Healthcare Kaizen : Engaging Front-Line Staff in Sustainable Continuous Improvements book cover
1st Edition

Healthcare Kaizen
Engaging Front-Line Staff in Sustainable Continuous Improvements

ISBN 9781439872963
Published June 21, 2012 by Productivity Press
408 Pages 201 Color Illustrations


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USD $66.95

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Book Description

Healthcare Kaizen focuses on the principles and methods of daily continuous improvement, or Kaizen, for healthcare professionals and organizations. Kaizen is a Japanese word that means "change for the better," as popularized by Masaaki Imai in his 1986 book Kaizen: The Key to Japan’s Competitive Success and through the books of Norman Bodek, both of whom contributed introductory material for this book.

Winner of a 2013 Shingo Research and Professional Publication Award!

In 1989, Dr. Donald M. Berwick, founder of the Institute for Healthcare Improvement and former administrator of the Centers for Medicare & Medicaid Services, endorsed the principles of Kaizen in the New England Journal of Medicine, describing it as "the continuous search for opportunities for all processes to get better." This book shows how to make this goal a reality.

Healthcare Kaizen shares some of the methods used by numerous hospitals around the world, including Franciscan St. Francis Health, where co-author Joe Swartz has led these efforts. Most importantly, the book covers the management mindsets and philosophies required to make Kaizen work effectively in a hospital department or as an organization-wide program.

All of the examples in the book were shared by leading healthcare organizations, with over 200 full-color pictures and visual illustrations of Kaizen-based improvements that were initiated by nurses, physicians, housekeepers, senior executives and other staff members at all levels.

Healthcare Kaizen will be helpful for organizations that have embraced weeklong improvement events, but now want to follow the lead of ThedaCare, Virginia Mason Medical Center, and others who have moved beyond just doing events into a more complete management system based on Lean or the Toyota Production System.

It’s often said, without much reflection, that people hate change. The experiences shared in this book prove that people actually love change when they are fully engaged in the process, get to make improvements that improve patient care and make their day less frustrating, and when they don’t fear being laid off as a result of their improvements.

Mark Graban explains why his new book Healthcare Kaizen is a great resource for healthcare organizations looking to make improvements on the frontlines.(

Check out a recent entry about this book on the Virginia Mason Medical Center Blog, Could this new book help drive your Lean journey? (

Check out what the experts at the Franciscan St. Francis Health System have to say about Healthcare Kaizen. (

Table of Contents


Kaizen and Continuous Improvement
Kaizen = Change for the Better
Bubbles for Babies
Kaizen: A Powerful Word
Kaizen Is Not Just Change, It Is Improvement
We Often Succeed As the Result of Failing More
Kaizen, PDSA, and the Scientific Method for Improvement
Changing Back Can Be Better For Babies
Kaizen = Continuous Improvement
Kaizen Starts with Small Changes
A Small Kaizen with Great Meaning
Kaizen = Engaging Everybody in Their Own Change
Kaizen Upon Kaizen Upon Kaizen
Kaizen Closes Gaps Between Staff and Leaders
Creativity before Capital
Expensive Mistakes Made without the Kaizen Mindset
Kaizen and Lean: Related and Deeply Interconnected Concepts
People Are the Ultimate Competitive Advantage
High-Level Kaizen Principles—The Kaizen Mindset
This Is Not a Suggestion System—It Is an Improvement System
Kaizen Has an Impact on People and Performance

The Roots and Evolution of Kaizen
Early Suggestion Programs
Downsides of Suggestion Box Programs
Recovering from Taylorism
The American Roots of Continuous Improvement—TWI and Deming
Kaizen: One of the Two Pillars of The Toyota Way
Masaaki Imai and the Spread of Kaizen (1986)
Dr. Donald Berwick’s Call for Kaizen (1989)
"Medicine’s Need for Kaizen" (1990)
Norman Bodek and American Kaizen
Discussion Questions

