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    Jessica A. Stellmaker
    Jessica A. Stellmaker
    Michelle R. Nordland
    Michelle R. Nordland
    Jeffrey R. Leland
    Jeffrey R. Leland, MA
    Ronald Menaker
    Ronald Menaker, EdD, MBA, FACMPE
    Nicole Bennett Engler
    Nicole Bennett Engler, MA

    All healthcare leaders are acutely aware of the major challenges faced by healthcare organizations: an aging society, increasing healthcare costs, dwindling reimbursement rates and access to quality patient care. To address these challenges, efforts to improve safety and quality in healthcare are needed.

    Healthcare organizations have utilized various methods to improve safety and quality for decades, stimulated by the publication of To Err Is Human and Crossing the Quality Chasm by the Institute of Medicine 20 years ago. Most U.S. hospitals joined the Institute for Healthcare Improvement 100,000 Lives campaign in 2005-2006 to improve care and reduce needless patient deaths.1 Many hospitals launched cross-functional project teams to address quality issues to quickly improve patient care. This project-based approach often has limitations due to a narrow focus on tasks, tools or operational aspects of the project, and fails to take the more holistic or system-wide view necessary for continuous improvement.2,3 If project-based organizations focus on the end of projects, they may not learn from and between projects and thus not share experiences continuously.4 

    In contrast, many healthcare organizations use a systematic approach to continuous improvement using Lean principles and methods. Lean management principles originated in manufacturing at Toyota Motor Corporation, with the goal of developing people while manufacturing automobiles.5 Lean principles recognize the need for frontline staff engagement versus traditional, top-down directed projects to improve daily work.

    Since the early 1990s, Lean principles have been successfully applied in many hospitals to achieve results.6 A top-down, command-and-control approach limits employee engagement and commitment, promotes resistance, and can prevent virtually any chance for success.7 Lean is a thinking process more than a list of tools, and can be used as an effective methodology to improve patient safety and quality, reduce costs and boost employee satisfaction.8 It is important to instill Lean behaviors in managers at all levels to sustain a culture of continuous improvement.9,10

    Principles of a Lean culture

    There are several principles upon which Lean culture is built:

    • Establish a true north. This compass guides all staff with the organization’s philosophy and metrics that measure what matters most — and aligns everyone in the organization with that philosophy. Every decision should be made based upon an organization’s purpose, and that purpose should be greater than money.11
    • The right process will produce the right results. Create flow to link processes:
      • The system and people together
      • Pull just-in-time work that needs to be performed at patient demand
      • Reduce waste
      • Level the workload
      • Build quality into the process
      • Build a culture willing to stop to fix problems as they arise
      • Standardize all tasks
      • Build a foundation that promotes continuous improvement and employee empowerment
      • Implement visual controls and use technology that only serves your people and processes.12
    • Develop your people. People — not organizations — deliver results. Grow leaders and teams from within who understand the philosophy and are guardians of the culture — those who live and apply the behaviors that enable the culture to grow and work for the company. Teamwork, humility and empathy are all engrained, and empowerment is growth.13
    • Continuously explore and solve the root cause of problems. Executives, managers and frontline staff directly see the work to understand what is happening to collaboratively solve problems.14 Continuously improving the processes, eliminating waste and ongoing reflection are part of the daily Lean culture that drives organizational learning and excellence.

    Lean and change management 

    Embedded in Lean is a culture of change stemming from the leaders who empower and support their staff to continuously improve their daily work. This culture embraces the belief that change is good; change that is tested by the people performing the work is expected and accepted. As part of this, leaders regularly observe the work unit through a Gemba walk. In Lean, Gemba refers to “the place where value is created.” By regularly observing the work unit, leaders provide coaching that is crucial to building and sustaining the Lean culture.15 Rather than offering solutions, it is vital that leaders show respect to employees; listen to, understand and learn what is happening; and ask humble, thought-provoking questions that prompt employees to think systematically. The objective of coaching and auditing the standard work is to help identify waste, understand value streams and observe gaps. Change that reduces chaos and waste and improves processes builds consensus and reinforces sustainability.

    Four pillars of our Lean management system

    Lean systems provide a framework that is supported by pillars of core principles practiced throughout the entire organization. In our academic medical center’s radiology department, we chose four pillars from industry-wide standards to guide the implementation of our Lean system: alignment, visual management, systematic problem-solving and standardization.16 Each pillar has tools, behaviors and principles that strengthen the Lean culture, and all the elements reinforce one another.

