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

Healthcare Kaizen

Engaging Front-Line Staff in Sustainable Continuous Improvements, 1st Edition

By Mark Graban, Joseph E. Swartz

Productivity Press

408 pages | 201 Color Illus.

Shingo Award Winner
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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 bookshows 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. (


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

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

About the Authors


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.

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Quality Control
BUSINESS & ECONOMICS / Industries / Service Industries
MEDICAL / Administration