Lean Hospitals Improving Quality, Patient Safety, and Employee Engagement, Third Edition

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
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
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 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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

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
Conclusion
Lean Lessons
Points for Group Discussion
Notes

A Vision for a Lean Hospital and Health System
Introduction
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
Notes

Glossary

Index

Biography

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.

"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