    Pillar 1: Alignment

    The goal is to create an aligned organization based on the true north of organizational philosophy and desired outcomes. Rather than a top-down process with decisions driven by leaders without involvement of frontline employees, alignment in Lean includes all the individuals who live the culture, continually learning and innovating together to add value for the customer. This alignment starts with organizational leaders and involves everyone, with a drive to develop people and promote from within.17

    Pillar 2: Visual management

    Visual controls are any communication device that can illustrate at a glance how the work should be performed and whether there is deviation from the standard.18 Just-in-time information is key to successfully improving the workflow. This is accomplished using visual aids illustrating where items belong, how many items are needed, the standard operating procedure, or the status of work in progress. This creates a transparent and waste-free environment that improves productivity, facilitates communication and provides staff with the best opportunity to succeed.19

    Pillar 3: Problem-solving

    To empower problem-solvers, one must empathically listen and ask open-ended questions. One cannot underestimate the power of coaching and humble leadership, resulting in others feeling comfortable opening up and exploring new ideas and thoughts.20 In our practice, we found coaching to be the foundation to A3 thinking, which is a scientific approach to problem-solving that enables teams to systematically solve problems.21 In addition, it is important to have a culture in which leaders feel comfortable taking credit for errors in the system and working collaboratively with others to find solutions. Teams learn to gather and use data to understand what is happening and where gaps are occurring, and to identify root causes and best countermeasures based on facts to eliminate problems and meet goals. Structured A3 thinking is used to enhance communication and solve problems and can also be used as a management system to plan, innovate, and build operational structures. 

    Pillar 4: Standardization

    An inefficient process can foster mistakes; a good process that incorporates standardized tasks allows people to be more efficient and successful.22 Standardized tasks are the foundation for continuous improvement, innovation and employee empowerment. Standard work is the time required to complete one job, the sequence of tasks performed, the amount of inventory needed, and the essential level of quality that must be built into the process. Standards must be specific enough to be useful guides yet allow for flexibility. People conducting the work should systematically develop and improve the standards, allowing them to control their own work and establish accountability.23 Leaders also have standard work, which is a set of behaviors and recurring activities that advances a Lean thinking culture from the leadership level.24

    Case study: CT radiology

    To illustrate implementation of a Lean culture, we utilize our CT radiology experience as a case study highlighting how the pillars guided the steps of the process and addressed the metrics that were measured.

    The catalyst for change included increasing patient wait times, exam access issues, and low staff satisfaction scores. We had the “why” we needed to get started; changing to a Lean mindset provided the “how” to accomplish it in a complex practice setting with more than 200 staff. The change required multiple steps, which we termed CALM: CT Actualization of Lean Management (Figure 1). Through changing our management mindset, examining the current condition, determining the root causes of issues and establishing targets, we were able to work through an implementation plan that produced positive results.

    In our first step, departmental leaders identified the values and goals our organization should embrace and pursue. The resulting true north was simple, yet impactful:

    Empower everyone: Empower staff to improve the work they perform every day to ensure our patients have the highest quality, most efficient care.

    This provided alignment at the leadership level, which was extended to the frontline staff, building synergy to embrace a new way of problem-solving. When meeting with physicians, nurses, desk operations and other operational areas within the practice, our message was clear: patients and people first; outcomes second. We understood that successful people feel motivated to work and change and we aimed to empower everyone to be the change that they wanted to see within CT radiology.

    Following alignment, the next step was developing and educating leaders and frontline staff in Lean. Our CALM program utilized a two-pronged approach for each meeting:

    • Lean education: Lean principles, A3 thinking, coaching skills, leader standard work, improvement systems, Gemba, standard work, etc.
    • Application of Lean: Role playing — asking probing questions starting with “how” and “what” as opposed to “why.” Practicing and applying the skills just in time.

    Utilizing the pillars of problem-solving and visual management, we used A3 thinking to guide our leaders to better understand root causes of organizational problems — including lack of standardization and adequate communication among groups, firefighting individual issues rather than continuous process improvement, and lack of staff engagement — to be part of the solution. Visual management tools were essential, and we learned the best approach was to keep it simple with only the key information presented in a clear way. A “vital few” electronic dashboard of graphs including year-to-year exam volumes, exam access timing, and percent of on-time exams provided a baseline to understand our current condition and facilitate identifying issues to solve. To centralize key daily information, huddle boards were implemented as an important visual tool utilized in every work area of our department (Figure 2).

    These boards created a single stop for employees to understand at a glance what was happening. Our boards are standardized across the practice and are broken down into the three Rs: Reflection, Readiness and Recognition. Our goal is to reflect on yesterday, be ready for today, and recognize contributions of staff. Included on huddle boards are daily metrics of exam volumes and percent of on-time exam starts, daily staffing, and other important information that enhances staff engagement.

    To further enhance problem-solving, we instituted an improvement system (Figure 3) in each CT area to empower frontline employees to become problem-solvers and engage in continuous improvement. Staff were encouraged to complete Kaizen cards to suggest ideas that were openly shared. The visual process of showing ideas being acted upon or currently on hold created transparency with all team members and built trust as staff ideas were heard and acted upon.

    In establishing a Lean approach to problem-solving, leaders were taught to work closely with staff and to coach problem-solving through structured conversations, which in turn empowered staff to improve their daily work. We recognized that a root cause of process issues was lack of standardization. To address this, standardization was segmented into two categories: leader standard work and frontline standard work. A significant shift involved instituting leader standard work consistent with Lean, which in our clinical CT environment include the following:

    • Physically observe the work unit to understand the process (Gemba walk)
    • Audit standard work to ensure consistency in processes
    • Update daily metrics for monitoring performance
    • Attend huddles to enhance communication
    • Attend improvement system meetings to continuously improve the practice.

