On the Mend

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Revolutionizing Healthcare to Save Lives and Transform the Industry


ISBN: 978-1934109274

Published: June 2010

Author: Emily Adams, John Toussaint, Roger Gerard

Pages: 181

Publisher: Lean Enterprise Institute


On the Mend

Revolutionizing Healthcare to Save Lives and Transform the Industry

About the book

Part case study, part manifesto, this groundbreaking new book by a doctor and a healthcare executive uses real-life anecdotes and the logic of lean thinking to make a convincing argument that a revolutionary new kind of healthcare — lean healthcare — is urgently needed and eminently doable.

In On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry John Toussaint, MD, former CEO of ThedaCare, and Roger A. Gerard, PhD, its chief learning officer, candidly describe the triumphs and stumbles of a seven-year journey to lean healthcare, an effort that continues today and that has slashed medical errors, improved patient outcomes, raised staff morale, and saved $27 million dollars in costs without layoffs. Find out:

  • How lean techniques of value-stream-mapping and rapid improvement events cut the average “door-to-balloon” time for heart attack patients at two hospitals from 90 minutes to 37.
  • What ThedaCare leaders did to replace medicine’s “shame and blame” culture with a lean culture based on continuous improvement and respect for people.How the lean principle of “building in quality at the source” broke down divisions among medical specialties allowing teams to develop patient care plans faster.
  • Why traditional modern management is the single biggest impediment to lean healthcare.
  • How the plan-do-study-act cycle coupled with rapid improvement events cut the wait time at a robotic radiosurgery unit from 26 days to six.
  • How the lean concept of “one piece flow” saved time in treating ischemic stroke patients, increasing the number of patients receiving a CT scan within 25 minutes from 51% to 89%.
  • How senior leaders at other healthcare organizations can begin their own lean transformations using a nine-step action plan based on what ThedaCare did — and what it would do differently.

Toussaint and Gerard prove that lean healthcare does not mean less care. On the Mend shows that when care is truly re-designed around patients, waste and errors are eliminated, quality improves, costs come down, and healthcare professionals have more time to spend with patients, who get even better care. Get your copy of this important new book today.

About the authors

John Toussaint, MD

John is the founder and CEO of the ThedaCare Center for Healthcare Value. As the Center’s founder and president, John has the experience and passion to be a driving force in creating healthcare value. From 2000 to 2008, he served as president and chief executive officer of ThedaCare, Inc., a community-owned, four-hospital health system including twenty-one physician clinics, as well as home health capabilities, senior care facilities, hospice care, and behavioral health. ThedaCare is the largest employer in Northeast Wisconsin with nearly 5,400 employees, serving an eight-county region.

During his tenure as president and CEO of ThedaCare, John introduced the ThedaCare Improvement System (TIS), which is derived from the Toyota Production System. This model of continuous improvement helped save millions of dollars in healthcare costs by reducing patient errors, improving outcomes and delivering better quality care at a higher value.

Roger Gerard, PhD

Roger is the Chief Learning Officer for ThedaCare, a N. E. Wisconsin-based integrated healthcare delivery system. He has been with ThedaCare since 1991, when ThedaCare was called Novus. Roger has a career history that includes primarily significant work within the healthcare industry. However, he has also spent a quarter of his career in manufacturing and service industries nationwide. He specializes in executive and management development, process improvement, and the use of lean methodologies in bringing about significant and measurable organizational improvement. In addition, he has his own management consulting business and creative photography/illustration business that he shares with his wife, Debra.

Roger has over 35 years of experience leading executive and management development initiatives, in both large and small organization environments, focusing specifically on organizational performance improvement processes. He has presented at numerous national conferences (most recently at the Association for Manufacturing Excellence on lean in the healthcare industry), and locally throughout Wisconsin and Michigan. Roger is a member of AQP, ASQ and OD Network. He earned his PhD in Management and Applied Decision Sciences from Walden University in 2001.

Emily Adams

Emily is an award-winning journalist and writer who has developed an expertise in writing about lean transformations, among other topics. She can be found at byemilyadams.com.

Author Q&A

A conversation with John Toussaint, MD, and Roger A. Gerard, PhD, authors of the book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry

Q: Lean originated in manufacturing; how does it apply to healthcare?

Like lean manufacturing, lean healthcare strives to increase value to patients by taking the waste out of processes and improving quality. Nationwide, there is a growing emphasis on continuous quality improvement, cost reduction, and increased patient value — the same type of principles originally applied in manufacturing.

Manufacturers that have diligently and thoroughly applied lean thinking have reaped steady productivity gains while reducing errors and improving the customer and employee experience. Imagine the results that similar improvements could bring in healthcare.

Q: What is lean healthcare?

A lean approach to healthcare involves the application of lean thinking to the process of care delivery — whether in hospital rooms, clinics, operating rooms, pharmacies, emergency rooms or outpatient centers.

It stems from a belief that the solution to delivering better care isn’t only about having electronic health records, more insurance coverage, or more advanced technology. Instead, lean healthcare focuses on fundamental improvements that systemically identify and eliminate waste, leading to improved quality, cost, and patient value.

