We would like to express our gratitude to Mark Graban for taking the time to provide in-depth answers to questions regarding his experience in lean healthcare as well as expounding on ideas and examples from his book Lean Hospitals. Thanks also to the readers who have left comments.

Q15: One of the tenets of standardized work and lean management is to remove the need for as much judgment as possible from front-line work. The argument is often made that skilled workers must be allowed to make on-the-spot judgments rather than pull the andon cord (call for help when they are unable to follow standard work), yet this goes against TPS. You argued that physicians need this sort of leeway to make judgments. In order to guarantee quality outcomes how do we balance this and the desire of physicians to rely on their own judgment?

This is a bit of a tough one. I can understand the need for or the theoretical argument for standardizing everything. There can be, right or wrong, a lot of resistance to standardized work in healthcare. Look at the one comment on Part 1 of our Q&A where the person played the "each patient is unique" card. That isn't really true in the sense that a hospital does need 6 billion different ways of treating chest pains when a patient arrives. There are many aspects of care that can be standardized (as I talked about in Part 2 with the cardiac surgeons at Geisinger).

To gain buy-in to the idea of standardized work, we have to start somewhere. This is often in the non-clinical aspects of hospital operations. It's often surprising to outsiders how much variation there is in processes in different departments of the hospital. It's traditionally a culture of technical and clinical brilliance saving the day. Hospitals are learning that procedural brilliance also has a role to play. If we start by standardizing non-clinical aspects of care, we can start down the path where physicians or surgeons take it upon themselves to standardize the parts of the care process that can be standardized. Even in the case of Geisginger, with good standardized work defined by the surgeons, they still had to leave themselves an "out" where the surgeon could deviate from the standardized work if there was a real clinical need and they could justify that variation to their peers.

Q16: There was a very enlightening passage in Chapter 9 on patient flow where you described how physicians will make patients wait on purpose. If I have a 3PM appointment with a doctor and the hospital asks me to arrive 15 minutes early, at what time should I really arrive?

It's true, that physicians will often intentionally queue up patients so that they (the scarce and expensive resource) is 100% utilized. Their best protection against idle time is to sometimes double book patients, or book more than capacity. If everyone shows up, you might have to wait (they aren't going to "bump" you like an overbooked flight).

I think patients need to start being a bit more demanding. I dumped my family practice doctor in Texas and switched to another one because they made me wait too long (and too unpredictably). My dad has a doctor in Michigan who promises he will be on time and, likewise, if you're late, you lose out. That's the expectation that's set up front. There are studies, going back to the 1950's, that talk about the math and the customer perceptions that come from making patients wait. It's a problem that's been around for a long time. But, hopefully, increased customer/patient focus will bring an increased focus on not making patients always wait - maybe the system won't always be suboptimized around MD efficiency.

Q17: What percentage of hospital staff have you found to be effective for dedicated full time to implementing and supporting lean?

I think hospitals are still figuring out how many full time staff they need to help facilitate and coach enterprise-wide engagements. For a departmental or value-stream implementation, the group I work for recommends that the hospital dedicate 4 to 6 staff members for a 13-week period to help with the initial implementation. This dedicated staff time helps break the cycle of "not having time to improve." The short-term dedication of staff can cause some short-term pain (such as overtime for other staff), but it's necessary to create some breathing room (time) to allow continuous improvement. This is a different model than "kaizen events" and one that I outline a bit more in Chapter 11 of my book.

Q18: What are the most important points regarding change management within hospitals implementing lean management?

Oh, I think it's the same as any industry -- it's just people being people. The classic change management models apply just as well to healthcare. I think you have to give individuals a natural intrinsic incentive to implement Lean. Ask the classic "what's in it for me?" question. Healthcare people are incredibly motivated and passionate about the patients. Some hospitals purposefully do not talk about cost improvements that would come from quality and patient safety improvements. They know the cost savings will be there (and are important), but cost savings will not motivate employees. Initiatives to improve patient care WILL. When Lean is implemented properly, it benefits everyone - the patients, the staff members, and the hospital itself.

Q19: The high profile bankruptcy a few years ago of showcase lean companies such as Delphi, to name just one, remind us that lean management is necessary but not sufficient for the long-term survival of an organization. What areas in addition to lean do you see as being critical to the success and survival of hospitals?

Another excellent question. I don't have all of the answers to this, but one thing I do believe is that Lean (as powerful as it is) is not the end-all be-all solution for healthcare. There are many big picture dynamics -- payer structures and systemic interactions between hospitals, providers, payers, drug companies, manufacturers of medical equipment... it really is a complex industry. I'm happy to keep my head down in the operational details and local leadership issues because those are things that can be fixed relatively quickly.

Regardless of whatever systemic changes that may get introduced into the U.S. healthcare system, there will still be a need for Lean - for quality, safety, and productivity improvement. Lean is quite successfully used in countries with single payer or government-based healthcare (like Canada and the U.K.). Much as Lean is not the single silver bullet, neither is changing the payer structure.

Q20: What are your plans for future books on lean hospitals?

Still uncertain. My publisher has asked me "what's next?" As time goes on, we'll understand more about what's successful at the hospital-wide or health system-wide "enterprise" level. So that could be one opportunity to explore. Or, a series of guidebooks on different Lean methods, as my book isn't a detailed "how to" guide for implementing Lean. I also have a lot of personal interest in a book that details the long 100 year plus history of engineers working together with healthcare professionals - Frank Gilbreth, Henry Ford, Dr. Deming, and others through today. But I'm not sure how much of a market there is for that book. I might just write it anyway for my own sake, we'll see. Suggestions from readers?