Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition, 3rd Edition (Paperback) book cover

Lean Hospitals

Improving Quality, Patient Safety, and Employee Engagement, Third Edition, 3rd Edition

By Mark Graban

Productivity Press

330 pages | 63 B/W Illus.

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Organizations around the world are using Lean to redesign care and improve processes in a way that achieves and sustains meaningful results for patients, staff, physicians, and health systems. Lean Hospitals, Third Edition explains how to use the Lean methodology and mindsets to improve safety, quality, access, and morale while reducing costs, increasing capacity, and strengthening the long-term bottom line.

This updated edition of a Shingo Research Award recipient begins with an overview of Lean methods. It explains how Lean practices can help reduce various frustrations for caregivers, prevent delays and harm for patients, and improve the long-term health of your organization.

The second edition of this book presented new material on identifying waste, A3 problem solving, engaging employees in continuous improvement, and strategy deployment. This third edition adds new sections on structured Lean problem solving methods (including Toyota Kata), Lean Design, and other topics. Additional examples, case studies, and explanations are also included throughout the book.

Mark Graban is also the co-author, with Joe Swartz, of the book Healthcare Kaizen: Engaging Frontline Staff in Sustainable Continuous Improvements, which is also a Shingo Research Award recipient. Mark and Joe also wrote The Executive’s Guide to Healthcare Kaizen.


"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 of Studer Group, 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’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 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

"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, Executive Vice President for Health Affairs, University of Virginia

"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 J. Spear, Sr. Lecturer at MIT Sloan School of Management and Sr. Fellow at the Institute for Healthcare Improvement, 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 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 the staff in these efforts. Mark Graban has deep experience applying lean in the healthcare field, and in his book 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 front line staff level. This is a must-read for any leader in today’s increasingly complex healthcare industry."

—Brett Lee, PhD, FACHE, Market Chief Executive Officer, Tenet Healthcare

"The Institute of Medicine (IOM) calls for systems in healthcare that support continuous learning and process improvement, and highlights waste as a fundamental obstacle to attaining highly reliable and value-based healthcare systems. Lean is a proven way to eliminate waste, while hardwiring systems to ensure sustainability. Eliminating waste and engaging employees are the key to value-based medicine, where waste is identified and eliminated, and value emanates seamlessly from continuous process improvement in the rich environment of a continuously learning organization. Lean Hospitals is a foundational text for understanding the concepts and application of continuous process improvement in a healthcare environment, and provides practical guidance and concrete examples to eliminate waste and increase value to the customer."

—Beverly B. Rogers, MD, Chief of Pathology, Children’s Healthcare of Atlanta; Clinical Professor of Pathology, Emory University School of Medicine

"Mark Graban's book will leave you with an appreciation for what Lean is and what it can do for your healthcare organization. Since the original edition in 2008, I have conducted Lean Hospitals book studies for all my staff. Everyone gets a personal copy of Lean Hospitals for the study and to keep as a reference. I look forward to the third edition. It's my Lean bible."

—Jim Adams, Admin Director of Laboratories, Children's Healthcare of Atlanta

"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, Former Improvement Advisor, Iowa Healthcare Collaborative

"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. Health care is different than car making. This is true but many, many hospitals are learning from Toyota and making remarkable improvements. The two pillars of the Toyota Way certainly fit the health care environment—Respect for People and Continuous Improvement.

Unfortunately, the remarkable improvements are in specific areas and seem difficult to sustain because of a mysterious ingredient, which the folks at Toyota seem to understand quite well—humans. Health care exists to serve humans and humans provide the services. Humans 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 Way. 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 Way into language any health care professional can understand."

—Jeffrey K. Liker, Professor, University of Michigan, Author of The Toyota Way

Table of Contents

The Need for Lean Hospitals

Better Results with Lean

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

Good Quality Costs Less

Interconnected Benefits

A Snapshot of Department Success: Laboratory, Children’s Health Dallas

From Departmental to Hospital- and System-Wide Success


Lean Lessons

Points for Group Discussion


Overview of Lean for Hospitals and Health Systems

What Is Lean?

Ohno’s Definition of Lean

Lean Thinking

The Toyota Triangle: Tools, Culture, and Management System

The "Toyota Way" Philosophy

Four Organizational Capabilities for Lean

Lean and Other Methodologies

What Lean Is Not


Lean Lessons

Points for Group Discussion


Value and Waste

Waste: A Global Problem with Local Solutions

Reducing Waste Is a Better Goal Than Reducing Cost

What Is Waste?

