2nd Edition (2011)

Learn more about the upcoming 3rd edition (June 2016)

Lean Hospitals Graban 350

Read a blog post, from the book’s author, about the second edition

Highlights of What Was New in the 2nd Edition:

  • New and updated material on identifying waste, A3 problem solving, employee suggestion management, and strategy deployment
  • New case studies—including a new Kanban case study (Northampton General Hospital) and another that ties together the themes of standardized work, Kanban, 5S, visual management, and Lean leadership for the prevention of patient harm
  • New examples and updated data throughout, including revised chapters on patient safety and preventing medical errors



  • “Points to Ponder” at the end of each chapter are now called “Points for Group Discussion,” with some new questions added.

Chapter 1

  • Updated initial introduction (talking about “starting from need” in terms of why we use Lean methods and principles)
  • Added callout talking about Toyota’s reputation and quality
  • Updated lean history to reference Joan Wellman and Seattle Children’s early lean work
  • Updated/new metrics that show lean improvement examples in healthcare
  • Updated data on cost pressures, staff shortages, quality problems in healthcare
  • New departmental case study (Children’s Medical Center Dallas – lab)
  • 1st edition case example moved to later chapter on improving flow
  • The bulk of the Avera McKennan case study (from 1st edition) moved to later chapter on getting started with lean

Chapter 2

  • Various updates, including some references to ThedaCare’s lean management system
  • Updated “Toyota Way” framework to change first pillar wording from “elimination of waste” to “continuous improvement” – the main idea is the same, but this is more consistent with Toyota wording
  • New callout on “respect for people” pillar
  • Added the “four rules in use” as a Lean definition framework

Chapter 3

  • New introduction, “Waste is Not the Same as Cost”
  • New data from Virginia Mason about reducing waste to free up RN time at the bedside
  • Refined description of “pull” in healthcare, why pull should be about patients pulling on resources, not a unit “pulling” the patient when a room is available
  • Improvements in the section on defining value, incorporating insights from Dr. Don Berwick
  • Edits and, in some cases new examples, about the types of waste in healthcare
  • Fuller discussion of “Required Waste”

Chapter 4

  • Edits and some new examples in intro to value streams
  • New callout on electronic VSM – downplaying the need for that software and technology
  • New “activity of the employee” example for primary care physician, with new figure

Chapter 5

  • New figure showing the “Park Nicollet System of Care” version of the “Lean House” diagram
  • Edits and refined section on standardized work for healthcare
  • New callout on looking at the communication process and standardized work instead of just blaming parents for not following NPO instructions properly.
  • New callout on standardized work in a radiology department
  • New section on determining staffing levels based on data
  • New section on quick changeover as a form of standardized work (O.R. turnover, etc.)
  • New material on managers coaching on standardized work, rather than being punitive when they see problems
  • New material on lean, standardized work, and checklists
  • New material on standardized work for managers
  • New callout on standardized work and Training Within Industry (success story example)

Chapter 6

  • New examples of visual management used to help manage patient flow
  • New 5S callouts and small case examples
  • New Kanban examples and new case study from Northampton General Hospital (UK), Seattle Children’s, Park Nicollet, Henry Ford Health System, New York HHC
  • New material on Kanban vs. par levels
  • New material on Kanban vs. automated inventory cabinets
  • New culminating case study about the use of standardized work, 5S, Kanban, and visual management to prevent patient harm

Chapter 7

  • New intro case study of the Mary McClinton case and lessons learned (Virginia Mason)
  • New quality improvement data and examples from ThedaCare and others
  • New examples and discussion about workarounds
  • New section on A3 problem solving, with example
  • New 5 Whys problem solving examples

Chapter 8

  • New introduction and case example of patient harm and lessons learned (Darrie Eason case) – blame vs systems
  • New examples about quality at the source and not blaming individuals
  • New error proofing and quality improvement data and case examples
  • New material about Lean and “Crew Resource Management”
  • New material on Virginia Mason “patient safety alert” system
  • New figures and photos

Chapter 9

  • New intro – “Waiting: A Worldwide Problem” with data from many countries and waiting times and improvements
  • New material on the “Seven Flows of Healthcare”
  • New examples and data on flow improvements
  • New material on matching staffing to demand in emergency departments
  • New examples of E.D. flow improvement
  • New case example (ThedaCare) on reducing door to balloon time

Chapter 10

  • New quotes and callouts on lean leadership, including John Toussaint’s comparison of “white coat leadership” and “lean leadership.”
  • New section on strategy deployment
  • New material on goals versus hard targets and a warning about dysfunctions
  • Additional material on daily standup meetings
  • Updates on managing kaizen and continuous improvement
  • Updated format for an “idea card” to be used on visual idea boards

Chapter 11

  • New callouts about organizations getting started with Lean
  • New material on “what do we call it?” – giving a name to a formal Lean program
  • Updates on kaizen events – different formats and success/failure data updated
  • Replaced LeBonheur Children’s Hospital “getting started” lean transformation case with updated/expanded version of Avera McKennan case

Chapter 12

  • Updated and expanded “Vision for a lean hospital.”