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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Philosophy
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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Current
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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

A Vision for a Lean Hospital
Introduction
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
Patients
Employees
Waste and Kaizen
Technology and Infrastructure
Points for Group Discussion
Notes

Glossary of Terms

Index

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

General

• "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)
• 1^st edition case example moved to later chapter on improving flow
• The bulk of the Avera McKennan case study (from 1^st 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."