I Sometimes Sort of Hate My Book’s Title, I Think


Another interesting discussion that came up during my trip to The Netherlands… my book's title: Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction (see the 2016 3rd edition).

I'd have to admit, the phrase “Lean Hospital” is a tough description to live up to. The term “lean” originally referred to the performance gap between auto plants run under the Toyota/lean system and those run the traditional way. To be “lean” meant that your plant was significantly better in many regards – not 5% better but 50% better: quality, labor productivity, etc.

Are there hospitals that are uniformly 50% better than the standard benchmark? Probably not… yet. Maybe some are getting there, but it will still take time. To be a “Lean Hospital,” does that mean half the infection rates, half the preventable mortality rates, twice the nursing labor productivity, etc.? Is that possible?

We have to be careful that “Lean” doesn't mean “perfect.” Lean is not a destination, a point we reach where we get a flag to fly out in front of the hospital. If Lean meant perfect, then nobody is lean, including Toyota, since everybody has waste.

Ultimately, “Lean Hospitals” was meant to be a snappy short title. A more accurate title might have been:

“Hospitals That Are Using The Lean Methodology in a Significant Way.”

More accurate, but probably not a better title.

Then, there's the discussion about the subtitle. Where does long-term financial performance enter into the picture? Is this not important? Toyota says the goal of TPS is long-term corporate vitality, as they put it. Long-term vitality is important for a hospital… have to not lose tons of money, have to keep the doors open.

So maybe a better subtitle is:

“Achieving Long-Term Hospital Financial Vitality through Continuously Improving Quality, Patient Safety, and Employee Satisfaction, Amongst Other Important Goals.”

Nah, it's probably better the way it is… what would you call it?

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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. It's gratifying to see the degree of humility you continue to bring as you become world-famous — no, I'm not kidding actually.

    If I understand your angst, you have a concern that the title and subtitle of the book in some ways have undesired implications — tending to hold people to impossible standards. You certainly can't argue with the number of copies sold in worldwide distribution this first year.

    Personally, I think the title and subtitle are great. It is my understanding that many authors, both fiction and nonfiction, don't get to choose the title of their book. In many cases this decision is reserved to the publisher and often the title is chosen by the publisher’s marketing people to reflect what will sell rather than what speaks authentically to the reason for the book.

    With regard to the 50% versus 5% better, remember that our hospitals in general are very early in their lean journeys compared to the benchmark Toyota who have been at it for more than 50 years.

    To respond to your final question, if it were mine to choose, the title and subtitle might be:

    Lean Hospitals: Simultaneously Perfecting Patient Care, Financial Performance and Employee Development.

    On the other hand, why mess with a good thing?
    /Dr. Pete

  2. Mark,

    To be honest I think you're overanalyzing it. The goal of a book title is to help sell the book. That's it. Good book titles are simple yet intriguing…just enough to perk the interest of a potential buyer. Off the top of my head I came up with:

    "The Secrets of Achieving World-Class Performance in Hospitals"


    "Saving Lives: How the Best Hospitals on the Globe Achieve World-Class Performance"

    Notice I didn't even put the word "lean" in there. Put "lean" in the subtitle.

    Obviously the other consideration is to use keywords in the title, subtitle, and description that will generate the most hits when people browse Amazon. So the question is, who will most likely purchase your book and what type of search terms will they use?

    In the end, your publisher should have the best ideas on book titles.

  3. I'm not wringing my hands or worrying about it too much. Just thought it made for an interesting discussion point around "what is lean?" and "who is lean?"

    I don't regret the title… you gotta sell books and this was squarely targeted at those who are interested in lean.

    You could write a similar book that avoids the word lean too.

    I came up with the title, my editor and publisher didn't fight me on the title.

    We did have different ideas about covers… the cover was my own concept (I found the graphic) and I was very insistent that lean be pictured as a friendly and satisfied team, since that's what a lean environment should be like.

  4. Hi Mark,

    First off, thank you again for your visit to our hospital in June, it was a rich experience.

    I remember discussing this with you, great that you continue reflecting on what lean really refers to. I agree with you that lean isn't a state to be reached but a journey, that's why I like the title of Jeffrey Liker: The Toyota Way.

    I think 'lean hospitals' is a good title considering the interest of the readers, but if you would want to choose I title that better reflects the journey, you could consider titles like:
    'lean thinking in hospitals'
    'lean principles for hospitals'

    Marc Rouppe van der Voort
    St. Elisabeth Hospital, Netherlands

  5. Marc – thanks for your ideas (and thanks, especially, for hosting me in The Netherlands).

    I might have gotten sued by the LEI if I had used "Lean Thinking" in the title? :-)

    Developing a new course for the LEI, the working title is "Key Concepts of Lean in Healthcare" which better fits that pattern of language, I think.

  6. Mark,
    Go easy on your book's title. I took the meaning to indicate that a 'Lean Hospital' as one that had consciously put itself on the spectrum of 'Lean.' I think it means to admit the following things:
    *that things and efforts that don't create value are waste and are generally bad things (this requires a new understanding of waste)
    *the system as a whole and not just isolated parts should be optimized (value stream)
    *people are smart and generally care about what they do and need to be provided an environment and one or more mechanisms for improvement (continuous improvement)
    *speed and batch size (flow) are generally good things
    *rapidly reactive (and simple) systems tend to outperform highly designed and complex ones (pull – pull is more than this but that is another comment)
    * there are limits on human performance – specifically on human vigilance – the old way focused too much on the assumption that capability and willingness are all that is required to world class human performance, it ASSUMED perfect human vigilance (and when the system fails – you have a 'behavioral' issue – Robert Mager's legacy) and the new way ASSUMES willingness, respects people’s need for knowledge and respects flawed human vigilance (jidoka/respect for humanity/visuality)
    *there must be a baseline of performance for today from which we EASILY see deviations and from this baseline we can experiment (std wrk / visuality / abnormality abvious at a glance)
    If an organization has admitted those things, places some belief (or better yet faith) in that following those principles will lead to better results (long term orientation) and pays attention to how they are changing and improving (process orientation) then they are 'lean' in my mind. I think lean is a philosophy more than a threshold of performance. I believe that because I have faith in the FACT that if you can pull off all of the above you will cross the threshold (whatever it is) at some point. I might add that there has to be some level of execution (measured by means not ends – initially anyway) required to claim to be 'lean', i.e. it isn't enough to talk about it and hire a consultant and call somebody the Lean Manager or whatever.

    I learned a lot of this from Mitsubishi Steel mManufacturing when they were a customer and I was in a quality role. They were very patient as long as we were learning and improving contrasted to other automotive OE's who demanded 'instant perfection.' Your new boss and his colleagues helped me understand what I had learned when I read their books. Bodek bolster my faith. You and others keep me connected and learning. Thanks. It’s a good title – don’t sweat it.


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