-Miss Problems
The Safety Pyramid
Lean Lessons
Points for Group Discussion

Preventing Errors and Harm
A Problem That Is Not Going Away
Moving Beyond Blaming Individuals
The Darrie Eason Case
Creating Quality at the Source through Error Proofing
Being Careful Is Not Enough
Why 100% Inspection Is Not 100% Effective
Types of Error Proofing
Make It Impossible to Create the Error
Make It Harder to Create the Error
Make It Obvious the Error Has Occurred
Make the System Robust So It Tolerates the Error
Error Proofing, Not Dummy Proofing
Examples of Error Proofing in Hospitals
Banned Abbreviations as Error Proofing
Computer Systems as Error Proofing
Preventing Surgery Errors through Error Proofing
Stopping the Line (Andon)
Error Proofing the Error Proofing
Lean Lessons
Points for Group Discussion

Improving Flow
Waiting: A Worldwide Problem
Focusing on Flow
Value Streams Should Flow Like a River
Uneven Workloads as a Barrier to Flow
Naturally Occurring Unevenness
Mura Caused by Morning Rounds
Mura Caused by Suboptimizing Courier Routes
Mura Created by Clinic Scheduling
Mura in the Patient Discharge Process
Addressing Mura by Matching Staffing to Workloads
Improving Patient Flow
Improving Patient Flow in the Emergency Department
Reducing "Door-to-Balloon" Time
Improving Patient Flow in Outpatient Cancer Treatment
Improving Flow for Ancillary Support Departments
Improving Flow in Clinical Laboratories
Reducing Delays in Specimen Collection
Reducing Delays in the Receiving Areas of the Lab
Improving Flow Also Improves Quality and Teamwork
Reducing Delays Inside the Testing Areas of the Lab
Improving Flow in Anatomic Pathology
Improving Flow in Pharmacies
Lean Lessons
Points for Group Discussion

Engaging and Leading Employees
Changing How We Manage
What Is a Manager’s Role?
Strategy Deployment
Common Management Problems
Lean as a Management System and Philosophy
A Daily Lean Management System
Process Audits or Rounding
Standardized Audits of the Standardized Work
A Hierarchy of Rounding
Performance Measures
Timely Measures Drive Timely Improvement
A Balanced Scorecard Focuses on All Stakeholders
Metrics Should Be Visible, Visual, and Statistically Meaningful
Daily Stand-up Team Meetings
Kaizen and Suggestion Management
Problems with Suggestion Boxes
The Role of Supervisors in Kaizen
Finding a Better Method for Managing Kaizen
Visual Tracking of Suggestions
Communicating Kaizen Changes
Lean Lessons
Points for Group Discussion

Getting Started with Lean
How Do We Start?
Where Do We Start?
What Do We Call It?
Types of Kaizen
Kaizen Events
Pitfalls of Kaizen Events
Lean Transformation
Executive Sponsorship and Leadership
Starting from the Middle
Establishing a Model Line and a Road Map
Chartering a Project
Dedicating Internal Resources: The Lean Team
The Importance of Change Management
A Snapshot of Hospital Success: Avera McKennan Hospital
Lean Lessons
Points for Group Discussion

A Vision for a Lean Hospital
When Is a Hospital Lean?
What Would a Lean Hospital Look Like?
What Would a Patient Experience in a Lean Hospital?
What Would It Be Like to Work in a Lean Hospital?
How Would We Describe a Lean Hospital?
Strategy and Management System
Waste and Kaizen
Technology and Infrastructure
Points for Group Discussion

Glossary of Terms


Chapter-by-Chapter Breakdown of What's New in this Edition:


  • "Points to Ponder" at the end of each chapter are now called "Points for Group Discussion," with some new questions added.

