Updating “A Vision for a Lean Hospital”


I am working on finishing up the revised and updated edition of my first book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. I'm adding new case studies and examples, refining the book in general, and adding some new topics like strategy deployment and A3's.

I've shared the first chapter of the book for those who signed up on my book's site. Now as I'm making revisions, I'd like to get your input and ideas around the final chapter – “A Vision for  a Lean Hospital.” I think the chapter has some good ideas, but given my audience here, I'm not going to pretend I have all the answers for hospitals. So I'd like to hear what you think in the comments for this post, or email me. What's missing? What's confusing? What's wrong?

Here is a portion of that final chapter…

…this reflects SOME edits that I've already made. I've made some additional edits, but I'm curious if what you find to be missing matches up with my assessment.

What Would a Lean Hospital Look Like?

Having a chance to tour or walk through a hospital that is implementing Lean, you might look for visible Lean methods in use. Visible indicators might include 5S and visual controls, marking and labeling where items are supposed to be stored. You might also see standardized work or kanban cards posted and in use. Suggestions, metrics, or A3 reports might be displayed on walls. The physical structure and layout might be compact, logical, and neatly organized.

Much of what makes a Lean hospital, however, cannot be directly observed during a tour. Can we directly observe the thought processes and mindsets of the organization? Can we see how people solve problems? Given enough time, we might be able to directly observe supervisors interacting with their employees, but we usually do not get that chance on a tour. Toyota has been very open in letting other manufacturers, even direct competitors, tour their factories. Other companies have typically copied the tools and the visible methods, often coming away not understanding the true nature of the Toyota Production System.2

What Would a Patient Experience in a Lean Hospital?

A good exercise might be to think through what the perfect patient care experience would look like and how it would feel. For example, for an outpatient surgery patient, what would be an experience of perfect service and perfect care? This might seem similar to the creation of an ideal state version of a future state value stream map. We can challenge ourselves on how things should work, to set goals for our Lean improvements.

This can include presurgical steps such as scheduling and making sure everything is communicated properly (such as the need to arrive for labs or presurgical fasting) to avoid miscommunications, rework, or delays. Think through the patient experience from the time the patient drives up to the hospital. Is everything clearly labeled for where to park and where to come for registration? Is the patient able to get registered without repeating the same information to multiple people? Is the patient able to avoid excessive delays before the procedure starts?

From a clinical and surgical standpoint, does the hospital ensure that all proper preparation and quality steps are followed before the procedure, including confirmation of the patient identity, marking of the site, and the time-out of the universal protocol? How is the process error proofed to protect the patient from harm? Are all of the participants (nurses, physicians, anesthesiologists, etc.) aware of their role, interactions, and standardized work? Is there a team environment where everyone is focused on the patient instead of hierarchy and titles?

Beyond the surgery itself, what service is provided to any family or loved ones who are waiting? Are they kept informed of the patient's status, to ease their worrying? Is the patient able to get through the postoperative recovery area and to being discharged without any avoidable delays beyond their required recovery time? Has clear and unambiguous communication been made about the patient's postoperative responsibilities, to help in recovery and to prevent infection?

Whatever vision you create for perfect care, be sure to include both the clinical care and the service aspects of the patient's experience. Starting with fresh eyes and thinking toward perfection will drive better improvements than looking for incremental improvements over today's practices and waste.

What Would It Be Like to Work in a Lean Hospital?

Working in a Lean hospital should be a positive experience for employees and physicians. After seeing many cases where morale and employee engagement improved with Lean, employees should not want to leave a Lean hospital to go work someplace else. In some cases, work life has become so fundamentally different (and better) that employees who have left to go to a traditional hospital or clinic have come running back, no longer able to (or wanting to) operate in a non-Lean environment and culture.

Many of the key points have already been covered, but an employee in a Lean environment should expect, among other things:

  • To be listened to by supervisors, to have their ideas solicited, to have the freedom to make improvements for the betterment of the system, and to be treated with respect
  • To develop the discipline to work within a system, but also to maintain the creativity required for kaizen
  • To not be overburdened with more work than can be done in a high-quality manner, nor to be standing around with nothing to do
  • To be challenged to grow, personally and professionally, always striving to learn and improve his or her technical, leadership, and problem-solving skills
  • To feel a sense of pride for contributing to a high-performance organization, for understanding his or her role and how his or her work impacts patients, coworkers, the hospital's bottom line, and the community

Again, Lean is not a system that is soft on people or an environment where everyone is nice to each other, avoiding conflict. The Lean culture of “respect for people” also demands a sense of responsibility, as true respect challenges employees, and each other, to get better, for the sake of the patients and the organization.

