Mini-Review: First Three Chapters of the Virginia Mason Medical Center Lean Book


I've finally started reading the new book by Charles Kenney, Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience, and I wanted to post a mini-review of the first three chapters. You can also buy (cheaper at the moment) through the publisher's site.

I'm really enjoying the book, I think it emphasizes some great Lean principles, thinking, and philosophy, and I can highly recommend it so far to those who want an organization's case study and narrative about their Lean journey.

The book tells the history of VMMC leading up to Lean, including the threat of being a mid-sized hospital in a major city, Seattle, with large competitors. It was “Change or die,” as their CEO Dr. Gary Kaplan said. This environment of financial stress led some doctors (and other stakeholders) to think that Lean and the Virginia Mason Production System would be the death of VMMC… and that the 3-week long learning trips to Japan were mere boondoggle and wasteful spending. It's an honest warts-and-all portrayal of what they learned, what succeeded, and what they wish they had done differently.

Chapter 1 takes us through the initial sparks of the idea that Toyota/Lean principles had something to offer that other approaches did not – Lean was seen as “a tangible method – a management framework” that Kaplan and VMMC could use to move beyond goals, visions, and rhetoric about improvement.

VMMC shares, in a few points in the first chapters, that they (like most other hospitals) are physician-driven, not patient-driven. “Everything was designed around us [the doctors],” says Kaplan. Chapter 3 shares the story of their patient-driven redesign of an outpatient cancer center using the 3P (production preparation process) methodology – similar to what Park Nicollet used for their cancer center (see video). In both cases, the care comes to the patient; patients aren't forced to use precious energy walking from location to location.

The first three chapters highlight the stating point that there was “a surprising lack of understanding of the work at a granular level.” VMMC was learning to view their work as interconnected processes, an improvement beyond heroic siloed efforts. Kaplan said, “So we had well-intended, good people, but we didn't have a system.” As Chapter 3 emphasizes, “their first step was to understand the reality of the current state.” By observing and studying their current state, including the cancer patient's “meandering journey” through the hospital, people “began to understand the work of others on the team.”

I saw that same dynamic, recently, at a major children's hospital. By observing the current workflow (or lack thereof), one of the chief physicians commented proudly that he finally now understood what everyone else in different roles was having to do (workarounds and jumping through hoops) just to make things work. That understanding was the first step in change there and at VMMC.

VMMC realized that they had different types of patients, using a classic Lean “PQ” (Product Quality) analysis. They learned their demand was comprised of different types of patients – quick visits and longer stays – and they designed their new cancer center accordingly. Study the work, then improve it, with everybody having a voice at all levels – a departure from old top-down thinking.

Kaplan and VMMC describe how they learned from manufacturing companies including Boeing, Genie Industries, and Wiremold. They realized that their work was made of processes and that, as Taiichi Ohno himself had written, the Toyota approach is “not just a production system,” but is “a management system adapted to today's era…” Kaplan commented that the idea wasn't to “adopt the Toyota method wholesale, but rather to learn and adapt the system to healthcare.

But, as Chapter 2 highlights their visits to Toyota and other companies in Japan, Diane Miller, a VP at VMMC said, “there wasn't anything she saw that wasn't applicable to healthcare.”

VMMC was impressed with the andon cords – not just the idea that any worker could pull that cord when they saw a problem, but more so that “in seconds, a three-person team of technicians swooped down to the factory floor and huddled with the worker.” Could you imagine that level of support when you found a problem in a hospital, as a staff member? VMMC wondered the same thing and created its “Patient Safety Alert” system.

They were also impressed with the empowerment of the line workers as well as the “frontline engagement of the supervisors in the pursuit of quality.”

Also of interest to clinicians and Lean Thinkers alike will be the discussion (including the internal debates and consternation) about standardized work in healthcare. Dr. Jacobs, one of their physician leaders, said “A lot of poor quality comes about through variation and a lack of standardization,” while emphasizing that VMMC wasn't striving for “cookbook medicine,” but rather a system that was based on rigorous medical evidence WITH the expectation that people would be innovative on top of that standardization layer.

The book says, as you often hear, that “doctors don't like to be told what to do.” Does any professional enjoy being told what to do? That's a good lesson for people doing Lean work in any setting.

It's light on results data right now, but that appears to be coming later in the book (and no control charts yet).

From the cancer center, results included:

  • Patient stay cut 50% (with no negative impact on quality or safety)
  • 88% reduction in time required to administer meds
  • Patient satisfaction for the cancer center went from about 70% to over 90%
  • Increased # of visits by about 8% with no increase in employees

Final quote, about Dr. Jacobs:

“… whether it's Canada or the U.K. or the U.S. [quality] is what people want. This method lets you get at quality and safety, and it also helps reduce the cost of the delivery of care.”

Again, from the first three chapters, I recommend this book wholeheartedly. I can't wait to read more and write more mini-reviews every few chapters. You can buy the book here via

Conflict of interest statement: The book is published by CRC Press / Productivity Press, the publisher of my book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. I received a free copy of this book to review.

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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. From facebook:

    “I would love to read it, but $71 is the cheapest you can buy it on Amazon. What’s up with that??? Is it printed with gold ink?”

    Yes, it’s pricey. But I think well worth it in terms of value. Some books aren’t worth $70 of course.

  2. I just got my copy in the mail 10 minutes ago!

    I am glad to hear the book comes with worts and all. Any Lean journey will have struggles and the path will not always be direct. Kudos for Virginia Mason for being transparent so we can learn too.

    Some of my favorite parts in ON THE MEND is where they explain the mistakes made and what they would do differently next time. Powerful stuff!

    I can’t wait to read the VM book!

  3. The book is currently cheaper on the CRC PRESS website for $39.95. I have tried to post a link three times but it hasn’t worked. If you google CRC PRESS it should get you there and then search for the book.


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