Table of Contents

The Case for Lean Hospitals
Why Do Hospitals Need Lean?
Lean Methods Are Not New to Healthcare
Toyota’s Role in Popularizing Lean
Origins of the Term Lean
Lean Is Proven to Work Outside of 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
A Snapshot of Hospital Success
Conclusion
Lean Lessons
Ponder
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
Lean Is about Reducing Waste and Respecting People
Elimination of Waste
Respect for People
Fixing Healthcare from the Inside
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 to Ponder
Notes

Value and Waste
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 Right 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 to Ponder
Notes

Observing the Process and Value Streams
How Do We Find Waste?
What Is a Value Stream?
Value Stream Mapping
Creating a Value Stream Map
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—Perioperative Services
Conclusion
Lean Lessons
Points to Ponder
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"
Standardized, Not Identical
Written by Those Who Do the Work
Considering How Long Tasks Take
Types of Standardized Work Documents
Standardizing Daily Routines
Defining Roles and Responsibilities
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 Being Followed
Standardized Work Can Apply to Physicians
Another Example of Having to Ask Why
Training through Standardized Work
Conclusion
Lean Lessons
Points to Ponder
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
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 within a Department
A Kanban Case Study
Conclusion
Lean Lessons
Points to Ponder
Notes

Proactive Root Cause Problem Solving
Improving Quality and Patient Safety
Cultural Obstacles to Quality Improvement
Why Do Errors Occur?
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
The Five Whys Method
Example of the Five Whys: Hand Hygiene
Be Proactive and Use FMEA
Proactive Resolution of Near-Miss Problems
The Safety Pyramid
Conclusion
Lean Lessons
Points to Ponder
Notes

Preventing Errors
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 to Ponder
Notes

Improving Flow
Processes 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
Improving Patient Flow in Outpatient Cancer Treatment
Improving Flow for Patient Care and Support
Improving Flow in Clinical Laboratories
Reducing Delays in Specimen Collection
Reducing Delays in the Lab’s Receiving Areas
Improving Flow Also Improves Quality and Teamwork
Reducing Delays Inside the Lab’s Testing Areas
Improving Flow in Pharmacies
Conclusion
Lean Lessons
Points to Ponder
Notes

Engaging and Leading Employees
Changing How We Manage
What Is a Manager’s Role?
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 Audits
Performance Measures
Timely Measures Drive 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 to Ponder
Notes

Getting Started with Lean
Where Do We Start?
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 Roadmap
Chartering a Project
Dedicating Internal Resources: The Lean Team
The Importance of Change Management
The Beginnings of a Lean Enterprise
Starting in the Lab
Moving to Other Areas
Designing a Hospital for Lean
Designing a New ED Process for the New Space
The Future Roadmap
Conclusion
Lean Lessons
Points to Ponder
Notes

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
Patients
Employees
Waste and Kaizen
Technology and Infrastructure
Final Thought

About the Author

Mark Graban is the Director of Communications and Technology for the Healthcare Value Leaders Network.

Reviews

“Mark Graban’s book has documented what is now happening in hospitals all across America as we learn to apply the Toyota Production System methodology to healthcare. This book lays out the nuts and bolts of the lean methodology and also describes the more difficult challenges, which have to do with managing change. Graban’s book is full of wins --- these are the same type of wins that are happening at ThedaCare every day. I wish I could have read this book six years ago, as it might have prevented some of the mistakes we made in our lean transformation journey.”
— John S. Toussaint, MD, President/CEO ThedaCare Center for Healthcare Value

“Coupled with a foundation of alignment and accountability, the ideas in this book provide a powerful tool to help hospitals get closer to the goal we want – perfect care.”
— Quint Studer, CEO, The Studer Group, author of Results that Last

“Mark Graban is the consummate translator of the vernacular of the Toyota Production System into the everyday parlance of healthcare. With each concept and its application, the reader is challenged to consider what is truly possible in the delivery of healthcare if 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 payers.”
— Steven Spear, Senior Lecturer, MIT, Senior Fellow, IHI

“Mark Graban’s work has been a steady companion in the three years I have been studying and applying lean in healthcare. He has an accurate sense of how things work in health systems, and he brings a patient-centered perspective that makes me want to do more for the people we serve.”
— Ted Eytan, MD, Medical Director, Health Informatics & Web Services

“The medical community has a tremendous opportunity to learn methods and techniques to improve the quality and efficiency of care and reduce costs, while at the same time engaging staff in these efforts. Mark Graban has deep experience applying lean in the healthcare field; in his book, he provides an outline of how to transfer concepts originally developed in manufacturing into the unique environment of medical care. Don’t miss the opportunity to learn and apply some great ideas in your organization.”
— David Meier, co-author of the bestselling books, The Toyota Way Fieldbook and Toyota Talent

“The concepts outlined in this book are the most powerful tools that I have ever encountered to foster innovation, ownership, and accountability at the frontline staff level. This is a must-read for any leader in today’s increasingly complex healthcare industry.”
— Brett Lee, PhD, FACHE, Vice President, Children’s Medical Center Dallas

“The lean approach to healthcare, including a strong emphasis on culture, is the best way to ensure that we care for our patients in the very best way possible. Lean Hospitals emphasizes not only the 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 Medical Center, Dallas, Professor of Pathology, UT Southwestern Medical School

“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

“Ít’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, Lean Improvement Specialist, Iowa Health System

“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, manager, Lean Management + O.D, Steelcase, Inc., author of Creating a Lean Culture

“Lean healthcare is becoming a global movement. The reasons given are overrun costs, errors that compromise patient safety, wasted time for patients, and general bureaucratic inefficiency. In lean terms, the problem is how to eliminate waste. Healthcare is different than car-making. This is true, but 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 healthcare 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 quick-fix technical solutions, and this takes time and patience. Many healthcare 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 healthcare professional can understand.”
— Jeffrey K. Liker, University of Michigan, author of The Toyota Way