Competing Mark Graban


Mark Graban is a Senior Consultant with ValuMetrix Services, a Johnson & Johnson organization. Mark earned a bachelors degree in Industrial Engineering from Northwestern University and was a fellow in the Leaders for Manufacturing program at the Massachusetts Institute of Technology, earning dual masters degrees in Mechanical Engineering and Business Administration. He has led process improvement efforts in various industries, having moved into healthcare in 2005. Mark is the author of a book entitled “Lean Hospitals: Improving Quality, Patient Safety, and Patient Satisfaction,” due out in late July. He is also founder of the Lean Blog website at

What two operational issues are the primary focus of your healthcare clients?

Well, as in any industry, hospitals face a wide range of issues and challenges. For Lean folks who are familiar with the SQDC framework, it maps well to a hospital’s concerns — Safety (patients and caregivers), Quality (of care and of service), Delivery (avoiding delays and ensuring the right care is delivered), and Cost. Most everyone has been aware of the increasing costs of healthcare – the general public is recently becoming more aware of the patient safety and quality risks they face in a hospital. And these are all problems that can be address with Lean.

One interesting (and I think positive) development is the trend for Medicare/Medicaid (now followed by private insurers) to NOT pay for preventable medical errors. Traditionally, healthcare has been a “piecework” pay structure — if you did work, you got paid for it. So even if a patient got a bedsore (due to lax care) or suffered from some other preventable medical error, the hospital could submit for reimbursement to cover the care that shouldn’t have been needed – if care had been provided right the first time. I think this is a step in the right direction – creating more of a financial incentive for quality… although it’s somewhat sad that quality requires incentives. The incentives are right, in theory, but we also need to provide hospitals with a METHOD for actually improving quality, something more than demanding that people “be more careful”.

Do you find cultural issues relating to continuous improvement and change in general in healthcare?

It’s been very interesting. On the one hand, the types of waste, the mindset, the management issues were all eerily familiar as I moved from manufacturing into healthcare. You have hospital cultures that tend to think batching is the most efficient way of doing work. Hospitals tend to fall in love with automation and information technology as a single bullet solution as much as factories — with similar disappointments and results. The most important cultural factor is basic relations between employees and management. My heart sank the first time I heard a skilled hospital professional complain “Nobody ever asks me what I think… I’ve been turned into a robot” (and that had NOTHING to do with automation). Non-Lean hospital managers have to unlearn some of the same bad habits that factory managers struggle with — you have to get out to the Gemba, you have to ask why instead of blaming people, and you have to get everybody involved in kaizen, instead of relying on top-down decision making and control. Now, the one HUGE advantage that hospitals have is the orientation around serving patients. Even if people have gotten a bit crusty over time, most people went into healthcare to take care of people. There’s a huge intrinsic motivation that you can tap into that I never saw in a place that made widgets. If you can orient people around Lean being incredibly good for patients AND the employees, you can go far with Lean in a hospital.

Why are so few healthcare providers implementing continuous improvement/lean?

To some extent, there’s the “we’re different” factor. Something that’s viewed as just a factory toolkit will get resistance from hospitals. But when Lean is understood as a philosophy and a management system — it makes sense. There are enough great examples out there now – ThedaCare, Virginia Mason, Avera McKennan — hospitals that are transforming their management system and the entire organization …. these aren’t hospitals that are just dabbling with Lean tools. I think the “Lean doesn’t apply to us” argument doesn’t hold water anymore. The things that interfere with Lean adoption in hospitals are the same dynamics that we face in manufacturing organizations — a lack of willingness to change from executive level, supervisors and managers not wanting to give up control of the workplace, people being measured on their own department’s budget and results instead of overall system effectiveness…. hospitals are, at a detailed level, just another workplace – people doing work, fighting systems that often don’t serve their needs, and people who manage those people — many of the challenges across hospitals and factories are just human nature.

You have written a book, “Lean Hospital” could you tell us about it……….

Certainly…. It’s called Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction (you can get more information at … after having a successful blog for three years, I was referred to Productivity Press, who asked me to write an overview book about Lean in hospitals. I was able to draw on my own experience as well as my colleagues and other clients of the firm I work for, ValuMetrix Services, as well as other hospitals that cooperated and shared their stories. The book is written as more of “why lean?” and “what is lean?” book more so than a detailed implementation guide. My book shares many examples of hospitals and departments who have made great improvements with Lean methods – laboratories, pharmacies, operating rooms, emergency departments, and more. I also try to define Lean in a way that hospitals can relate to, using their own examples and terminology, but without trying to change the essence of what we know Lean and the Toyota Production System to be. I do cover some of the Lean tools, such as kanban, standardized work, error proofing, and 5S, but I try to frame those tools in the philosophy and the management system of Lean. I wanted this to be the type of book you could hand to a hospital CEO or manager who knew little or nothing about Lean – the type of book that could motivate them to take action in their own hospital. I mean books are fine… I obviously like books… but we won’t gain much as a society if we have learning without action. There’s a huge opportunity to improve the quality of patient care — without spending tons of money… with Lean we truly can have better quality at a lower cost… we all deserve as much.

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