Management on the Mend

ThedaCare Center for Healthcare Value (2015)

While studying and assisting hundreds of organizations transitioning to lean healthcare, Dr. John Toussaint witnessed many flaws and triumphs. Those organizations that win—creating better value for patients while removing waste and cost in the system—have senior managers that lead by example at the frontline of care. The best health systems have also discovered ways to engage everyone in solving problems and embracing change.

Management on the Mend is the result of years of investigations by Dr. Toussaint and dozens of healthcare organizations around the world. Using their collective experiences, he has built a model for lean transformations that work. This book describes the model, step by step, through people in 11 organizations who are doing the work. It is the story of many journeys and one conclusion: lean healthcare is not only possible, it is necessary.


All Tish wanted was a little less winter. The cold Midwest was hard on her scoliosis and arthritis plagued her nights. Sleeping pills helped some, but what she really needed was sunshine and warm, balmy nights. So she and her husband of more than half a century, Ted, went south.

A few weeks into their stay in a Florida condo, Tish started coughing. She coughed so long and hard she was nauseous and feared pneumonia. At the immediate-care clinic, a doctor prescribed an antibacterial drug and steroids for what was probably a nanovirus and told Ted to take her home to rest. But Tish could not keep the pills down and her coughing got worse. They called the doctor, but he never called back.

Three days later, Tish was in an emergency room, severely dehydrated. Then she was admitted to a medical unit where she developed a urinary tract infection, was repeatedly stuck with a needle, and was ignored when she complained about a skin tear above her elbow. In 48 hours she was discharged, still nauseous.

Things did not get better from there. Tish and Ted were back at the ER and the clinic more than once, hoping against hope. She was given antibiotics, a steroid, and potassium. Then she developed a staph infection in her elbow, which swelled up like grapefruit; this required rehospitalization. Then she watched in horror as nurses, technicians, and cleaning crews in the hospital routinely ignored the quarantine posted on her door—failing even to wash their hands in her room. She knew enough about medicine to know it was wrong, but she was at their mercy and was raised to be polite.

When Tish was finally discharged to a nursing home, her daughter Susan was given a quick overview of her mother's medications—now ballooned to 20 separate prescriptions—and sent on her way.

Tish was a college counselor and helped many young people find their way in life. Along with Ted, an architect, she raised three daughters and served on the boards of several museums and theaters in her Iowa town. At 80, she still had all of her faculties and had the help of her very intelligent, educated daughter. Despite these advantages, it would take her another week to unravel this dangerous bag of sometimes-conflicting medicines—one of which was not even her prescription—to get her sleeping pills administered at night instead of in the morning, to have her original symptoms treated, and to finally get home. Tish was lucky to get out of medical care alive.

When she told me this story, the question Tish asked was typical of her. Instead of being angry, she was worried about others who might be more frail. She asked, "What would happen to a patient in that situation with dementia? What if he couldn't ask questions?"

These are questions that keep me up at night. They should keep you up, too, because this is what you need to know: this happened in your hospital, your clinic, your convalescent care facility. Also, it happened in mine.