Table Of ContentBusiness Management / Healthcare Process Improvement G
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bo Patricia A. Gabow MD, MACP (cid:127) Philip L. Goodman
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(cid:127)
G
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o
d The Lean
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The Lean Prescription a
n
Powerful Medicine for Our Ailing Healthcare System
“This book can teach specific techniques to other leaders in the medical
field on how to improve their delivery of healthcare, with the focus on Prescription
where it should be: on patients and their care. Dr. Gabow has offered the
great gifts of her experience and wisdom. For those with the will to
improve, this book can be their guide.”
—John Hickenlooper, Governor of Colorado
T
“This book is a prescription for excellence. It vaults to the top of the
management must-read list.” H
—Bruce Siegel, MD, MPH, President and CEO, America’s E
Essential Hospitals Powerful Medicine for Our Ailing Healthcare System
L
“By mixing explanation, thought exercises, and real-life examples, Gabow
E
and Goodman provide a thoughtful and accessible introduction to the
A
discipline of Lean and its application within healthcare systems.”
N
—Risa Lavizzo-Mourey, MD, MBA, President and CEO, Robert Wood
Johnson Foundation
P
In this book, Dr. Gabow, former CEO of Denver Health for 20 years, R
teams up with Philip Goodman, a 34-year veteran of Denver Health
E US HEALTHCARE
who directed the Lean System group, to share their Lean journey.
S
The Lean Prescription: Powerful Medicine for Our Ailing
C
Healthcare System tells the story of how Dr. Gabow led Denver
Health to become the first healthcare organization to be awarded R
the Shingo Bronze Medallion Prize for Operational Excellence. I
P
Detailing the foundational Lean principles, the book provides T
readers with the benefit of the experience of an integrated healthcare
I
system's successful seven-year Lean journey. It includes helpful O
exercises and examples of Lean applications. The book goes beyond
N
the hospital to include Community Health Centers, HMOs, paramed-
ics, and call centers.
K23587
Endorsements
“This is a terrific book. It is engaging and should be enormously helpful to anyone wanting to
improve the efficiency and functioning of their healthcare enterprise. It clearly lays out why and
how to implement Lean in healthcare settings.”
Richard D. Krugman, MD
Vice Chancellor for Health Affairs and Dean
University of Colorado School of Medicine
“An inspiring book by one of the nation’s leaders in health systems change that not only chronicles
one major institution’s transformation but empowers readers to follow suit.”
Sara Rosenbaum, JD
Harold and Jane Hirsh Professor
George Washington University
School of Public Health and Health Services
Department of Health Policy
“For years, discussions of the broken US healthcare system have been long on diagnosis and short
on solutions. The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System aims to
fix that. By mixing explanation, thought exercises and real-life examples, Gabow and Goodman
provide a thoughtful and accessible introduction to the discipline of Lean and its application within
healthcare systems. By grounding the book in their real-life experience, they paint a clear and real-
istic picture of the commitment necessary, the enthusiasm and empowerment engendered and the
exceptional results Denver Health achieved for its patients and its staff. For any leader who’s looking
for a serious approach—not a silver bullet—to making their system work better for all stakeholders,
this book holds a powerful message.”
Risa Lavizzo-Mourey, MD, MBA
President and CEO
Robert Wood Johnson Foundation
“The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System is a prescription for
excellence. It vaults to the top of the management must-read list. Patty Gabow charts a way forward
for every health executive working to achieve breakthrough results for every patient.”
Bruce Siegel, MD, MPH
President & CEO
America’s Essential Hospitals
“Dr. Gabow demonstrates in The Lean Prescription: Powerful Medicine for Our Ailing Healthcare
System how a CEO can change a culture and deliver massive improvement in healthcare delivery,
including over $190 million in financial benefit over seven years, through disciplined Lean leadership.”
George Koenigsaecker
President of Lean Investments, LLC
“Patty Gabow and Philip Goodman have succinctly captured the enormous power of Lean manage-
ment as applied to healthcare. In the process they provide exercises which can deepen the reader’s
grasp of concepts and tools. Notably, the accomplishments they document have been achieved in
safety net institutions—a challenge and inspiration to everyone who works in such settings: even
with constrained resources we can get better outcomes for our patients by systematically reducing
waste and improving reliability.”
Mark Smith, MD
Retired, President and CEO
California HealthCare Foundation
“Dr. Gabow’s amazing process improvements at Denver Health Medical Center were the inspiration
for our own journey with Lean techniques. Her new book can teach specific techniques to other
leaders in the medical field on how to improve their delivery of healthcare, with the focus on where
it should be: on patients and their care. In these pages, Dr. Gabow has offered the great gifts of her
experience and wisdom. For those with the will to improve, this book can be their guide.”
