Lean Hospitals: Thoughts from a Health System C.O.O. on Lean, Purpose, and Safety

lean hospitals 3rd edition

In the previous editions of my book Lean Hospitals, I've included case examples from Avera McKennan Hospital and Avera Health. Fred Slunecka is the former president of Avera McKennan and he is now chief operating officer for the Avera system.

I talked with Fred again for the updated and revised third edition (available for pre-order now, shipping in June), with my highlights added for this post:


Reflecting further in 2015, Slunecka says:

“After over a decade of trial and error, American healthcare organizations are finally understanding the need to adopt Lean principles. It is only through rigorous attention to work redesign and eliminating variation that we can provide the safe and reliable care that our patients deserve. I believe that, for the last decade, most healthcare organizations viewed Lean as a tool without a major purpose. Today's focus on value requires that organizations embrace Lean to assure our patients receive what they deserve: safe and highly reliable patient care.

The historically slow adoption of Lean has probably been due to the amount of time and energy needed to change a single process in a single organization. The juice, as we say, was not often worth the squeeze. Today, the largest organizations are developing highly reliable practices and then disseminating them across all their many hospitals. Now the juice is worth the squeeze. The rapid development of ‘service lines' is helping to assure that practices are quickly disseminated.

When our revenues were based on volume, quality and value took a back seat. As we confront ‘star ratings' and payment penalties we are now focused on safety and quality. I believe that can only enhance the adoption of Lean over the longer term.”

I'd love to hear your reaction to his comments and to these questions:

1) Have too many organizations used Lean as a tool without a major purpose?

My thoughts: I see a lot of what Fred is describing… too many organizations try to train a lot of front line staff, or they use isolated Lean tools like 5S, or they run a bunch of disconnected projects or events. Lean needs to be tied deeply to the questions of “what problem are you trying to solve?” (John Shook) and what is your “most pressing need?” (Taiichi Ohno).

2) Is the slow adoption of Lean due to the “purposeless tools” problem or the fact that it's hard to change the culture in an organization?

My thoughts: One can make the argument that “Lean has never failed” — when it looks like failure, it's more a case of “people giving up on Lean” when it gets difficult or when it challenges their core beliefs and common behaviors (such as thinking the “problem” is bad employees and, therefore, leaders need to blame and punish people). Those ideals run counter to Lean at a very fundamental level.

3) Are hospitals really more focused on safety and quality than they were 5 years ago? Do incentives, penalties, and ratings help push hospitals in the right direction or does it just cause other dysfunctions?

My thoughts: I'd HOPE that hospitals are more focused on safety and quality, but I wish the lack of focus on safety and quality had never been a problem to begin with. Leaders can't delegate safety and quality (that's an old lesson from W. Edwards Deming) and leaders can't delegate a Lean transformation. My fear with penalties and incentives is that it will be easier for organizations to “game the system” or “fudge the numbers,” so we'll see more of that instead of real improvement. I'd love to be proven wrong on that.

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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. It still comes down to leadership and as you pointed out having real and substantial problems to solve. My former organization has been working on Lean for eight years now. It took four years for the CEO to recognize that Lean isn’t something you can delegate. Now after an additional four years that organization has been able to move from “purposeless tools” to “purposeless principles”. As an example earlier this year they just retrained all managers on huddle boards (for about the 5th time). Even when measures are updated and color coded there is rarely a coherent plan for fixes because very few in the organization really understand problem solving including senior leaders. And there is hardly a senior leader that can give a meaningful explanation about why Lean is important other than just a bunch of generalizations about the benefits of making things visual and the need to go and see. This same organization is taking a $500K penalty on hospital acquired conditions for the last year when many of the unLean hospitals in the area aren’t taking any penalties. I think there are very few healthcare organizations that can show juice worthy of the squeeze (great metaphor btw) and those that do (we know who they are) have very exceptional leaders. In my mind Lean success in healthcare is still very elusive.


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