Types of Kaizen
The Continuous Improvement of a Lifesaving Innovation
Three Levels of Kaizen
     Imai’s Three Levels of Kaizen
     Complementary Nature of the Levels of Kaizen
     Three Types of Kaizen at Children’s Medical Center Dallas
Events Alone Will Not Make You Lean
     The Origins of Kaizen Events
     Basic Structure and Format of an Improvement Event
     Impressive Results from Kaizen in Healthcare
          Virginia Mason Medical Center
     Criticisms of Weeklong Events
Not All Kaizen Organizations Rely on Events
     Kaizen Leads to Innovation at Franciscan

Moving Toward a Kaizen Culture
The Real Goal—Cultural Transformation
What a Kaizen Culture Feels Like
     Everyone Is Engaged
          Drivers of Engagement
     Everyone Is Relentlessly Searching for Opportunities to Improve
     The Two Parents of Transformation: Pain and Possibility
     You Have Control over Your Workplace
     Patients and Families Are Happy
     Staff and Physicians Are Happy
     Work and Patient Care Flow Like Clockwork
     The Workspace Is Clean, Orderly, and Safe
     Everyone Works Together
     Everything Gets Questioned
     Small Successes Lead to Bigger Successes
Small Kaizen Leads to More Big Ideas
     Bite-Size Chunks
     Imai’s Three Stages of Kaizen


Quick and Easy Kaizen
How to Do Kaizen
Quick and Easy Kaizen
Starting the Franciscan Kaizen Journey
The Quick and Easy Kaizen Process
     Step 1—Find
          Start Small
          Start With You
          Make Your Work Easier
          Make Your Work Safer
          Make Your Work More Interesting
          Build Your Skills, Your Capabilities, and Your Knowledge
          See an Opportunity or a Problem
     Step 2—Discuss
          Discuss with your Direct Supervisor
          Discuss with Your Team Members
          Quantify the Idea
     Step 3—Implement
          Enrolling Others to Help
          Implement the Improvement Idea
          Seven Days Grace
     Step 4—Document
          Finalize the Kaizen report
          Submit Report For Approval
     Step 5—Share
          Leveraging Improvement Ideas from Others
          Sharing Kaizens

Visual Idea Boards
Making the Improvement Process Visible
Setting up a Visual Idea Board
     Boards Should Be Highly Visible in the Workplace
     Boards in "Public" Settings
Communication That Should Occur before the Visual Idea Board Is Put Up
     What Happened to the Suggestion Box?
     What Employees Can Expect
     A Communication Example
Formats for Idea Cards
     Sticky Notes versus Structured Cards
     Idea Cards versus Suggestion Cards
     Modeling the Kaizen and PDSA Process in Writing
Visual Idea Cards
     Suggestion or Idea
     Date Originated
     Created By
     Expected Benefits
     Input Needed From
     Implementation Steps
     Results Verified?
     New Method Standardized?
     Completion Date
Idea Card Examples
     Staff and Patient Annoyances
     Asking for Help
     Addressing Patient Needs
     Getting Input from Others
Other Formats of Idea Boards and Cards
     Park Nicollet’s KEEP Form
     Akron Children’s Hospital
     Seattle Children’s Hospital Pharmacy
Visual Management of the Idea Boards
Using Idea Cards to Coach People on Kaizen
     The Suggestion to "Be More Careful"
     Something’s Not Happening—So Don’t Forget
     Easier for Us, but Not Best for the Whole System?
Tracking Completed Cards