John Hickenlooper
Governor of Colorado
“If you have any responsibility for any part of the healthcare systems in the United States, your
experience and the health of your patients will be better for having read, understood and acted on
the clear steps described in this unusual book. Not a treatise, it is a guidebook to take us from the
jungle of cost, waste, and confusion to the clarity of efficiency and mission.”
Christine Cassel, MD
President and CEO
National Quality Forum
“With Lean, Dr. Gabow applies a concept developed and honed in the private world to public ser-
vices. Lean’s approach empowers workers to eliminate waste, improving quality, and reducing costs.
We should embrace this thinking to improve the value of our public organizations.”
Senator Michael Bennet
United States Senator from Colorado
“Dr. Gabow and Phil Goodman have thoroughly captured seven years of experience in this engag-
ing and straightforward re-telling of their highly acclaimed Lean transformation of Denver Health.
All of us who know and worked closely with Patty appreciate her unparalleled attention to detail and
hands-on leadership of her operations as CEO of this magnificent public hospital system. In The Lean
Prescription: Powerful Medicine for Our Ailing Healthcare System that same Gabow mastery of nuances
and the critical elements of transforming a large health system are factually presented, covering not just
select clinical areas but the whole enterprise … as it should be done. Bravo Patty and Phil for your crisp
presentation of the why, the how to, and the real results of Lean’s impact on Denver Health!”
Marc Hafer
President and CEO, Simpler Consulting
“To non-initiates, Lean can seem alternately intimidating or dull. Patty Gabow has demonstrated
its power in action through the results she achieved at Denver Health. Now she has written a read-
able guide to Lean that will be useful for managers, providers and all who are struggling to make
healthcare work. This book is a great way to dive in.”
Margaret O’Kane
President
National Committee for Quality Assurance
Patricia A. Gabow (cid:127) Philip L. Goodman
MD, MACP
The Lean
Prescription
Powerful Medicine for Our Ailing Healthcare System
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
A PRODUCTIV ITY PRESS BOOK
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To our own families who have given us support,
encouragement, and most of all, love.
To our Denver Health family whose tireless commitment to doing
the right thing has been the inspiration for our Lean journey.
To the millions of patients whose suffering and
resilience made us always want to do better.
Contents
Foreword ................................................................................................xi
Acknowledgments ................................................................................xv
About the Authors ..............................................................................xvii
Introduction .........................................................................................xix
Chapter 1 Why Worry about American Healthcare .........................1
Those Left Out ..............................................................................1
Huge Cost .....................................................................................2
Quality Chasm .............................................................................3
Prevailing Culture of Healthcare ..............................................4
Impact on the Rest of the World ...............................................5
Potential Solutions .......................................................................5
Chapter 2 Role of Leadership in Health System Transformation ....7
Defining the Journey ...................................................................7
Implementing the Journey .......................................................11
Committing to Outcome ..........................................................11
Chapter 3 Why Pick Lean for Healthcare Transformation.............13
Philosophy of Lean ....................................................................13
Eight Wastes ...............................................................................15
Chapter 4 Toyota Principles and Working Concepts of Lean ........21
14 Toyota Principles ..................................................................21
Working Concepts of Lean ......................................................24
Customer Defines Value ......................................................24
Standardize to Solve and Improve .....................................25
Deliver Value on Demand without Waste/ Flow the
Process ...................................................................................28
Manage for Daily Improvement and Relentlessly
Pursue Perfection .................................................................30
Mutual Respect and Shared Responsibility Enable
Higher Levels of Performance ............................................31
vii
viii • Contents
Chapter 5 Lean Tool Box ...................................................................33
Tools to Create Prioritization and Alignment .......................33
True North .............................................................................33
Transformation Plan of Care (Simpler Business System®) ...35
Value Streams ...................................................................36
Tools to See Waste ....................................................................40
5 Whys ...................................................................................40
Waste Walk ...........................................................................42
Spaghetti Diagram ...............................................................44
Communication Circle ........................................................45
Takt Time and Cycle Time .................................................46
Takt Time .........................................................................46
Cycle Time ........................................................................47
First Pass Yield ......................................................................50
Process Mapping .......................................................................51
Seven Tools of Quality ..............................................................57
Fishbone .................................................................................57
Pareto Chart ..........................................................................58
Tools to Eliminate Waste .........................................................60
5S ............................................................................................60
Standard Work .....................................................................64
Poka Yoke, Jidoka, and Andon ..........................................64
Poka Yoke ..........................................................................65
Jidoka ................................................................................66
Andon ................................................................................67
Kanban ..................................................................................68
Quick Changeover ................................................................72
Level Loading ........................................................................73
Flow Cell ................................................................................75
Visual Management .............................................................76
Production Boards ..........................................................80
Tools for Quality ........................................................................81
Tools for Structure ....................................................................84
Rapid Improvement Events ................................................84
A3 ............................................................................................85
Tools for Design .........................................................................89
3P and 2P ...............................................................................89
Vertical Value Stream..........................................................90