How Would We Describe a Lean Hospital?

To create a vision, we can define in aggregate how to describe a prototype Lean hospital. One good starting point might be for a hospital to follow the general fourteen principles of The Toyota Way. A Lean hospital might also be characterized by the following traits.

Strategy and Management System

A Lean hospital has efforts and goals that are tightly integrated with hospital strategy and vision, moving beyond the isolated use of tools to the engagement of all employees and leaders in the building of a Lean culture. The Lean strategy and the hospital strategy are one and the same, being communicated widely and consistently throughout the organization.

A Lean hospital realizes that success comes not only from technology and clinical excellence, but also through employee engagement and operational excellence. Lean hospitals help stakeholders understand that spending money on new technology and new space is not the only way to demonstrate a commitment to serving the community.

A Lean hospital has a leadership method and model that is taught to supervisors and managers and is practiced by all leaders. Lean behaviors, such as going to the gemba, auditing the process, collaborating on improvement efforts, and being a servant leader, are used as criteria for employee selection, performance reviews, and advancement.

A Lean hospital creates collaborative relationships for all partners and stakeholders, including physicians, vendors, and payers. Patient safety practices and quality data are shared openly with other hospitals and the community, rather than using those methods as a source of competitive advantage.

A Lean hospital has a small centralized group that maintains consistent Lean practices and training. This group coaches line leaders to drive improvements and to own their processes, rather than doing it for them.


A Lean hospital is passionately and meticulously focused on the patients, families, and guests, aiming for perfect, harm-free care, while respecting patients and their time. The patient comes first in all activities, decisions, and priorities. Leadership helps create that expectation with all stakeholders.

A Lean hospital involves patients, as the ultimate customer, and their loved ones in process improvement efforts. New designs and processes are tested to make sure they meet patient needs.

A Lean hospital sets goals of zero preventable errors that cause patient harm, as any other goal is unacceptable. The staff works tirelessly toward that goal through standardized work, root cause problem solving, and error proofing, rather than relying on individuals to be careful or relying on inspection. When preventable errors occur, patients and payers are not charged for the work required as a result.


A Lean hospital recognizes that employees are the true source of value for patients and the hospital, rather than being viewed strictly as a cost to be reduced. Top leadership makes a consistent commitment to all employees that Lean improvements will not lead to layoffs.

A Lean hospital helps employees understand that not all activity is value-added. Rather than defining waste as being “our job,” everybody works to eliminate it so more time can be focused on the patients.

A Lean hospital fully engages every employee in improving their own and their team's work, supporting their innate desire to provide perfect care to patients. Leaders help employees understand how their work fits in to the value stream and work collaboratively with them in kaizen.

A Lean hospital does not overburden employees with more work than can be done in a high-quality manner, nor does it pressure people to work harder or be more careful as a means to quality, safety, or efficiency.

Waste and Kaizen

A Lean hospital recognizes that there is waste in every process, focusing on continuous improvement and root cause problem solving instead of workarounds and fire fighting. Individuals (employees or leaders) are not blamed for the waste or problems.

A Lean hospital proactively fixes problems and reduces waste, rather than being strictly reactive. Employees are encouraged to expose waste and make improvements to the system, instead of hiding problems and making things look good.

A Lean hospital breaks down departmental silos to focus on improving care and preventing delays for patients, allowing employees to feel pride in their work, by being able to cooperate across value streams instead of suboptimizing their own area.

A Lean hospital values the standardization of work methods in the name of improving safety, quality, and productivity, rather than allowing people to develop their own different methods for doing the same work, or precluding one patient to not get the best-identified method of care.

A Lean hospital is never satisfied with being better than average, being in a top percentile, or with winning awards; it always strives to get better. Perfection is a difficult goal to reach, but it is the only acceptable goal to a Lean hospital.

Technology and Infrastructure

A Lean hospital is physically designed to minimize waste for patients and for all who work inside its walls. It is designed to support workflows and value streams, rather than forcing departments and employees to adjust their work to the space.

A Lean hospital has process technology, automation, and information systems that make work easier or less error-prone. The hospital does not install automation or new systems for the sake of having new systems. Employees and patients are deeply involved in the selection of technologies that meet their needs.

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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. I would add something in the patient’s experience section about them receiving a clear bill that is correct the first time.

    When my child was born, they took an amount that they thought was our co-pay while in the hospital room. A month-and-a-half later we received a bill for half the amount we previously paid with no documentation of the original amount showing received by them. I called them and they confirmed payment was received and my bill was covered and to ignore the invoice. I then had to ask if they owe me a refund of half since the mailed invoice was less than what I paid. The person on the phone assured me the original amount paid was correct and this invoice was wrong.