Sharing Kaizen
Different Formats for Sharing
The Kaizen Wall of Fame Format
Kaizen Sharing Examples
     Making Things Better for Patients
          Supplies for Patients
          Improving Meal Rounds
     Easier to Get DVDs
     Little Details for Patients
Preventing Mistakes or Harm
     Ensuring Proper Bed Cleaning
     Preventing Pressure Ulcers
     More Accurate Lab Results Through Standardized Work
     Proper X-Ray Ordering
     Ensuring Equipment is Ready
     Eye Protection for Lab Staff
     Preventing Aerosolized Specimens
Making Work Easier for Staff
     Easier to Plug In Carts
     Improved Ergonomics and Specimen Quality
     Saving Sore Feet
     Better Phone Ergonomics and Productivity
     Combining Two Forms Into One
Preventing Delays
     Faster Code STEMI Heart Attack Care
     Meds for Discharged Patients
     Getting Patients to Rooms with Less Delay
     More Timely Test Results for Rounding
     Fewer Supply Chain Delays
     Better Access to Endocrinology
Saving Space or Cost
     Creativity over Capital in the Lab
     Company Medical Clinic Costs
     An Unnecessary Label
     Rethinking Freezer Use

The Art of Kaizen
Barriers to Kaizen
     Resistance to Change
     Lack of Time—We’re Too Busy
A Model for Mobilizing Support
     Tenet 1: Respect Others
     Tenet 2: Create a Vision That Matters
     Tenet 3: Convey the Why
     Tenet 4: Connect to the Mission
     Is This About Me or Is This About the Mission?
Working with Others Based on Their Willingness to Invest
     Strategy 1: Cocreate with Those Eager for Opportunity
          Seek Their Ideas
          Play Kaizen Catch Ball
          Reigniting Everyone’s Creativity
     Strategy 2: Sell Opportunity to Those That Are Cautious
          Seven Days Grace
          Measure Progress
     Strategy 3: Find Common Meaning with and Negotiate with Opposers
          Include Opposing Viewpoints
          Find Common Meaning
          Use Demands as a Last Resort
Kaizen and Positive Deviance
     Rules for Leaders


The Role of Leaders in Kaizen
Leading to Create the Culture
     Key Actions for Leaders at All Levels
     Key Action 1: Believe In the Power of Kaizen
     Key Action 2: Participate in Kaizen
     Key Action 3: Just Ask
          Ask, Don’t Tell
     Key Action 4: Use Kaizen to Develop People
     Key Action 5: Ensure Staff Members Are Recognized and Rewarded
     Key Action 6: Share and Spread Ideas
     Key Action 7: Sell the Benefits
          It Is Not Always about Cost
Role of Top-Level Managers
     Leadership and Kaizen Participation Starts at the Top
          Dr. John Toussaint’s Participation
          Going to the Gemba
     Kaizen Reports Are for Everybody
     Key Actions for Top-Level Managers
          Key Action 1: Communicate Expectations and Prioritize
          Key Action 2: Resource Adequately
          Key Action 3: Sponsor a Recognition and Incentives Program
          Key Action 4: Share Notable Kaizens
          Key Action 5: Thank People Personally
Role of Middle-level Managers
     Paula’s Baby Steps Lead the Way
          The "Great Big Pile of Problems"
     Leaders Drive Kaizen Success
     The Kaizen Difference
     Key Actions for Middle-level Managers
          Key Action 1: Be the Departmental Owner and Develop Co-Owners or Coordinators
          Key Action 2: Use Departmental Meetings
          Key Action 3: Encourage Staff to Participate by Asking for Their Ideas
          Key Action 4: Create a Departmental Recognition System
          Key Action 5: Put a Tracking System in Place, If One Does Not Exist
          Key Action 6: Tie to Performance Evaluations
Role of First-Level Managers
     A First-Level Manager Is a Coach
     Key Actions for First-Level Managers
          Key Action 1: Coach
          Key Action 2: Empower Staff—Do Not Do the Kaizen for Them
          Key Action 3: Use Rounding to Coach
          Key Action 4: Help Set Expectations
          Key Action 5: Review and Approve Kaizen Reports
          Key Action 6: Help Document Benefits
          Key Action 7: Make Kaizen Fun
          Key Action 8: Recognize and Reward
          Key Action 9: Share and Spread Ideas
          Key Action 10: Be a Cheerleader