    This shift to Lean management resulted in leaders spending dedicated time on the floor with employees, seeking to understand, humbly asking questions, and following through on action items. Employees reaped the benefits of this process, which created transparency in expectations, increased synergy as frontline staff engaged with their leaders daily, and more importantly, allowed employees to feel valued knowing their voices were heard.

    The next step was creating standardization of all roles within our department, from nursing to desk operations. Leaders utilized coaching — not to be restrictive or burdensome — but rather to create standards that enabled all team members to be successful. In the end, seeking to understand comprehensive workflow variations and defining a standard process resulted in numerous benefits: clear expectations of roles and tasks for all employees, reduced errors, improved collaboration and teamwork, and less training time for new employees. Our patients also benefited from our standardized work through improved on-time starts and reduced waiting times in pre- and post-assessment areas.

    To ensure sustainability of our standard processes, leaders were expected to consistently spend time on the floor. Our mantra was, “auditing was about the process, not the people.” If standardized workflows were not being followed, we sought to understand the reason, and either helped remove barriers or coached employees to follow the process. Above all, audits were about creating trust within the team without finger pointing or recriminations. It was simply about working toward our goal: Empower everyone.

    Case study outcomes

    Our department realized a multitude of improvements by utilizing the Lean process, which resulted in improved outcomes and increased patient and staff satisfaction. The ideas brought forward by frontline staff to improve issues of standard workflow were key. Among the improvements were results that addressed the issues that were the catalyst for change:

    • Outpatient on-time starts: The percent of outpatient exams on the table within 15 minutes of scheduled appointment increased from 44% to 85%.
    • Lead time (process time + wait time): The percent of lead time decreased from 148 to 48 minutes, or 68%.
    • Staff satisfaction: The percent of staff satisfaction increased from 41% to 84%.

    Process improvements benefiting the patient can also result in positive financial results for the organization, including reduced costs. Though increasing revenue was not a goal, the Lean management system allowed for efficiencies and incremental CT exams, which increased revenue by $3 million per year.

    Lessons learned 

    By embracing a Lean management system, we provided closer alignment with our true north by empowering staff to improve the work they perform every day to ensure our patients have the highest quality, most efficient care. Nearly two years later, we have implemented more than 100 process improvements brought forward by frontline staff who felt empowered to identify areas of improvement. Each of these process improvements enhanced the care of our patients.

    In our continuous journey of implementing a Lean culture, we have learned:

    • Stay true to established Lean principles
    • Coaching is essential in building Lean leaders and is needed at the forefront of a Lean journey
    • It is essential to find physician leaders who want to be engaged
    • Timing is everything — right time, right leaders
    • Empower everyone — a culture that empowers its people will grow and innovate
    • Model the desired behavior — every day.
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    1. Baehrend J. “100,000 Lives Campaign: Ten Years Later.” Institute for Healthcare Improvement. June 17, 2016. Available from
    2. Anderson K. Learning to Lead, Leading to Learn: Lessons from Toyota Leader Isao Yoshino on a Lifetime of Continuous Learning. Integrated Press, 2020.
    3. Backlund F, Sundqvist E. “Continuous improvement: challenges for the project-based organization.” International Journal of Quality and Reliability Management; 35(7), 1,306-1,320. Available from:
    4. Ibid.
    5. Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. McGraw-Hill, 2004.
    6. Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, 3rd ed. CRC Press, 2016.
    7. Anderson.
    8. Graban.
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    10. Mann D. Creating a Lean Culture: Tools to Sustain Lean Conversions, 3rd ed. CRC Press, 2015.
    11. Liker.
    12. Ibid.
    13. Balle M, Balle F. Lead With Respect: A Novel of Lean Practice. Lean Enterprise Institute, Inc., 2014.
    14. Anderson.
    15. Balle and Balle.
    16. Cleveland Clinic Improvement Model (CCIM). Cleveland Clinic. Available from
    17. Liker.
    18. Balle and Balle.
    19. Liker.
    20. Anderson.
    21. Shook J. Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor and Lead. Lean Enterprise Institute, 2008.
    22. Anderson.
    23. Liker.
    24. Schwarz S. “The Power of Leader Standard Work.” EON Solutions. June 23, 2021. Available from
    25. Hurle.
    Jessica A. Stellmaker

    Written By

    Jessica A. Stellmaker

    Jessica A. Stellmaker, quality analyst, Mayo Clinic, Rochester, Minn., can be reached at

    Jeffrey R. Leland

    Written By

    Jeffrey R. Leland, MA

    Jeffrey R. Leland, MA, is a former operations manager, Mayo Clinic, Rochester, Minn.

    Ronald Menaker

    Written By

    Ronald Menaker, EdD, MBA, FACMPE

    Ronald Menaker can be reached at

    Nicole Bennett Engler

    Written By

    Nicole Bennett Engler, MA

    Nicole Bennett Engler, MA, operations manager, Mayo Clinic, Rochester, Minn., can be reached at

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