A New Book That Says “Incrementalists Need Not Apply”


I'm very interested in the interface between healthcare architecture, space design, and processes. I've seen so many cases where poor design (often done without the input of nurses, medical technologists, and other front-line staff) leads to systemic inefficiency. Classic bad examples would include not having enough local storage space in a department for equipment and supplies that are truly needed or not having the chemotherapy center close enough to the oncology clinics. A great example of Lean patient-centered design is the cancer center at Park Nicollet, where “care comes to the patient” (yes, it makes a great ad slogan too).

I recently discovered a book, a “manifesto” the author calls it, titled Efficient Healthcare – Overcoming Broken Paradigms. It's not only the Lean people who get frustrated with the sorry state of typical layouts and space planning – it's this architect and author, David Chambers from Rice University.

The book is a slim tome (just over 100 pages), but the pages are packed full of text (so there's more content than you'd expect from a manifesto of this length). I've read 40 pages, but felt compelled to share it with you already.
“Efficient Healthcare” alludes to and dances around Lean terminology in the introduction and the first chapter, then it hits on Lean and Toyota methods directly in Chapter 2. There are many gems and insights that are conceptually aligned with what would you have read in Lean books – but the latter half of the book appears to get into more details about the design and construction process. The target for this book seems to be architects while other Lean books, like mine, are more directly targeted at hospital staff and leadership. So I think this book fills an important role – a book you can give to the architects and construction people you work with.
Some of the things I highlighted as I read:

From the first chapter (called “A Call for Change: Incrementalists Need Not Apply”):

“What if the build that houses clinical programs were to reduce the staffing need and required cycle times for care per outcome by 50% or even more?”

Yes – there's so much systemic waste in healthcare, aiming for 5% productivity improvement when designing a new space isn't aiming high enough. Looking to the manufacturing world for parallels, the transition from a functional “job shop” layout to a cellular layout with one-piece flow often leads to 50% productivity improvements (with less waiting time and better quality… and lower cost). Lean design is transformational, not incremental. We can save incremental for continuous improvement or “kaizen” activities. Design and construction can be a “kaikaku,” or radical change, event when we are given the chance.

For example, ThedaCare (not referenced in the book from what I read), held an open house last week for the new patient tower designed and built around the Collaborative Care model – this was such a huge opportunity for them to take advantage of. If they didn't build it right this time, they would have been just stuck with many of the core design decisions for the life of the building.

Chambers emphasizes key Lean principles without yet referencing Lean, such as:

“…this manifesto is not about cutting jobs… By building a care model that works far better than the current model, we can deliver quality care without overworking staff (which is too often the case)…”

I think Chambers might agree with my complaint about healthcare architecture awards being given for pretty spaces, as he writes:

“… I am engaging in vastly more than mere rhetoric about the healing environment… goes far beyond making spaces attractive or aesthetically pleasing…”

Chambers rightfully complains about the existing view of a hospital build as a group of departments, as overhead rather than “…view them as the machines by which we provide care.” He continues, “…and we learn that someone has invented a much more efficient and effective machine – then they become far more than mere costs in the conversation, they are an essential aspect of the value proposition.”

He's speaking to the role of the building (and value streams, as he covers more in Chapter 2) as it creates and encourages productivity, which correlates very well to better quality. Beyond looking at the value stream, Chambers is correct in pointing out that the patient is often missing from the design discussion and there's a huge opportunity in getting them involved.

He ends the chapter with:

“The potential for value, therefore, is far greater in rethinking care delivery processes and flows than it is in value engineering the building.”

I like how he thinks. We have to design a systemic whole, not just a bunch of locally efficient pieces.
My goal here was to introduce you to this book, to tempt you to get a copy yourself. I'll reach out to the author about a possible podcast interview. I'll most likely post again about Chapter 2, where Chambers addresses Lean in healthcare more directly. The introduction and Chapter 1 should sound very familiar (and congruent) to Lean thinkers.


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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

  1. George Rathbun says

    Mark, from what I gather, this looks like a good book to read, however the title is a bit misleading. In my oppinion, the majority of healthcare will need to improve on the base of Continuous Improvement and Kaizen. There is no magic bullet, unless, of course, most health facilities are demolished and rebuilt.

    More along the lines of what you preach, the nurses and doctors need to be ‘culturalized’ in lean concepts so they can systematically make the improvements. In simple math, 10 5% gains is the same as one 50% gain… and could be easier to achive. Of course, the transition to lean itself is a transformational change.

    If I were to make a statement about the authors point in his book (without reading it) is that indeed facilities need to be designed around functionality and not aesthetics… facilities need to be built with flexibility in mind (sort of like Auto Plants).

    George Rathbun
    CEO INCENT Innovation

  2. Mark Graban says

    Thanks for the comment, George. You are right that we’re not going to rebuild every single facility, but there’s a surprising amount of hospital construction going on right now, so those might as well be built “right” (and flexible!) the first time.

    We also have to teach radical process improvement (at the value stream and patient pathway level) — where we don’t have to rebuild the hospital — as well as small incremental changes (kaizen) that can be done today. Thanks for reading and for commenting.

  3. Richard Chapman says

    From my experience with lean in healthcare, a new hospital should be designed for:

    -service at the bedside (stop moving the patient!)

    -small batches (avoid “Central” this and that)

    -long sight lines (ensure people can see at a glance what they need to see, and don’t have to move from workstations to find basic things out)

    -less storage (where sins are hidden like obsolete and broken equipment, inventory that shouldn’t have been ordered etc)

    -simulation theater and wards (the idea that staff can learn medicine without practice is bizarre beyond belief. You wouldn’t fly an airline that didn’t use simulators these days to practice extreme situations or test new ideas so why should a hospital not use them?)

    -designed around the flow of major care streams, not “departments” if 90% of orthopedic patients are going to need 6 standard interventions and 100 standard drugs then have these within 5 minutes walk of where the patient entered the building and in a sequential line if required so that care streams are not ‘colliding’.

  4. […] about a book which I am very interested in reading. Mark Graban (aka @LeanBlog) tweeted a link to his blog that discusses a book that was unbeknownst to me: Efficient Healthcare: Overcoming Broken […]

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