UK Hospitals Gemba Walk the U.S.


I was sent a nice “gemba report” essay from a UK lean healthcare consultant, Andrew Castle. Andrew consults for the UK National Health Service and came with a group to tour two American sites:

Some highlights of their observations, brought back for a healthcare audience.


An interesting side note to TIE's growth over the last decade is that post 9/11 the US economy suffered from an industrial recession. Demand for forklift trucks decreased by approximately 10% from September 2001 for the following 12 months. A large number of people were laid off and made redundant following 9/11 as demand for products decreased but Toyota decided not to lay off a single member of staff. They accepted that they needed 10% fewer staff (approximately 30 of the 300 strong manufacturing workforce in place at the time) to meet demand but rather than lay staff off they chose to second them internally from Manufacturing to a Service Improvement team.

For the 12 months following 9/11 these staff worked on projects that would improve efficiency once demand picked back up. The rational behind this strategy was that whilst customers were not going to buy new trucks following 9/11, eventually they would, and once they did they would have to make the trucks that were not bought during the year in which demand fell as well as the trucks that would normally have been bought that year.

One year after 9/11 staff were seconded back from Service Improvement to production, demand for trucks increased to levels greater than pre 9/11 due to customers ordering trucks that they should have bought during the recession as well as customers ordering trucks that were due for replacement and not one member of staff was laid off during this period.

TIE have seen a 70% reduction in staff turnover since 1990, from 30% to 9%, compared to a local level of 13%. There is a six month waiting list for staff to start and TIE no longer advertise for employees.

There is a PERFECT example of taking a long-term view in the face of economic trouble. Toyota could afford to keep employees on board after 9/11 and put them to productive use, kaizening their processes and preparing for the plan demand increase that would eventually come.

Northwestern Memorial Hospital:

From the design of the building to the internal environment in which care is provided NMH strives to provide the best patient experience from the patient's perspective; recruit and retain the best people who share the organisation's values and achieve results; and achieve exceptional financial performance. 9 quality improvement leaders work full time on multiple service improvement projects. Since 2002 NMH has undertaken 125 improvement projects resulting in a 57% reduction in potentially avoidable severe harm events and a greater than 4:1 annual financial benefit from improvement. There is an annual quality day where all improvement project teams present the status of their projects to 300 senior managers and clinicians. There is a board retreat for half a day per year. The focus of the retreat is on quality and safety. All potentially avoidable incidents are reviewed and actioned immediately or become the focus of future improvement projects.

There are lots of great details — download the full report. Thanks again to Andrew for sharing this with the lean community.

Originally published in the Health Service Journal (

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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