    As a customer, this experience was frustrating and confusing. Most Lean literature shows a Value Stream as being all the way until the organization recieves payment. Besides the benefits to the organization to get money in the door sooner, a clear billing process has a big impact on patient experience.

    • Brilliant. Great point from an overall customer experience.

      I’ll extend that to the initial patient/customer interaction with the provider:

      “A lean hospital can clearly articulate standard pricing for common procedures to payers and patients.”

      I’ve been seeing a chiropractor about a literal pain in my neck.

      Office front desk on the First visit: “What’s your copay?”

      Me: “I don’t know…. can’t the insurance company tell you that??”

      I’ve been four times and it’s always a complete fire drill about what I’m supposed to pay between co-pays, deductibles, HSA’s, etc. It honestly seems like a GUESS of what they charge me. It’s a random number generator that’s set between $29 and $60 apparently.

      I have NO idea what these treatments are going to cost me out of pocket.

      John Torinus talks about this issue in his amazing book The Company That Solved Health Care: How Serigraph Dramatically Reduced Skyrocketing Costs While Providing Better Care, and How Every Company Can Do the Same. Torinus and his company (as an employer/payer) couldn’t stomach the lack of transparency in hospital pricing around the Milwaukee area, so they worked with hospitals who would provide standard clear pricing for things like a regular childbirth.

  2. Looking good. I would potentially more directly note the importance of the built environment relative to service quality and the need for updated processes to better manage the built environment. Healthcare costs are clearly out of control in the US and facilities represent a non-trivial component relative to cost and overall performance. The good news is that facility side has LEAN process available to be implemented… such as IPD and JOC…however bad news is that change is glacial in the AEC sector… and the healthcare sector….

    • I think that change in the AEC sector responds directly to the willingness of clients to adopt new ways of thinking about their processes. We in the design community can come up with multiple options to support new (LEAN) ways of operating, but if the client doesn’t wind up running operations that way, the built environment fails.

  3. Hi Mark,

    Great to visualize a lean hospital through your words!
    2 comments of which one about content:

    1) You’ve written about reducing waste and what that means for the hospital and the employees. I would definitely add the ‘green’ image of a lean hospital because of what it can mean for a better ecological environment by reducing waste of all kinds (in product and process).

    2) There are two style items about the text I would have another look at. In the paragraph “what would a patient…” there are so many questions that I find it not comfortable to read. Another thing is the logical but too much use of ‘A lean hospital is/will be…’. Perhaps it is possible to reduce the use of that specific combination.

    Good luck with your book!!
    Iris Vogt

  4. Mark,

    Good read. Maybe one suggestion: you include many stakeholders (viewpoints) in your description. What about hospital leaders themselves? What can they expect? Knowing their importance in a successful journey it might be a good thing to also discuss the expectations they may have concerning a Lean hospital.

    Good luck,

  5. Mark,
    Very thoughtful. What about designing environments that are not only greener but healing. We are starting to think through what a standardized inpatient room, exam room, procedure room, etc should include or how they should be designed to reduce chances of errors and harm as well as be more ergonomic to improve safety for our team.

    Instead of departments set up vertically as they are in traditional organizations, wouldn’t we try to organize ourselves horizontally to support the way patients flow as they enter the system, receive care, exit? And when does that horizontal flow of value end? In the ideal hospital, patients would say the extended value stream includes post acute care in our partner organizations (rehab, nursing homes, etc).

    Thank you for a thought-provoking and inspiring post! – Alice

  6. Mark,

    I think this will be a great addition to your book. While it is tough to actually see, it would be great to describe how staff goes about their work in a lean hospital. Instead of creating workarounds (1st order problem solving) describe how in a lean hospital they work to determine the root cause of problems and create solutions that are sustainable (2nd order problem solving). Maybe describe how employees are encouraged and expected to “go and see” the problem and collaborate with other departments to create solutions that work for the entire system, not just one group. This is one of my ideal visions at East Tennessee Children’s Hospital. How can we change the culture where managers and lean leaders are not only thought of as problem solvers, but as learners, teachers, and enablers of employee engagement in front line problem solving.

    Hope to see you in Seattle in June at the Summit.


  7. Very enjoyable to read. I will need to buy the next addition as well. Consider adding a little more about what a Lean hospital manager and / or supervisor would ” look” like. Also, the standard work of managers and supervisors and what they should expect in a lean hospital, day to day. They will be the ones helping to lead lean on an ongoing basis.


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