Organization-Wide Kaizen Programs
Getting Started
     When Will You See Results?
     Tying Kaizen to the Organization’s Strategy
The Kaizen Promotion Office
     Staffing the KPO
Activities of the Kaizen Promotion Office
     Activity 1: Facilitates the Practice of Kaizen
     Activity 2: Reports Kaizen Metrics
     Activity 3: Coordinates Rewards and Recognition
     Activity 4: Facilitates Kaizen Sharing across the Organization
     Activity 5: Develops Kaizen Standardized Work
     Activity 6: Develops and Delivers Staff Education
     Activity 7: Facilitates the Documentation and Tracking of Kaizens
Sustaining a Kaizen Program—Incentives and Rewards
     Pros and Cons of Financial Incentives
Electronic Kaizen Systems
     Advantages of an Electronic Online Database
          Quick Entry
          Automatic Routing and Electronic Approval
          Ideas to Hold for Later
          Quick Search and Retrieval
     Electronic Kaizen within Intermountain Healthcare
     Electronic Kaizen at Park Nicollet
     Electronic Kaizen at Vanderbilt

Lean Methods for Kaizen
Technique 1: Add Value
     The Internal Customer’s Point of View
     Different Forms of Patient Value
Technique 2: Eliminate Waste
     Waste 1: Transportation
     Waste 2: Overproduction
     Waste 3: Motion
     Waste 4: Defects (Errors and Rework)
     Waste 5: Waiting
     Waste 6: Inventory
     Waste 7: Overprocessing
     Waste 8: Lost Human Potential, Creativity, and Opportunities
     Seeing Waste Through Process Observation
          "Go See"
          Spaghetti Diagrams
Technique 3: Visual Workplace
     Color Coding
     Home Locations
          Kitchen Example
Technique 4: 5S—Workplace Organization
     S1: Sort
     S2: Set in Order
     S3: Shine
     S4: Simplify and Standardize
     S5: Sustain
Technique 5: Workstation Design
Technique 6: Problem Solving
     A3 Problem-Solving Technique
     Example Problem-Solving A3
     Problem-Solving Methods Used with A3
          Find the Point of the Cause
          Identify the Root Cause
Technique 7: Error Proofing
     Fatal and Preventable Healthcare Errors
     Four Elements of a Zero Defect Quality System
          Element 1: Self-Check and Successive Check
          Element 2: Immediate Feedback and Corrective Action
          Element 3: Source Inspection
          Element 4: 100% Inspection

Kaizen At Home
Kaizen Tips from an Actress
Kaizen Tips from a Behavioral Scientist
Kaizen at Home
Kaizen before Work
     Kaizen for Breakfast
     Kaizen to Get Ready for Work
     Kaizen with Your Coffee
     Kaizen to Get Dressed
     Kaizening Cup Clutter
     Kaizen on the Way to Work
     Kaizen in the Home Office
          Kaizen on the Computer
          Kaizen on the Physical Desktop
     Kaizen after Work
     Kaizen for Dinner
     Kaizen in the Backyard
     Kaizen Home Repair
     Kaizen for the Earth
     Kaizen in the Bathroom
     Kaizen and Your Kids
     A Vacation from Kaizen?
     Kaizen for Repetitive Tasks
     Kaizen for the Kaizen Process

A Minute to Learn, a Lifetime to Master
Your Next Steps
Building a Kaizen Community

Each chapter includes a Conclusion, Discussion Questions, and Endnotes

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Mark Graban is an author, consultant, and speaker in the field of lean healthcare. He is the author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition. Mark has worked as a consultant and coach to healthcare organizations throughout North America and Europe. He was formerly a senior fellow with the Lean Enterprise Institute and continues to serve as a faculty member. Mark is also the Chief Improvement Officer for KaiNexus (, a startup software company that helps healthcare organization manage continuous improvement efforts. Mark earned a BS in Industrial Engineering from Northwestern University and an MS in Mechanical Engineering and an MBA from the MIT Sloan Leaders for Global Operations Program. Visit his website at and his blog at