What Is Value? Start with the Customer

How Do We Define Value in a Broad Sense?

How Does Lean Define "Value?"

Examples of Value-Added and Non-Value-Added Activities

Learning to Identify and Describe Waste

There’s Not Always an Easy Answer

What Non-Value-Added Activities Are Required?

Non-Value-Added, Pure Waste


Lean Lessons

Points for Group Discussion


Observing the Process and Value Streams

Learning to See

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 Employee


Lean Lessons

Points for Group Discussion


Standardized Work as a Foundation of Lean

Helpful Standardization: From 171 Forms to Just Six

The Need for Standardized Work

The Toyota House Metaphor

Overview of the Lean Foundations

Lean Foundations: Standardized Work

Definition of Standardized Work

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 for Raising Concerns

Standardized Work Can Apply to Leaders

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

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 Tragic and Preventable Mary McClinton Story

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

Find Root Causes Using Simple Methods

A3 Problem Solving

Toyota’s Practical Problem Solving

Be Proactive and Use Failure Modes and Effects Analysis

Proactive Resolution of Near-Miss Problems

The Heinrich Safety Pyramid


Lean Lessons

Points for Group Discussion


Preventing Errors and Harm

A Serious Problem with Large, Unknowable Numbers

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

Error Proofing, Not Dummy Proofing

Examples of Error Proofing in Hospitals

Stopping the Line (Andon)

Error Proofing the Error Proofing


Lean Lessons

Points for Group Discussion


Improving Flow

Lean Is Both Quality and Flow

Waiting: A Worldwide Problem

Targets without a Means for Improvement Might Lead to Improvement or Dysfunction

Focusing on Flow

Value Streams Should Flow Like a River

Uneven Workloads as a Barrier to Flow

Addressing Mura by Matching Staffing to Workloads

Improving Patient Flow

Improving Flow for Ancillary Support Departments


Lean Lessons

Points for Group Discussion


Lean Design

Better, Faster, and Cheaper

Understanding the Current State before Designing the Future

Lean Design at East Tennessee Children’s Hospital

Integrated Lean Project Delivery at Akron Children’s Hospital


Lean Lessons

Points for Group Discussion


Engaging and Leading Employees

Improving the Way 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

Performance Measures


Lean Lessons

Points for Group Discussion


Getting Started with Lean

How Do We Start?

The LEI Lean Transformation Model

Where Do We Start?

What Do We Call It?

Getting Started with Kaizen

Kaizen Events

Lean Transformation Projects

The Lean Project Team

Executive Sponsorship and Leadership

Starting from the Middle

Establishing a Model Line and a Road Map

Dedicating People to Lean Beyond Projects

The Lean Department

The Importance of Change Management

A Snapshot of Hospital Success: Avera McKennan Hospital & University Health Center


Lean Lessons

Points for Group Discussion


A Vision for a Lean Hospital and Health System


When Is a Health System Lean?

What Would a Lean Health System Look Like?

What Would a Patient Experience in a Lean Health System?

What Would It Be Like to Work in a Lean Health System?

How Would We Describe a Lean Health System?

In Conclusion

Points for Group Discussion




About the Author

Mark Graban is an internationally recognized expert in the field of "Lean healthcare," as a consultant, author, keynote speaker, and blogger. Mark is also co-author, with Joe Swartz, of the book Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements. He has been recognized twice (for this book and Healthcare Kaizen) as the recipient of the prestigious Shingo Research & Professional Publication Award.

Mark is an experienced 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, to make healthcare more affordable, 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, a not-for-profit education organization that is a leading voice in the Lean world. In this role, Mark also served as the director of communications & technology for the Healthcare Value Network, a collaboration of healthcare organizations from across North America, a partnership between the Lean Enterprise Institute and the ThedaCare Center for Healthcare Value. Mark continues as a faculty member for the Lean Enterprise Institute and the ThedaCare Center.

In June 2011, Mark also joined the software company KaiNexus to help further their mission of spreading continuous improvement, while continuing his other work and activities. He also serves on the board of the Louise H. Batz Patient Safety Foundation.

Mark was raised in Livonia, Michigan, and currently resides in Texas with his wife, Amy.

To Interact with Mark, please visit www.LeanHospitalsBooks.com or www.MarkGraban.com.

Subject Categories

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