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Medical educators must begin teaching tomorrow's doctors to become much better at creating, improving, and managing processes and systems.


The agonizingly slow flow of patients through a hospital's units from admission to discharge can cause delays in treatment, medical errors, and poor outcomes. Lean can simplify, streamline, and optimize patient flows for optimal productivity, profitability, and patient outcomes, effectively eliminating the bottlenecks without adding resources.

If you've ever been to London and ridden on the famous Underground, you've probably seen signs: "Mind the Gap" (Figure 2.1). While the signs are designed to keep travelers from wrenching an ankle, I believe that the idea also applies to Lean thinking.


Here's what I mean: hold up your hand and spread your fingers wide apart. What do you see? Most likely you're first drawn to look at your fingers, not the gaps in between them. This is how most people look at process improvement—by looking at the people working, not at the gaps between people.

When you take your eyes off the employees and put your eyes on the patient, product, or service going through the process, you quickly discover that there are huge gaps between one step in the process and the next. You'll discover work products piling up between steps, which only creates more delay—a bigger gap.

Your turnaround-time problems are in the gaps, not the fingers. You can make your people work faster, but you'll find that this often makes you slower, not faster, because more work piles up between steps, widening the gap, not narrowing it.


The other sign you often see in the London Underground is a tube map (Figure 2.2). While it is much more interconnected than a typical value-stream map, you'll notice that the stations are quite small and the lines between them quite long.


London Underground map.

This is true of most processes: the time between stations is much greater than the time actually spent in the stations. As this map suggests, 95 percent of the time is between stations, not in them. If you want to reduce the time it takes to serve a patient, you have to mind the gaps.


At the American Society for Quality World Conference, I talked with two representatives from Botswana. They use the tools of Lean to mind the gap and reduce the response times of the police. They are using the benchmarks ...

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