1. Gould, Kathleen Ahern PhD, MSN, RN

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Gabow P, Goodman P. Boca Raton, FL: Taylor and Francis Group CRC Press; 2015.


This is an essential book for everyone involved in health care today! As I read it, I realized that it must be introduced in every classroom where we are preparing the new health care workforce and used as a guidebook for every leadership team currently practicing in health care. Its utility for transformational work in health care is endless.

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This is a solutions-based book, introducing Lean as a discipline, grounded in years of experience as the authors share their 7-year journey at Denver Health.


During this time, Dr Patricia Gabow served as chief executive officer and Philip Goodman was the director of Lean Systems Improvement. Gabow and Goodman generously offer a comprehensive look at how Lean thinking, and leadership based on Lean methods, changed a struggling organization. This work transformed Denver Health into a model system to eliminate waste, cut cost, engage employees, and improve patient care. However, this was no overnight success; it required almost a decade of hard work. The book chronicles their journey, adding historical perspectives, clinical examples, and lessons learned. Their struggles and triumphs provide inspiration and how-to examples of Lean principles in action, in essence, road maps for all of us who struggle to improve care and move health care forward.


As health care systems throughout the United States struggle to achieve the "Triple Aim," described by the Institute for Healthcare Improvement as: better care for individuals, better health for populations, and lower per-capita coast, this text serves as a blueprint toward this goal. Dr Don Berwick's words in the Foreword of this text speak volumes, "Here in these pages-and in Denver Health's story-is as close an approximation to the Tripe Aim in progress as one can find in America."


As Berwick suggests, the Triple Aim is the driver for all improvement work. Lean is a strategy that will get us there.


This book is a comprehensive guide, introducing the concepts and language of Lean systems, Lean tools, and Lean strategy-organized to create a different health care system. Gabow and Goodman clearly articulate Lean philosophy and simply explain why this is a great approach for health care in 4 statements: (1) it is a noble philosophy, (2) it has a robust tool set, (3) it is an easy-to-learn approach, and (4) it is an enabler of cultural transformation.


Although Lean systems evolved from Japanese automakers at Toyota, it is a perfect fit for health care. Gabow and Goodman explain that Lean philosophy reflects health care core values. Lean is built on 2 pillars: respect for people and continuous improvement. In this structure, workers are empowered to use their talents and knowledge to improve processes through initiatives such as Rapid Improvement Events (RIEs). The book describes how RIE methodology turns hierarchy systems on their head! I love this description, as the traditional hierarchy in health care has not brought us to where we need to be.


Using a Lean prescription, employees are taught to view every situation using a Lean lens, searching for waste, as they begin to appreciate the linkage between lower cost and higher quality. The 14 Toyota principles are translated into working concepts and tools, complete with examples that translate the principles into health care situations. One of my favorite sections is the Lean Toolbox, presented in a comprehensive table that provides a basis for action in logical sequence. For example, always begin with a "True North" statement before jumping into a project, then 7 tools for seeing waste precede the 11 tools for eliminating waste. The table highlights the strategy and the logistics that are required when incorporating Lean into a system. Examples of a "waste walk" and creating of things such as spaghetti diagrams are familiar, currently used by quality improvement teams in many hospitals.


The text provides examples and tools to begin or expand the process in all health care settings. The authors understand that, for many, Lean is still a new way of thinking, and it must be taught. They share methods used in the Denver Health Lean Academy. These include workshops and team training as well as individual programs such as Denver Health Lean Black Belts, beginning with 25 individuals and, over time, training 300. One example tells about a joint project led by a black belt from respiratory therapy and a black belt from pharmacy to identify problems associated with the use of inhalers prescribed for patients with reactive airway disease. Multiple inhalers were often dispensed to the same patient during hospital stays (averaging 4.2 days), even through each inhaler provided enough doses for about 1 month. Within the first year of the project, pharmacy cost for these items was reduced by 72%.


The book includes practical exercises and clinical examples of Lean philosophy that have been applied to successful projects. In a chapter titled Deploying Lean, the exercise tells the reader to start the Lean journey with the organization-wide 5S. Even if you are already on a journey, do an organizational 5S. Reminding readers: This is a foundational to Lean and cannot be skipped. The 5S system can be used to eliminate waste and organize a department, storage area, or patient care area. Briefly they are: sort, set in order, shine, standardize, and sustain-a sixth S could be added for safety. One exercise suggests going into your office to practice organizing using the 5S method. In manufacturing, the 5S focuses on physical space, but in health care it can have broader implications.


A final chapter is devoted to metrics: measuring, reporting, and archiving data, but in Lean thinking, it is not just statistics. It reflects 3 types of evaluation: financial, quality, and human development. These metrics align the organization and cascade goals from the leadership level to all frontline staff engaged in RIEs. This section guides teams in reporting, documenting, and archiving data as it explains the value of each step.


Gabow and Goodman offer realistic advice; all changes, especially transformative change, take time and patience. A timetable outlining their journey reminds us that you don't get Lean, you become Lean.



Rosen P. September 8, 2014. Accessed on October 29, 2014.


TED is a model framework for sharing new ideas; it does an excellent job introducing innovative ideas and speakers. It is Internet sharing at its best. Now, TEDx is offered as a mini TED TALK. It is still an international community that organizes TED-style events anywhere and everywhere, but now, a new format allows us to celebrate locally driven ideas and elevate ideas to a global stage using a YouTube platform.

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TEDx events are produced independently of TED conferences, selecting speakers independently, but still conforms to TED's format and rules, but often community based and self-organized. This format allows small group discussion and increases participation. These local events are branded as TEDx. Recently, Dr Paul Rosen spoke at a TEDx event discussing clinical experiences that challenge us to think about empathy.


Rosen tells us that emergency delays are a solvable problem. One example is that of early morning (4 AM) blood draws, often a sacred ritual, a throwback to the days when laboratory work took hours to process. Yet, is this in the best interest of the patient[horizontal ellipsis] waking them up to serve our outdated schedule? He challenges the audience to change this practice; the applause is enthusiastic! And, I wonder[horizontal ellipsis] so simple, another sacred cow we cannot let go of.


He also talks openly about burnout, still a common problem in health care. Are we considering what the patient is feeling, or how our colleagues are feeling? He asks: Is our culture driving empathy out of our practice? How are we caring for each other and supporting the work of our colleagues? Burnout, he says, is a barrier to empathy. If we can focus on the patient experience, we will all feel better about the work we do. Things such as delays frustrate all of us; however, many delays are the result of solvable problems. Procedural pain, fear, and anxiety can be addressed in many ways, and it should be our goal to prevent these things before they occur. He remembers a laboratory technician who wrapped the tourniquet around his shirt sleeve, saving him from the discomfort caused from pinching of skin with the rubber device rubber. This small act of kindness, deliberate and empathic, made the venipuncture almost painless.1


He reminds us what it feels like when we get things right. It is usually translated in words such as "the staff really listened to me," "my medical team saved my life," "my nurse really cared about me." When we fail, our patients feel rushed, voiceless, interrupted, and forgotten.


Paul Rosen, MD, is a pediatric rheumatologist, serves as the clinical director of Service and Operational Excellence at Nemours. He received a master's degree in public health from Harvard University and a master's degree in medical management from Carnegie Mellon University. He was named "One of the First 100 Innovators" by the US Federal Government Agency for Healthcare Research and Quality.


He challenges us to put patients first and change the culture of health care, making sure empathy is at the core of our practice.


The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.