What the Book “Lean Thinking” Said About Healthcare in 1996


When the book Lean Thinking (by Jim Womack and Dan Jones) was originally published in 1996, it seems likely that hardly anyone was applying Lean principles in healthcare. Sure, you had organizations applying TQM or CQI principles (or even some of the lessons of Dr. W. Edwards Deming). Joan Wellman did some of her first Lean healthcare experiments in 1995, but there weren't any “Lean healthcare” case studies yet.

The book (with the same text in the original and updated editions) spends about two pages talking about the potential of Lean principles in healthcare. You can likely read the pages (289 and 290) through the Amazon “look inside” feature or possibly through Google Books (search for “medical care”).

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What points did Womack and Jones make?

With increasingly specialized “centers of expertise” in healthcare, there are increasing demands to keep each of these silos “fully occupied.” This leads to long waits for patients, of course (and is a big problem, still, in 2013).

“How would things work if the medical system embraced lean thinking?”

First, Womack and Jones say “the patient would be placed in the foreground, with time and comfort included as key performance measures of the system.”

We see this increased focus on patient flow in settings ranging from Sami Bahri DDS to ThedaCare's primary care, to hospitals, large and small.

Second, they recommend that healthcare break down departmental functional structures and “reorganize much of its expertise into multi-skilled teams.”

We see this today in ThedaCare's “collaborative care” model and in integrated cancer centers like the Park Nicollet Frauenshuh Cancer Center (“where care comes to you”).

Another recommendation (to improve flow and cross-functional care) is to have “right-sized” equipment and facilities.

We see this in the decentralized clinic labs at ThedaCare and I saw similar thinking in Sweden with the “right sized” operating room in a cardiac unit.

Finally, Womack and Jones said the patient “would need to be actively involved in the process and up-skilled — made a member of the team — so that many problems can be solved through prevention or addressed from home.”

We see this patient engagement in the “e-Patient” community (and my friend “e-Patient Dave” deBronkart). We see the use of Lean thinking in “Patient Centered Medical Homes” like those run by Group Health Cooperative, which includes the use of telemedicine and electronic patient communication, as suggested in Lean Thinking.

What did Womack and Jones predict we would see with Lean healthcare:

  • Time and the number of steps required would “fall dramatically”
  • Quality of care should improve due to a reduced number of handoffs (less information lost)
  • Lower costs would free up research to find new cures

They ended the section by saying “most of today's health care debate in the political arena is simply a cost shifting or service elimination contest as the various parties along the value stream try to defend their own interests at the expense of others.” Remember, this was the era of “HillaryCare,” not “ObamaCare.”

17 years later, how are we doing?

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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. Just don’t try to involve the patient by wearing a button encouraging them to ask a question about hand hygiene. That’s the wrong kind of involvement/up-skilling.

  2. Good article Mark. To add to your excellent writing, Joanne Poggetti and John Black, both of John Black and Associates were the first to apply Lean to healthcare in the mid 90s, before James Womack had published the book. In fact, Womack was in Japan on a tour at the same time Joanne and John were on the tour hosted by Awata, so it may well be that he got some of his ideas from them.

    Additionally, Joan Wellman learned to apply Lean thinking to healthcare as a result of working with John in the late 90s. And it was John Black and Associates who originally trained both Virginia Mason and then Park Nicollet, which is where Tina Hallberg worked before she joined JBA.

    • “First” will probably always remain open to debate.

      GM and, I think, Ford were helping some Michigan hospitals with Lean concepts in the early to mid 90s. I’m not sure it matters who was first, but there was definitely an early wave of innovators who deserve recognition.

      • GM and Ford were not even helping themselves with Lean concepts in the early to mid 90s, so I have to differ with you there. For GM it was right about that time that Roger Smith was adamantly installing robotics, and had no earthly idea why the chairman of Nissan praised a six minute setup time of their largest machine, in his 1994 annual report. To which I say, an art gallery is a dull place to a blind man.

        That it matters who was first is probably irrelevant as you suggest. Just noting some facts as they pertain to the statement “When the book Lean Thinking was originally published in 1996, it seems likely that hardly anyone [sic] was applying Lean principles in healthcare.”

        There was someone doing exactly that – John Black and Joanne Poggetti and you’re right, they do indeed deserve recognition. In fact, when John was presenting to Virginia Mason in the late 90s, Mr. Womack stood up right in the middle of the presentation and vehemently announced that “this will never work in healthcare” and stormed out of the room. Luckily this did not deter John and Joanne, or the smart folks at Virginia Mason.

