QUERI – Quality Enhancement Research Initiative

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Quality Improvement Methods

24. Lean Approach

a. Definition: Lean is an effective and popular approach to improve quality and operations through the use of many methods. It is also referred to as the "Toyota Production System or TPS," as much of it was initially developed at the Toyota Motor Company (with contributions from other earlier operations improvement efforts by various individuals and organizations). Some refer to Lean as the Toyota Production System or TPS. Many of the components of Lean are referred to by their original Japanese name. Particular hallmarks of these Lean methods are a reduction in waste and focus on value or what is important to the customer or patient.

The Lean approach has become popular in the healthcare industry although it was initially developed for manufacturing. Many large healthcare systems employ Lean to some extent. Certification of one's ability to use Lean is given by a number of organizations. However, there is no single Lean authority.

Depending on the practitioner, one or more of several Lean tools are emphasized. These are described in this handbook and their relevance to Lean is noted in their separate sections.

Lean management implies the broad application of the principles of increasing customer (patient) value by eliminating waste and creating a smoothly flowing experience for the customer. A lean transformation means changing to ongoing Lean thinking and not doing just short term changes that may not have a lasting impact.

b. Literature: While the Lean or Toyota method was initially developed in the automobile industry in Post-War Japan, it has found much use in healthcare in recent years. There is considerable literature regarding the use of Lean specifically in healthcare although much of the Lean literature outside healthcare is applicable. The books on Lean generally provide details on all of the Lean methods although some focus on one particular component of Lean. Literature on Six Sigma (See Section 44) generally covers many these same topics. Some popular Lean books are:

  • Womack, James P., and Daniel T. Jones. Lean thinking: banish waste and create wealth in your corporation. Free Press, 2010. Popular reference by one of the early writers about Lean.
  • Miller, David. The Toyota way to healthcare excellence: increase efficiency and improve quality with LEAN. Health Administration Press, Second Edition, 2016.
  • Graban, Mark. Lean hospitals: improving quality, patient safety, and employee satisfaction. Productivity Press, Third Edition, 2016.
  • Hadfield, Debra, et al. The New Lean Healthcare Pocket Guide: Tools for the Elimination of Waste in Hospitals, Clinics, and Other Healthcare Facilities. MCS Media, Incorporated, 2009.
  • Sayer, Natalie J., and Bruce Williams. Lean for dummies. For Dummies, 2012.
  • Jeffrey, Liker. "The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer." McGraw-Hill, (2004). and Liker, Jeffrey; Meier, David (2006). The Toyota Way Fieldbook. New York: McGraw-Hill
  • Kenney, Charles. Transforming health care: Virginia Mason Medical Center's pursuit of the perfect patient experience. Productivity Press, 2010.
  • Mazzocato, Pamela, et al. "Lean thinking in healthcare: a realist review of the literature." Quality and Safety in Health Care 19.5 (2010): 376-382.
  • Scoville R, Little K. Comparing Lean and Quality Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2014. (Available at ihi.org) Compares IHI's approach to Lean.
  • Toussaint, John S., and Leonard L. Berry. "The promise of Lean in health care." Mayo Clinic Proceedings. Vol. 88. No. 1. Elsevier, 2013.

c. Example: A group of hospitals wished to reduce readmissions for CHF patients. They initiated a project to do so with a project leader, an owner who was in authority over the functions involved and a multidisciplinary set of staff. Kaizen events (see Section 22) were held to define the problem, develop solutions and plan implementation of changes. Various methods were employed, such as process mapping and Pareto Charts (see 31), in order to understand the problem. The change was done via PDSA (see 33) cycles and reported via A-3s (see 1) posted in affected areas. At the end of the effort improvements were implemented through checklists (see 7) and written standard work (see 47) . Control Charts (see 9) were used to monitor results and to sustain the change.

d. Steps: As noted, Lean can employ a variety of methods. The details and sequence of how it is used it will depend on the particular issues to be addressed. Lean projects to improve a particular function or to address a particular problem should follow a PDSA cycle (Plan, Do, Study, Act) as described in Section 33. The components of Lean are often described as a hierarchy built up from a base as in the figure below.

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