Joseph E. Swartz is the Director of Business Transformation for Franciscan St. Francis Health of Indianapolis, IN. He has been leading continuous improvement efforts for 18 years, including 7 years in healthcare, and has led more than 200 Lean and Six Sigma improvement projects. Joseph is the co-author of Seeing David in the Stone and was previously an instructor at the University of Wisconsin. Joseph earned an MS in Management from Purdue University as a Krannert Scholar for academic excellence.


Mark Graban is one of the most respected voices in the Lean world. He is the founder and driving force behind Lean Blog, ( a vibrant site he continuously updates with compelling information and analysis about lean in health care. Mark’s new book, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements (co-authored with Joseph E. Swartz), is a must read for anyone on a Lean journey. At Virginia Mason, the concept of kaizen, which Mark and Joe write about so well in the new book, is ingrained in the organization’s cultural DNA. … The real goal of Lean in health care, they write, is cultural transformation. This is an essential insight. At Virginia Mason, the work of adapting the Toyota Production System to health care in the form of the Virginia Mason Production System has cultural transformation at its core. This sort of change is anything but easy. Culture, as the saying goes, tends to eat strategy for lunch. But cultural change is transformative.. … Mark and Joe understand the patience required to do this work well. They recognize the power of the sort of continuous incremental improvement at the heart of the Toyota Production System. … The book is highly detailed and includes helpful discussion questions at the end of each chapter.
Virginia Mason Medical Center Blog, Could this new book help drive your Lean journey?
Read the full review at:

I hope you will discover, as we have, the incredible creativity that can be derived by engaging and supporting each and every employee in improvements that they themselves lead.
—Robert (Bob) J. Brody, CEO, Franciscan St. Francis Health

Front line staff must know, understand, embrace and drive Kaizen and its tools to achieve incremental and continuous improvements. This book will help health care organizations around the world begin and advance their journey.
—Gary Kaplan, MD, FACP, FACMPE, FACPE, Chairman and CEO, Virginia Mason Medical Center, and Chairman of the Board, Institute for Healthcare Improvement

Healthcare leaders need to read this book to understand that their management role must radically change to one of supporting daily kaizen if quality safety and cost are to improve in healthcare.
—John Toussaint, MD, CEO, ThedaCare Center for Healthcare Value

The healthcare industry is in the midst of truly fundamental change, and those organizations that engage their front line staff … will be well positioned to thrive in a post-reform environment.
—Brett D. Lee, PhD, FACHE, Senior Vice President, Health System Operations, Children’s Healthcare of Atlanta

Healthcare Kaizen
is a practical guide for healthcare leaders aspiring to engage frontline staff in true continuous improvement. Graban and Swartz skillfully illustrate how to foster and support daily continuous improvement in health care settings.
—John E. Billi, MD, Associate Vice President for Medical Affairs, University of Michigan

I hope everyone reads this book and recommits to the fundamentals of Lean, particularly the involvement of frontline staff in process redesign.
—Fred Slunecka, Chief Operating Officer, Avera Health

Kaizen has marvelously engaged so many of our staff and enabled them to improve the world around them to the benefit of staff, patients and community.
—Paul Strange, MD, Corporate VP of Quality, Franciscan Alliance

Mark Graban and Joseph Swartz present a clear pathway for successful Lean practice in Healthcare Kaizen. This should be on every healthcare systems reading list.
—David Munch, MD, Senior Vice President and Chief Clinical Officer, Healthcare Performance Partners

Mark and Joe provide real-life examples of how those who do the work provide ideas for small changes that add up to BIG results. Healthcare Kaizen is a must for leaders whose focus is the patient and how to effectively and efficiently deliver quality and safety with improved outcomes.
—Betty Brown, MBA MSN RN CPHQ FNAHQ, President, National Association for Healthcare Quality