Chapter 1

  • Updated initial introduction (talking about "starting from need" in terms of why we use Lean methods and principles)
  • Added callout talking about Toyota’s reputation and quality
  • Updated Lean history to reference Joan Wellman and Seattle Children’s early Lean work
  • Updated/new metrics that show Lean improvement examples in healthcare
  • Updated data on cost pressures, staff shortages, quality problems in healthcare
  • New departmental case study (Children’s Medical Center Dallas – lab)
  • 1st edition case example moved to later chapter on improving flow
  • The bulk of the Avera McKennan case study (from 1st edition) moved to later chapter on getting started with Lean

Chapter 2

  • Various updates, including some references to ThedaCare’s Lean management system
  • Updated "Toyota Way" framework to change first pillar wording from "elimination of waste" to "continuous improvement" – the main idea is the same, but this is more consistent with Toyota wording
  • New callout on "respect for people" pillar
  • Added the "four rules in use" as a Lean definition framework

Chapter 3

  • New introduction, "Waste is Not the Same as Cost"
  • New data from Virginia Mason about reducing waste to free up RN time at the bedside
  • Refined description of "pull" in healthcare, why pull should be about patients pulling on resources, not a unit "pulling" the patient when a room is available
  • Improvements in the section on defining value, incorporating insights from Dr. Don Berwick
  • Edits and, in some cases new examples, about the types of waste in healthcare
  • Fuller discussion of "Required Waste"

Chapter 4

  • Edits and some new examples in intro to value streams
  • New callout on electronic VSM – downplaying the need for that software and technology
  • New "activity of the employee" example for primary care physician, with new figure

Chapter 5

  • New figure showing the "Park Nicollet System of Care" version of the "Lean House" diagram
  • Edits and refined section on standardized work for healthcare
  • New callout on looking at the communication process and standardized work instead of just blaming parents for not following NPO instructions properly
  • New callout on standardized work in a radiology department
  • New section on determining staffing levels based on data
  • New section on quick changeover as a form of standardized work (O.R. turnover, etc.)
  • New material on managers coaching on standardized work, rather than being punitive when they see problems
  • New material on Lean, standardized work, and checklists
  • New material on standardized work for managers
  • New callout on standardized work and Training Within Industry (success story example)

Chapter 6

  • New examples of visual management used to help manage patient flow
  • New 5S callouts and small case examples
  • New Kanban examples and new case study from Northampton General Hospital (UK), Seattle Children’s, Park Nicollet, Henry Ford Health System, New York HHC
  • New material on Kanban vs. par levels
  • New material on Kanban vs. automated inventory cabinets
  • New culminating case study about the use of standardized work, 5S, Kanban, and visual management to prevent patient harm

Chapter 7

  • New intro case study of the Mary McClinton case and lessons learned (Virginia Mason)
  • New quality improvement data and examples from ThedaCare and others
  • New examples and discussion about workarounds
  • New section on A3 problem solving, with example
  • New 5 Whys problem solving examples

Chapter 8

  • New introduction and case example of patient harm and lessons learned (Darrie Eason case) – blame vs systems
  • New examples about quality at the source and not blaming individuals
  • New error proofing and quality improvement data and case examples
  • New material about Lean and "Crew Resource Management"
  • New material on Virginia Mason "patient safety alert" system
  • New figures and photos

Chapter 9:

  • New intro – "Waiting: A Worldwide Problem" with data from many countries and waiting times and improvements
  • New material on the "Seven Flows of Healthcare"
  • New examples and data on flow improvements
  • New material on matching staffing to demand in emergency departments
  • New examples of E.D. flow improvement
  • New case example (ThedaCare) on reducing door to balloon time

Chapter 10

  • New quotes and callouts on Lean leadership, including John Toussaint’s comparison of "white coat leadership" and "Lean leadership."
  • New section on strategy deployment
  • New material on goals versus hard targets and a warning about dysfunctions
  • Additional material on daily standup meetings
  • Updates on managing kaizen and continuous improvement
  • Updated format for an "idea card" to be used on visual idea boards

Chapter 11

  • New callouts about organizations getting started with Lean
  • New material on "what do we call it?" – giving a name to a formal Lean program
  • Updates on kaizen events – different formats and success/failure data updated
  • Replaced LeBonheur Children’s Hospital "getting started" Lean transformation case with updated/expanded version of Avera McKennan case

Chapter 12

  • Updated and expanded "Vision for a Lean hospital."
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