Back in 2009, my friend and KaiNexus co-founder Dr. Greg Jacobson and his colleagues at Vanderbilt University Medical Center published an article that still feels as fresh and relevant as ever:
“Kaizen: A Method of Process Improvement in the Emergency Department”, Academic Emergency Medicine, December 2009.
The full text can be read for free online.
It's one of the earliest and clearest demonstrations of Lean and Kaizen principles applied thoughtfully in a healthcare setting. What I love most about this paper is how it captures the spirit of Kaizen — small, low-cost, low-risk changes driven by the people doing the work — in a high-pressure environment like an emergency department.
The authors, also including Nicole McCoin, Richard Lescallette, Stephan Russ, and Corey Slovis, began with a simple but profound belief: that continuous quality improvement (CQI) should be part of everyday work, not an occasional project or top-down directive. Their goal was to create “a CQI program using a suggestion-based model that did not require a large time commitment, was easy to implement, and had the potential to empower all physicians in the department.”
That phrase — “empower all physicians” — says so much about their mindset. The project wasn't about mandating participation; it was about creating the conditions for engagement.
From Toyota to Triage
The team drew heavily on Masaaki Imai's book Kaizen: The Key to Japan's Competitive Success as their foundation, distilling its philosophy into 13 practical principles tailored for the ED. These included:
- “No idea is too small.”
- “Focus change on common sense, low-cost, and low-risk improvements.”
- “Empower the worker to enact change.”
- “All ideas are addressed and responded to in some way.”
If you've read Lean Hospitals or Healthcare Kaizen, you'll recognize those same ideas as core Lean behaviors — respect for people, transparency, and iterative improvement. Greg and his colleagues didn't just borrow Lean terminology; they built systems to make it work in practice.
Initially, they launched a simple online “Kaizen Portal” where residents and faculty could submit ideas. It quickly became clear that email chains weren't enough — too many ideas, too little visibility. The solution was what they called the Kaizen Tracker, a web-based application that organized ideas, assigned responsibility, and ensured that every suggestion received a response.
In short, they created a digital visual management system for ideas.
Sound familiar? That same thinking later evolved into the KaiNexus software platform, developed to help organizations manage improvement work more effectively.
Measurable Engagement, Real Change
Over four years, the Vanderbilt ED team implemented more than 400 improvements through their Kaizen Program. Seventy-six percent of submitted ideas identified a “process problem,” and 53% led to operational changes within the department.
Just as striking were the participation rates:
- 93% of residents entered at least one idea, and 73% of them submitted more than one.
- 69% of attending physicians participated, with 89% submitting multiple ideas.
Those aren't vanity metrics — they're cultural ones. In an environment where physicians are often skeptical of “process improvement” initiatives, Greg's team demonstrated that when the process to improve is easy and meaningful, people participate.
The improvements themselves were both practical and diverse. A few examples from their table of “Kaizen Initiatives” include:
- A suggestion to add thyroid shields in trauma bays — implemented immediately.
- Fixing a computer order entry problem for foot X-rays — a small technical change with big workflow benefits.
- Posting a sign reading “Pelvic Exam in Progress” to protect patient privacy — a simple, zero-cost idea that improved respect and safety.
As the paper notes,
“These small, low-cost, and low-risk changes often addressed real operational pain points.”
That's classic Kaizen: solving problems that matter in the moment, at the front line, with the people closest to the work.
Parallels with Lean Hospitals and Healthcare Kaizen
When I wrote the first edition of Lean Hospitals in 2008, I emphasized that Lean is not just about efficiency — it's about improving quality, safety, and staff engagement. Greg's 2009 paper illustrated that principle beautifully in action.
In Healthcare Kaizen (co-authored with Joe Swartz in 2012), we described hundreds of examples of staff-led improvement across hospitals and clinics — many of which echoed the lessons from Vanderbilt:
- Make it easy to contribute. Greg's web-based tracker lowered the barriers to participation.
- Respond to every idea. Even when a suggestion couldn't be implemented, the system provided feedback and closed the loop — a key factor in sustaining engagement.
- Build improvement into daily work. The Vanderbilt team didn't add Kaizen on top of their jobs; they made it part of how the department functioned.
Those design choices align with the cultural conditions described in both books: respect for people, psychological safety, and the joy of solving problems together.
The Cultural Ripple Effect
One of the most telling findings from the Vanderbilt paper wasn't just the number of changes, but the sustainability of the system. After the initial enthusiasm faded, participation levels stabilized and continued. The authors wrote:
“Our program is self-sustaining and part of the workflow process of the ED, rather than a quality improvement program layered on top of all the other work that physicians must do.”
That line captures something many organizations still struggle with. Too often, improvement is treated as a side project — an extra initiative, a special event, or something that happens only when leadership mandates it. The Vanderbilt team's success came from embedding Kaizen into daily routines and expectations, not treating it as optional.
That's what Lean cultures do best: they normalize improvement.
Another aspect I appreciate is their humility. The paper openly acknowledges limitations: the study was retrospective, limited to one department, and lacked outcome data on patient safety or satisfaction. Yet, they were clear about what mattered most — engagement, participation, and learning. As they concluded,
“Our Kaizen Program provides a 24-hour-a-day mechanism to promote continual improvement.”
Lessons That Still Apply
Fifteen years later, I still reference this article when talking with healthcare leaders. The lessons endure:
- Start small, but start. Big cultural change begins with small ideas acted on quickly.
- Build feedback loops. People will stop suggesting improvements if they never hear back.
- Make improvement visible. Transparency builds trust and accountability.
- Respect people's time and ideas. Greg's team succeeded because their system fit naturally into clinicians' workflow.
And perhaps most importantly:
5. Technology should enable, not replace, culture. The Kaizen Tracker didn't create engagement; it supported it. The culture came first. The same is true with our KaiNexus customers in various industries today.
Why This Still Matters
Reading this article today feels a bit like time travel. It reminds me how much of the Lean movement in healthcare grew from a handful of pioneering experiments like this one — humble, data-driven, and deeply respectful of the people doing the work.
Greg's 2009 study didn't just improve one emergency department. It helped plant the seeds of a broader cultural shift — one that continues to shape how we think about improvement, engagement, and leadership in healthcare.
And in many ways, it led directly to the work we do today at KaiNexus: helping organizations capture, track, and learn from their daily improvements so that every idea — big or small — can make a difference.
References
Jacobson, G.H., McCoin, N.S., Lescallette, R., Russ, S., & Slovis, C.M. (2009). Kaizen: A Method of Process Improvement in the Emergency Department. Academic Emergency Medicine, 16(12), 1341-1349.
https://doi.org/10.1111/j.1553-2712.2009.00580.x
If you’re working to build a culture where people feel safe to speak up, solve problems, and improve every day, I’d be glad to help. Let’s talk about how to strengthen Psychological Safety and Continuous Improvement in your organization.
