Lean Methods to Improve Cardiac Surgery Featured in Annals of Thoracic Surgery


Hat tip to my friend and fellow Productivity Press author Naida Grunden for pointing out an article she is a co-author on, “Improving Patient Care in Cardiac Surgery Using Toyota Production System Based Methodology,” published in the journal of The Society of Thoracic Surgeons. I'm sorry that I can't share the full article, due to copyright restrictions, but I'll give highlights here.

From the summary of the article, freely available online:

Conclusions: By the systematic use of a real time, highly formatted problem-solving methodology, processes of care improved daily. Using carefully disciplined teamwork, reliable implementation of evidence-based protocols was realized by empowering the front line to make improvements. Low rates of complications were observed, and a cost savings of $3,497 per each case of isolated coronary artery bypass graft was realized.

It's great to see more peer-reviewed evidence that Lean and TPS methods can be used to both improve quality and reduce the cost of care.

The introduction to the article cites Dr. W. Edwards Deming and his philosophical contributions to Lean, stating that “reducing defects from complex processes results in less variable outcomes and higher quality.”

The article features the Ed Dardanell Heart and Vascular Center (HVC) that's part of Forbes Regional Hospital in Monroeville, PA. Given their proximity, they received assistance foam the Kennametal Center for Operational Excellence (KCOE) at St. Vincent College, including Dr. Richard Kunkel, who aI had the pleasure to meet when I spoke at their annual conference.

Lean for HVC included the vision statement of “perfect care” and their defined value stream (from initial contact with the HVC to the patient's full recovery) would be improved through methods of “daily safe improvement, originating from the frontline of work.”

Lean mindsets used in this work included:

  • Focusing on the value stream
  • Balanced scorecard of safety, quality, productivity, human development, cost
  • Performance measures reviewed by the team daily
  • Daily team huddles
  • Structured problem solving sheets (used 923 times)
  • Proper problem definition (not jumping to solutions)
  • Root cause analysis
  • Fast resolution of safety issues (24 hours) and other problems (48 hours)

The daily problem solving as described as a “systematic approach, by helping the nurses to fix defects as they occur, produces ownership of work and caregiver pride.” This method included a “no blame” mindset as part of a culture where “problems are blessings” instead of a setting where “problems are punished.”

Having the nurses involved in daily improvement has “greatly improved glycemic control” for patients.

Other tools were introduced, but only in response to particular problems and needs, such as:

  • visual management
  • kanban
  • standardization
  • single-piece flow
  • 5S

As the article states, “the tools were learned and applied in the context of work, as needed, and not in the classroom.” This is a great approach for learning-by-doing.

So what were the results from this 24-month effort, compared to a “Like Group” from the same period? Results included:

  • Reduction of Length of Stay by 1 day (from 9.1 days to 7.9)
  • Reduction of post-operative LOS by 1 day (from 6.8 days to 5.8)
  • Shorter ICU stay (from 72 hours to 35.1)
  • Shorter ventilation time (from 22 hours to 11.2)
  • Less operative mortality (from 2.1% to 0.4%)
  • Fewer complications (From 37.5% to 16.1%)
  • ZERO infections (compared to 1.5% in the Like Group)

On the negative side, 30-day readmission rates were slightly higher (12.6% compared to 10.6% in the Like Group).

Patient satisfaction is rated at 99%, per the article.

In the article's commentary, they cite nearby Geisinger Medical Center and their 40-step CABG surgery bundle (as famously featured in the New York Times piece ” “, which I blogged about here. The authors of this article question whether Geisinger had just a one-time standardization effort, without continuous improvement, as they write:

“… it is not evident in these notable efforts how cultural change occurs so all caregivers and administrators are continually learning to perform rapid-cycle safe improvement.”

The article concludes by claiming that:

“The effect of OE has been remarkable. Methodically, problems are addressed daily as they arise, and the risk-adjusted incidence of major adverse events has decreased by 50%… cost savings of $884,900 in the isolated CABG cohort have resulted… emphasis on safety and quality saves large amounts of money by reducing defects in care.”

Congratulations to everybody involved and best wishes for their continued improvement efforts.

You can find Naida's outstanding book (The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods) via Amazon and other booksellers. In the coming weeks, I'll have two podcasts with Naida, as well, so please come back for those at www.leanpodcast.org.

