Group Discussion Questions

This page is a collection of the group discussion questions that appear at the end of each chapter in the 3rd edition of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, by Mark Graban. Please use these questions in book club discussions or other settings.

You can download this list of questions as a PDF document.

Chapter 1 – The Need for Lean Hospitals

  • Are rising healthcare costs impacting your hospital’s quality of care?
  • How can better quality cost less?
  • How does personal satisfaction on the job have an impact on productivity and quality?
  • What are the biggest problems your department faces? Your hospital? Your health system?
  • Why does a hospital typically have departmental silos?
  • Are there situations where your departments or processes are not as patient-focused as they could be?
  • Why have other improvement methodologies or programs not achieved lasting benefits? How can your organization avoid repeating the same mistakes?
  • What percentage of leadership time is spent expediting, firefighting, or working around problems?
  • How can our Lean efforts be oriented around the mission and purpose of our organization and our people?

Chapter 2 – Overview of Lean for Hospitals and Health Systems

  • If asked, “What is Lean?” what is your best 30-second answer?
  • What has to change and be implemented to create a Lean culture?
  • How can we develop leadership skills in employees, from top to bottom?
  • If the first principle of The Toyota Way is taking a long-term view, how can we hope to be successful with Lean if our thinking and decisions are still driven by short-term demands?
  • Are there ways in which people in our hospital have previously not shown respect for people? What is the impact of this? How can that be addressed?
  • Why do some hospital employees get burned out or cynical over time?
  • What methods or practices have just evolved in your area rather than being designed?
  • What conditions and mindsets would you expect to be necessary to have everybody participating in continuous improvement?
  • How do you strike the balance between not reinventing the wheel yet not blindly copying other units or other hospitals?
  • Are there any misperceptions that we have heard about Lean in our organization? If so, how does that occur and what can we do about that?
  • How can we combine Lean with existing methodologies or other approaches that our organization is adopting?

Chapter 3 – Value and Waste

  • Who are our customers? Is the customer always right in a hospital setting?
  • How do our patients define value? Have we talked to them about this? What steps in our process are value-adding?
  • How can we reduce delays in one part of the process without negatively impacting another part?
  • Which types of waste are most prevalent in your department or hospital? Can you find an example of each?
  • Are there times when we make the patient wait for the benefit or convenience of everyone else in the system? What can we do to change that?
  • Are there times when the desires of “internal customers” are out of alignment with patient needs?
  • How far are our employees walking on an average day? What can we do to reduce that?
  • What are some reasons we might err on the side of having too much inventory rather than too little?
  • In the clinic example of Table 3.4, how would you categorize those steps? What questions would you ask as a result?
Step Category (Value, Required Waste, Pure Waste) Rationale or Questions
Patient fills out forms at front desk
Walk to waiting room
Wait in waiting room
Walk to scale
Get weighed by medical assistant
Walk to exam room
Get blood pressure & temperature taken
Wait in exam room
Describe symptoms to nurse or medical assistant
Wait in exam room
Describe symptoms to physician
Receive diagnosis and treatment advice
Walk to front desk
Pay co-pay

Chapter 4 – Observing the Process and Value Streams

  • How can we avoid having people take waste identification personally?
  • Why must we observe processes firsthand to identify waste?
  • Why are we sometimes surprised by what we see when observing the process?
  • For a patient who arrives in the emergency department, how many different functions, departments or silos are involved in their care?
  • Can you think of an example where part of the entire value stream was suboptimized? Why did that happen? What can be done about that?
  • Why do products and patients spend so much time waiting in the value stream?
  • Pick a process you are accountable for. Could you sit down and diagram it for one of your customers? Would that match today’s reality?
  • What keeps nurses away from the bedside? What can be done to reduce that?
  • What can we do to use freed-up time instead of sending people home early?

Chapter 5 – Standardized Work as a Foundation of Lean

  • How is patient safety impacted by standardizing our work?
  • How do irregular or unexpected circumstances fit into standardized work?
  • Why is it important that the people who do the work author standardized work documentation?
  • How does standardized work apply to physicians and surgeons?
  • How can standardized work be helpful for your supervisors and leaders?
  • How can we gain acceptance of standardized work?
  • In your workplace, what might be some examples of critical tasks, important tasks, and unimportant tasks?
  • What methods do you currently have in place to verify if work methods are being followed?
  • What would be an example of overly specified work in your area? What problems does this cause?