Using examples from Franciscan Health and other forward-thinking medical groups, the book contains valuable strategies for organization-wide cultural transformation to create an more efficient, patient-centered healthcare system dedicated to continuous quality improvement.
Donald W. Fisher, Ph.D., President and CEO, American Medical Group Association

This inspirational book is packed with examples and is informed by the authors’ years of experience on the ‘front-lines’ themselves, helping leading healthcare organizations around the world to build successful kaizen programs.
—Alan G. Robinson, PhD, Professor, Isenberg School of Management, University of Massachusetts; and Author of Ideas Are Free: How the Idea Revolution Is Liberating People and Transforming Organizations

At Beth Israel Deaconess Medical Center, everybody improving every day is a critical aspect of our Lean and quality improvement efforts. Healthcare Kaizen, is full of relatable examples as well as practical ideas that will inspire staff, clinicians and leaders at all levels.
—Alice Lee, Vice President, Business Transformation, Beth Israel Deaconess Medical Center

In Healthcare Kaizen, Mark and Joe remind us of the great power of daily problem solving. The story of Franciscan St. Francis Health is compelling, where leaders created the opportunity for great people at the frontline making great improvements for patient care.
—Michel Tétreault, MD, President and CEO, Bruce Roe, MD, Chief Medical Officer, St. Boniface Hospital, Winnipeg, Canada

I have learned that respect for the people who work for you is key to any transformation. Mark Graban and Joseph Swartz do a great job of capturing this truth in their book… This book is a long needed addition to my growing lean healthcare library.
—Patrick Anderson, Executive Director, Chugachmiut, Anchorage, Alaska

The vision of a world in which our healthcare institutions operate with a universal discipline of relentless, patient-centered improvement remains a vitally important yet distant dream. In Healthcare Kaizen, Mark Graban and Joseph Swartz illustrate just how to make that dream a reality.
—Matthew E. May, Author of The Elegant Solution and The Laws of Subtraction

The philosophy, tools and techniques discussed in the book work, and work well, in any environment. We in healthcare must improve – we owe it to our patients and communities – and Mark and Joe are helping to show us the way.
—Dean Bliss, Lean Improvement Advisor, Iowa Healthcare Collaborative

What Mark Graban and Joseph Swartz have done in Healthcare Kaizen is to bring hope and light to a part of our society that is facing increasing challenges. Healthcare Kaizen will be a reference on the subject for many years to come.
—Jon Miller, CEO, Kaizen Institute

Hopefully this book will become a blueprint for healthcare organizations everywhere that truly want to be great!
—Jeffrey Liker, Professor of Industrial and Operations Engineering, University of Michigan; and Shingo Prize-Winning Author of The Toyota Way

Fixing health care may be our generation’s great test. We’ll need to engage all the good people who currently work in broken systems. Mark and Joe have helped to show us how.
—Pascal Dennis, Lean Pathways, Inc., Author, The Remedy and Andy & Me

Graban and Swartz present the kaizen philosophy in the most accessible way I’ve seen yet. THIS is the missing link in healthcare reform.
—Karen Martin, Author of The Outstanding Organization and The Kaizen Event Planner

In this new book, Graban and Swartz offer a new and innovative approach towards improving the healthcare delivery system. Unlike previous attempts by too many others, the book introduces the reader to the concept of “Kaizen”, often described as the source of Toyota’s transformation into an auto giant, acclaimed worldwide for its quality and service. The timing for the publication could not be better. … Focusing on ‘Kaizen Theory’, the book is illustratively rich in theory and applications. … The reader is introduced to concepts, tools, and exercises that foster creativity and innovation. Graban and Swartz present vivid examples to illustrate visibility, participation and accountability. … Every reader will find great value in this publication. In closing, we look forward to their next book … .
—Miguel Burbano and Whitney Churchill, writing on