Naida Grunden and Lean Healthcare


The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods

Below is a guest post from fellow author and Lean Healthcare practitioner, Naida Grunden. Her book (linked above) is an outstanding collection of principles and case examples from the Pittsburgh Regional Health Initiative. She was recently interviewed by a National Public Radio station and you can listen here.

What follows is a letter that Naida posted to the “” website, where the Obama team is asking for specific input about healthcare reform, posted here with her permission.


The Problem

Here's an encouraging possibility: there's probably enough money in the healthcare system today to pay for basic health care for every man, woman and child in this country. Estimates are that half of every healthcare dollar currently goes up in the form of waste. Consider that:

  • A third of lab tests ultimately have to be repeated unnecessarily, because the results were misplaced in the paper jungle.
  • A hospital nurse spends about one third of his time involved in direct patient care – and two thirds either looking for supplies, people or things like missing medications and doing paperwork.
  • Still from time to time, despite the publicity and the threat of Medicare's suspension of funding, somebody in America operates on the wrong limb – it's unthinkable!
  • The creativity of workers, who know their work best, is stifled by a top-heavy, command-and-control management system that tells them that their ideas are worthless. And yet in highly successful organizations, like Toyota, it's the workers themselves who hold the key to drastic and stunning improvements in the way work is done, saving millions of dollars.

Efficiency for its own sake is probably worth pursuing. But ask anyone involved in a safety culture, like an airline pilot, and you'll hear that efficiency saves lives. By reducing the number of handoffs, the chance for introducing error goes down. In the current Byzantine health system, disconnected pieces of processes create danger at every turn. And those mistakes are costly, both in money and altered lives.

If you take at face value the 2000 IOM report stating that up to 100,000 Americans die from preventable medical error in our hospitals, and add the 2001 CDC report that another 90,000 die from hospital-acquired infections, that statistic is sobering indeed. It means that hospital errors cost the lives of 520 Americans each day. (By comparison, the Tenerife air disaster in 1977 cost 575 lives – and that one loss led to a wholesale change in the way airline crews are trained and processes are standardized.) Put another way, as many people die in American hospitals each week from preventable error as died on September 11.

So far, governmental reaction has involved demands for more and more data. The amount of data collected in the American hospital is staggering: the requirements are also discontinuous and often contradictory. Of the mountains of data collected, very little interpretation is done, or is even possible. The data don't speak. It's as if data collection is imposed as a punishment for the wave of medical errors in this country. Data collection, which could really tell us how we're doing, has become another huge form of waste.

The Solution

There's no shortage of good ideas about “what” to do. If you look at guidelines issued by the CDC or the Institute for Healthcare Improvement, or the Joint Commission, or Baldrige, or Magnet…there's a plethora of good ideas about “what” needs to be done.

The struggle comes with “how.” How do you change culture in a hospital? How do you get measurable results in a big hurry? How do you stop hospital-acquired infections, start standardizing procedures, and give people down the hierarchy permission to stop an unsafe procedure? How do you unleash the creativity of people on the front line of patient care, letting them help figure out how to take better care of patients?

Nobody can argue that a national standard and implementation of electronic medical records are good ideas that will enhance patient safety. But even the most advanced, easy-to-use EMR is not a silver bullet, and will not cure all that ails health care. That synapse where machine meets man is the most vulnerable part. Simple problems – is the battery charged? – end up defeating the most advanced electronic systems unless the organization itself has an underlying system. Introducing EMR into a chaotic hospital with no standardized procedures will not improve patient outcomes as much as desired.

Changing hospital culture involves a total redesign, analogous to the sweeping changes in training that followed the Tenerife air disaster. After that, flight crews were taught that the captain is the leader of the team, not the dictator. Captains were taught to listen to every team member and use the collective wisdom of the group to operate the aircraft more safely. Most important, all procedures were standardized from airline to airline, and pilots were required to call out checklists every time – by law. That training and the standardization were not “suggested,” or “incentivized.” They were commanded from the top, from the FAA, and airlines had to comply with training by date certain.

Something similar needs to happen in hospitals. Top-heavy management that dictates frontline work from a distant conference room must transform into teachers and mentors who encourage change from the bottom up. Physicians, who are often not employees of hospitals, must still be held to standardized work. Leadership from the highest levels of government must mandate changes in the way our hospitals are managed, to more closely reflect a well run Toyota Production plant, where frontline workers' ideas are honored, and managers are mentors. Data are collected, to be sure, and often they tell the story of continuous improvement or point directly to the place that needs work.

Toyota methods – also called Lean – has been shown to work in hospitals, health centers and nursing homes, producing sweeping gains in patient safety and saving huge amounts of money. My book, The Pittsburgh Way to Efficient Healthcare, outlines some of the improvements. There are many, many more examples of how the intersection of industrial engineering and medicine can improve both patient safety and worker satisfaction.

Two books for your consideration:

The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods by Naida Grunden (me)

Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction, by Mark Graban


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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.


  1. Great article. As Naida said, we generally know the “what” to do, and certainly the “why”. The question is “how” to get it done. Will it take an FAA-like mandate? Will it work with a transformation at all levels of healthcare? Will the payment system be changed to provide incentives and/or penalties? I wish we had the answer. Maybe the next step is to get the best and brightest together to develop the answer.

  2. I think one key is that we don’t have to get the best and brightest to develop an answer to tell us. The answer is found by asking the people who do the work. EXPERience = EXPERtise.

    Go and see what is really happening in the workplace. Little problems add up over an entire system. I worked with one hospital that had a pharmacy tech that did nothing but flip scanned images right-side up before they went to the pharmacist. It saved time for the pharmacist, but did not really add any value to the medication process. By working with the nursing units and labeling all the fax/scanners “Face Down/Feet First”, we could eliminate this work (but not the job) of the pharm tech and have them do something useful– like delivering meds!

    We are sitting on a gold mine of knowledge in the people that do the work! We just have tap into it.

    Richard Tucker

  3. I agree with Naida’s comments that we need a more empowered workforce to avoid “death by the slow no,” as a response to reform efforts.

    When physicians, nurses, and allied healthcare professionals feel that they are making their time count, the practice environment improves dramatically.

    Quality and safety will save dollars; it is always less expensive to do things right the first time rather than treat complications.

    Kenneth H. Cohn, M.D., MBA, FACS
    Author of Better Communication for Better Care and Collaborate for Success!


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