Q: Why is lean healthcare necessary?

The quality of U.S. healthcare is uneven at best. Best practices, evidence-based guidelines, and new technologies are not widely and quickly adopted. The current system creates more waste and errors than value.

At the same time, we continue to be plagued by medical errors, and more and more U.S. companies find it hard to compete in a global marketplace due to rising healthcare costs. These issues, combined with specific concerns at individual organizations, create the burning platform that lean leaders can use to push for change. Lean healthcare helps spread the industry’s best ideas for creating patient value and accelerating much-needed improvement.

Q: What’s the significance of the book’s title?

It’s no secret that U.S. healthcare could be improved. While there’s plenty to be proud of, we continue to make grievous medical errors and create waste that puts patients at risk. Lean healthcare has the potential to revolutionize our system for the better. It is a way to take healthcare away from its current “sick” state and ensure that care delivery is “on the mend.”

Q: What are the attributes of a lean leader?

Healthcare won’t change unless people — beginning with industry leaders — start to think differently about their work. Lean leaders need to adopt a philosophy of continuous learning. They must be inquisitive and have a true desire to problem-solve.

The best leaders also act as mentors. They should be patient with colleagues and staff who might be struggling to learn or embrace lean. In order to build momentum for a cultural transformation, lean leaders must be skilled communicators and put themselves in the middle of the action (at the patient bedside) instead of remaining behind their desks.

Q: What are the basic components of the 9-step plan outlined in the book?

On the Mend proposes 9-steps that will help healthcare organizations begin a lean transformation:

  • Identify the crisis
  • Create a lean promotion office
  • Find change agents
  • Map your value streams
  • Engage senior leaders early in strategy deployment
  • Acquire and disperse knowledge broadly
  • Teach a man to fish (or, become a mentor)
  • Involve suppliers in lean
  • Restructure your organization into product families

Another rule to remember when implementing lean: Don’t let anything stop you. You must continue to move forward, even if you do not yet know the best metrics to portray your success.

Q: What’s next?

The goal of On the Mend is to introduce the idea of lean healthcare and demonstrate how one particular organization implemented lean principles to achieve success. We are currently planning two additional books that examine healthcare policy and lean tools in further depth. These books will provide detailed guidelines to help individual healthcare organizations begin their own lean journeys.

Praise for the book

“Everyone interested in medical care should read this book. It describes a way to markedly improve outcomes from medical care interventions, while simultaneously reducing costs.”

“The ideas practiced at ThedaCare in Wisconsin should be adopted across the country. If they are, it will be easy to afford financial access for every citizen, because we will reduce national medical care spending by hundreds of billions of dollars per year, while improving outcomes.”

Paul H. O’Neill, former Alcoa CEO and U.S. Treasury Secretary, and co-founder of the Pittsburgh Regional Health Initiative

“I avoid reading business improvement books. I made an exception because this one came from ThedaCare, one of the 2 or 3 US health care organizations that consistently score at the top of national and regional rankings on BOTH quality and affordability.”

“In On the Mend, John Toussaint and Roger Gerard explain simply, clearly and briefly how it was done. They use story-based prose. It can be read in a single day by a high school graduate. Its sweet logic and instant digestibility resonate with the book’s topic – how to deliver more patient benefit with less time and fewer resources.”

“Worried that reaching the top of national rankings on quality and affordability is unattainable by ordinary mortals? Read this book in one day. Then ask your organization’s most senior physicians, most junior clerks and everyone in between to read it. Your journey will have begun.”

Arnold Milstein, MD, Professor of Medicine and Director of the Clinical Excellence Research Center at Stanford University

“We need health care that is sustainable and excellent – both. That will require rethinking our work and redesigning our systems of care boldly and guided by proper theory. These authors are masters of the change we need; under their guidance, ThedaCare has become a bright spot in the landscape of American health care. Their work and this book show that lean thinking and true patient-centeredness are not just compatible; they are, at heart, the very same thing.”

Donald Berwick, MD, MPP, FRCP, founder and former President and CEO of the Institute for Healthcare Improvement

“The USA is twisted in knots debating health care payment reform, afflicted as it is with a system that is compromised in quality, affordability, and access. But for all the talk, changing payment schemes promise nothing but zero sum tradeoffs. The real potential for win win improvement is at the provider level–adoption of more sophisticated approaches to managing the delivery of care so far more value is created while requiring fewer resources and less effort.”

“John Toussaint, as former CEO of ThedaCare, has demonstrated how this is done, and if his organization’s approach and results were replicated nationally, we would be having health care surplus, not crisis.”

Steven J. Spear, Author of The High-Velocity Edge: How Market Leaders Leverage Operational Excellence to Beat the Competition, Sr. Lecturer at Massachusetts Institute of Technology, and Sr. Fellow at the Institute for Healthcare Improvement

“ThedaCare has become a national leader at delivering measurably better value to its patients. This book is a practical tool for any health care leader to create better patient value in health care, and begin the real process of health care reform.”

Michael Porter, Author of Redefining Health Care

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Additional information

Weight 0.6 kg

Lean Enterprise Institute