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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. Mark: Thanks for noting KCOE. The real success story here is threefold:
    1. Dr. Mike Culig – the required champion.
    2. Lesley Rehak, RN – the nurse leader who changed her team’s culture by following our prescribed process without wavering
    3. Dr. Rick Kunkle, FACEP – the KCOE coach who kept the team on mission and moving forward

    This is the kind of healthcare reform that could be the necessary catalyst for changing the playing field. But, just so your readers understand: this was all about the culture change FIRST and using the classic Toyota countermeasures to remove root causes second. Imagine being on Dr. Culig’s team and being told by Dr. Kunkle, “I don’t want you to solve problems, I just want you to do problem solving sheets…”.

    Thanks for sharing this with your readers. And, thanks for doing such a great job on the Blog! Looking forward to the next book!

  2. David – I am curious, can you elaborate on the statement by Dr. Kunkle?

    I’m not sure I get the nuance there. Was he emphasizing learning of the improvement method over “getting results” (which might have meant “jumping to solutions” as we see in so many healthcare settings)?

    Learning the method is important, but ultimately real improvement needs to come out of it, not just a bunch of sheets…

  3. Thanks for the question, Mark. I agree that real improvement is needed. We just insist that we work our way up to real improvement based on skill. You can give me the best driver, the best ball and even a one hour lesson on how to drive my golf ball straight for 300 yards. You can even insist that I perform (drive it straight 300 yards), but unless I practice my butt off, it isn’t going to happen. So, like a golf coach, we insist that our teams swing…a lot. Every once in awhile the team hits a long, straight drive. When they do, we celebrate, ask what went right, ask how we can improve, and then we keep on practicing…I wrote about this a few months ago on our blog LINK.

    Ours is a balanced approach: the human with the operational. If all I do is monkey with the ops side without recognizing how we humans change and learn and engage, I risk short term gains built on weak foundations. Rather, we build the human and ops systems simultaneously, using the system components like problem solving to “pull” them together.

    For example, one of the problems encountered in Dr. Culig’s OR was a surgical lamp that was located such that techs would bump their heads on it. It was a simple problem, but it kept recurring as we considered employee safety on the BSC daily and monthly. We coached the human system (behaviors and mindsets in the earliest stages of change) towards principles like PDCA and Visual Management. We coached the operational system in some basics: workplace organization, safety audits, etc.. As the problem recurred, it was an opportunity to hone problem solving skills by asking the question, “What in your problem solving process went wrong? Wrong point of cause, wrong root cause, wrong countermeasure?” As those coaching cycles emerged, we were able to ask questions that led to the use of operational countermeasures as possible solutions.

    By pulling the mindset into problem solving and pulling a countermeasure into problem solving, the problem solving process (through repetition) knit the two together, exciting some of the deeper values we hope to stimulate (team work, pride, customer (patient) first.

    A long-winded answer…I hope that it helps.

    • I fixed the link in your comment… no worries.

      I understand the need and desire to improve the thinking and people’s problem solving organization by asking questions and coaching…

      How long did it take to solve the head bumping problem?

      I think we need a balance between the lean lesson of having a bias for action along with the need to not give people solutions and to build capabilities.

  4. Thanks for fixing the link.

    The head-bumping was “solved” three times. The third time was the charm – I don’t recall the exact fix, but I do recall that the team had to work through issues with the sterile field (no tape, etc.). The great thing was the learning through the multiple cycles of problem solving.

    I don’t disagree with a bias for action; I just think the actions are sometimes aimed at getting quick “buy in”. I prefer ownership over buy in.

    I also realize that we are taking the ideological high ground and that is a difficult pill to swallow (pun intended). Many of the so-called thought leaders in lean have concluded that we need more than tools – we need culture. The tricky thing is figuring out how to build the framework that gets the culture you are seeking.

    Making those changes – changes to the very fabric of the way an organization operates both on the people side and the process site – is a really hard thing to do. It is a tough hill to climb and only a few amazing teams and leaders will get to the top. Dr. Mike Culig and Lesley Rehak and two of those amazing people.

    I am thankful that you (having met you) and the work you are doing is leading people to understand both the dilemma and the way forward. I was with Dr. Culig two weeks ago when he was addressing a group of physicians and top administrators at a system outside the US. He challenged them thus: if you want big differences you need big changes.

    • Thanks for expanding on that, David – great stuff.

      We both know that it’s easier to say “this is what a lean culture is” than it is to actually move somebody in that direction.

      I appreciate that you take that ideological high ground. I think you know that my comments are meant to be critical, but I’m somewhat playing devil’s advocate because I know what you’re talking about is indeed hard to swallow (nice pun!).


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