Lean Health Care: The Success of a Toolkit Depends Also on the People Who Use the Tools

To the Editor:
It is encouraging to observe the growing interest in developing lean health care systems, though in our view the current literature demonstrates only a partial understanding of what a truly lean health care system might look like. Although we agree with Ackerman et al1 that cultural change and whole-system optimization are vital, we suggest that it is precisely these considerations that underpin the lean philosophy. Of the 14 principles of the Toyota Production System identified by Liker,2 half directly address the management of process flow; the rest are concerned with long-term philosophy, respect for people, and organizational learning. There are dangers in seeing lean as a tool, or even an adaptable toolbox, because this distracts attention both from the values that lie at the core of the Toyota Production System and the coherence of the lean philosophy. Although methods might change, principles remain constant