An urgent need in American health care is improving quality and efficiency while controlling costs. One promising management approach implemented by some leading health care institutions is Lean, a quality improvement philosophy and set of principles originated by the Toyota Motor Company. Health care cases reveal that Lean is as applicable in complex knowledge work as it is in assembly-line manufacturing. When well executed, Lean transforms how an organization works and creates an insatiable quest for improvement. In this article, we define Lean and present 6 principles that constitute the essential dynamic of Lean management: attitude of continuous improvement, value creation, unity of purpose, respect for front-line workers, visual tracking, and flexible regimentation. Health care case studies illustrate each principle. The goal of this article is to provide a template for health care leaders to use in considering the implementation of the Lean management system or in assessing the current state of implementation in their organizations.

Patient-centeredness-the idea that care should be designed around patients' needs, preferences, circumstances, and well-being-is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs.A dozen years ago a landmark Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, recognized the importance of patient-centeredness, listing it as one of six aims for health care improvement. The report described patient-centered care as "respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions." 1 A contemporary interpretation of this concern for patientcentered care is patients' engagement in their own health care: the idea that engaged, empowered patients are central to achieving better outcomes at a better value.The 2012 Institute of Medicine report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America lists "engaged, empowered patients" as one of seven characteristics of an effective, efficient, and continuously improving health system. The report describes the ideal relationship between patients and providers in this way: "Clinicians supply information and advice based on their scientific expertise in treatment and intervention options, along with potential outcomes. Patients, their families, and other caregivers bring personal knowledge regarding the suitability-or lack thereof-of different treatments for the patient's circumstances and preferences. Information from both sources is needed to select the right care option." 2 For CEOs of health care organizations, the move toward engaging patients in their own care is not simply the right thing to do. It is quickly becoming the norm amid growing evidence that Patricia Gabow, the former CEO of the Denver Health and Hospital Authority, is a professor of medicine at the University of Colorado School of Medicine, in Aurora.Gary Gottlieb is president and

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U.S. taxpayers waste far too much money on health care that is merely average or worse. Some health care providers, including ThedaCare, a major Wisconsin health care company, are using the tools of lean manufacturing to eliminate millions of dollars of waste that obstructs the provision of effective medicine. ThedaCare studies care delivery processes to improve care and lower costs. Lessons from lean manufacturing and the Institute for Healthcare Improvement are lowering incidence of preterm births, improving heart attack response rates, and changing the way care is delivered in hospitals to a collaborative, team-based approach.

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