        The point is, it’s one thing to write about what Lean thinking might look like (in any industry). But as many have found out since 1996, it’s quite another to actually get others to use Lean thinking to manage an organization. Let’s celebrate the actual pioneers who were doing just that, with some real recognition and respect.

        • Jim – Did you work at GM?

          I did. GM was absolutely working to figure out Lean in the mid 90s. Were they too tool focused and not focused enough on changing their culture and management system? Sure. But GM was involved with NUMMI from 1984 on. My one plant manager at GM was one of the original NUMMI guys… he had turned around another plant and was working to turn around my plant in Livonia, Michigan.

          So, you’re incorrect that GM wasn’t doing anything to help themselves. Facts are facts.

          The Roger Smith obsession with robotics was the 1980s, not the the 1990s.

          Yes, Virginia Mason was investigating Lean… but Mike Rona and John Black didn’t meet until 2000.


          Maybe John Black was in there at VMMC first, but I don’t know about your timeline. It doesn’t really matter, just as we agree that it doesn’t really matter who was “first.” Anyway, this post was about what was going on in 1996.

          What’s your source on that meeting with Womack? Were you there?

          Joan Wellman was doing work with Seattle Children’s in the 1990s and I’ve given her credit for that before here on the blog and in a podcast with her. I’ve given her and others recognition and respect. But thanks for your comment.

  3. I did indeed mess up my timeline and the name of the CEO, Jack Smith in the mid-90s. And no, I did not work there but I’m not surprised that you did. What I did do was watch in fear as GM crashed predictably into bankruptcy between then and 2009. That’s the only fact about GM I know.

    And I also know some “facts” were left out as you document the history of Lean healthcare here, which as a “self-proclaimed expert” in Lean healthcare, can lead to “revisionist history.” Despite my timeline mistakes about John Black and VMMC, I thought it important to keep that from happening since you have chosen not to acknowledge Mr. Black and Ms. Poggetti.

    • I didn’t “choose to not acknowledge” Black and Poggetti. This post and my follow up comments were about the 1990s. Like I said, Black didn’t meet the VMMC leaders until 2000. This wasn’t a comprehensive history of Lean healthcare. I’m not being “revisionist.”

  4. Mark, I apologize. It was unfair to suggest you were being a revisionist. On the contrary, you have done an outstanding job with this blog and have provided the world a gigantic service with your excellent assortment of posts, interviews and insights. On behalf of those of us who have chosen to push for this fantastic advancement in management technology, thank you! You’ve done an amazing job and I for one am very grateful to you.

    Having said that, Joanne Poggetti is among American healthcare’s Lean pioneers. After working with W. Edwards Deming during his consultations with GM and others, a trip to Japan led her to realize that it was possible to implement the Toyota Production System in healthcare. In 1995, Sister Monica Heeran, the CEO of PeaceHealth, signed on for a two year Lean implementation with Joanne and John Black, under her company Poggetti & Associates.

    In October 1996, Ms. Poggetti took Sister Heeran and five other PeaceHealth executives on a study mission to Japan. They conducted kaizen on the factory floor at Hitachi’s Narashino Works, along with trips to Toyota Motor Works, Yamatake Honeywell, and Hokushin Kogyo. PeaceHealth was also exposed to training led by MIT’s James Womack, Wiremold’s Art Byrne, Pratt and Whitney’s Bob D’Amore, and Hon Industries’ George Koenigsaecker. Additionally Ms. Poggetti and Mr. Black exposed PeaceHealth to senior executives from Hitachi, Showa Tekko, Yamatake Honeywell, and Hokushin Industries, as well as Shingijutsu senseis Yoshiki Iwata, Senji Niwa, Chihiro Nakao, and Akira Takenaka.

    They developed a Lean leader certification process for PeaceHealth, with phenomenal results. By 1997, the efforts had substantially streamlined processes involved in scheduling home nursing visits, saving more than 15,000 staff hours, cutting administrative space requirements by 74 percent, and removing more than $640,000 from the annual budget. Similarly, an administrative team cut its billing cycle from 28 days to 3.

    For more information about who was applying Lean principles in healthcare when the book Lean Thinking (by Jim Womack and Dan Jones) was originally published in 1996, go to http://j.mp/HealthLean.


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