Chapter 6 – Lean Methods: Visual Management, 5S, and Kanban

  • What is an example of an information deficit in our area? What waste does that cause? Can we use visual management to eliminate that waste?
  • How much time is wasted each day due to disorganization? What could we better use that time for?
  • How can we free up time to work on Lean methods?
  • What are some problems we face with our existing materials management systems? What drives people to hoard supplies?
  • Is it possible to calculate the cost (financial or human) of a patient being harmed or dying because of an inventory shortage or stockout?

Chapter 7 – Proactive Root Cause Problem Solving

  • What are the lessons from the Mary McClinton case? Is it fair that Carl Dorsey lost his job? Was that “just?”
  • Why do we tend to blame individuals when errors occur? What can we do to reduce our tendency to blame?
  • If workarounds prevent the identification of root causes, why are they so tempting?
  • Is leadership taking responsibility for creating an environment of openness in the name of patient safety and error prevention?
  • What can we do to encourage people to report errors, near misses, and unsafe conditions?
  • How can we free time for proper root cause problem-solving?
  • How do you turn errors into learning opportunities?
  • How do we find a balance between blaming the system and making excuses for people?
  • What prevents hospitals, employees, or physicians from being open about problems, errors, or near misses?
  • Is a goal of “zero infections” inspiring or demotivating? Why is that? What can you do to change the culture that makes it OK to aim for zero?

Chapter 8 – Preventing Errors and Harm

  • Are the caution and warning signs in your hospital anything more than a short-term response to quality problems?
  • Can you find a sign that can be replaced with better standardized work or with error proofing?
  • How would you evaluate your equipment and tools differently, keeping error proofing in mind?
  • How should leaders react if pre-surgical timeouts are not taking place?
  • What are frequently occurring errors and mistakes in our area?
  • What ideas for simple error proofing do our team members have?
  • How do we ensure that methods like banned abbreviations are followed all of the time?
  • How can hospitals better learn from mistakes made at other facilities?
  • In what circumstances would it be appropriate for society to jail individuals who are involved in errors that harm patients?
  • Can you recall a time when patient safety was made a top priority, even if that wasn’t a popular decision or if it cost more in the short-term? How can you celebrate stories like that in the organization?

Chapter 9 – Improving Flow

  • How would hospital processes or your department be different if physician rounds were level loaded?
  • How can you better balance staff levels with workloads?
  • Why might nurses feel disrespected or not valued by being sent home early when census is low?
  • What improvements would the hospital see if we could discharge patients evenly across all 7 days of the week? Is this possible?
  • How might the hospital level load elective surgeries throughout the year? What departments or functions might need to get involved?
  • How might improved flow help improve the quality of care for patients?
  • What are the longest waiting times for appointments or care that we might want to address with Lean?
  • What is the proper balance between patient waiting time and physician waiting time?

Chapter 10 – Lean Design

  • What new spaces are going to be built or significantly redesigned in the next few years? What is our vision for how Lean Design can help?
  • If departments or leaders are planning for new space, are we sure we have first done everything we can to maximize the use of the existing space and capacity, using Lean methods for improvement?
  • What can we do to free up staff time to participate in current state analysis, mockup review, or similar activities?
  • Why is it important to have actual patients and families participating in these efforts?
  • How can we determine if architecture and construction firms are seriously committed to Lean Design or if they are just using the buzzwords?

Chapter 11 – Engaging and Leading Employees

  • Why might our supervisors and managers be afraid of empowering their employees?
  • Is our organization very top down or command and control? If so, what problems are caused by this?
  • How does a new frontline supervisor or manager get trained in our organization today?
  • Why do we need to audit the audits?
  • What are some reasons why our employees might not speak up or make more suggestions for improvement? Why might employees not take action? What can leaders do to encourage a culture of continuous improvement?
  • Is our current culture more of a helpful coaching leadership style or a corrective and punitive style?

Chapter 12 – Getting Started with Lean

  • What problems really need solving? Where should we start? Is there broad agreement about the need to improve and our ability to improve?
  • How would you answer Shook’s five Lean Transformation questions?
  • Why is a pledge of no layoffs due to Lean so important for engagement and success?
  • How can we transition our Lean efforts from a tools and project mentality to a way of thinking, managing, working, and improving every day?
  • What skills or personalities make the best Lean team members?
  • How do we get our senior leaders engaged and involved with Lean if they are not already?

Chapter 13 – A Vision for a Lean Hospital and Health System

  • What core measures can we improve by half in our organization?
  • How might people react to a goal of “zero” or “perfection”?
  • How are some of these patient-centered goals complicated by the payer system and financial incentives in our country?
  • What is your own long-reaching vision for a Lean hospital within your department, your hospital, and more broadly?