Cleveland Clinic’s Lean Transformation 

The vision for the Cleveland Clinic, a massive not-for-profit healthcare system, is to be “the best place to receive care anywhere and the best place to work,” said Dr. Lisa Yerian, Executive Vice President and Chief Clinical & Operational Improvement Officer. “We have integrated the expectation of excellence, the aspiration for excellence, in everything we do right in parallel with being the best place to work.” 

The Clinic consists of 23 hospitals, 280 outpatient locations, approximately 83,000 caregivers, and nearly 16 million patient encounters annually. The Clinic was recognized as one of America’s best hospitals, according to the 2025-2026 U.S. News & World Report “Best Hospitals,” and for the 35th consecutive year was named to the Best Hospitals “Honor Roll” for delivering exceptional care across a wide range of specialties and procedures. 

Lean thinking is helping the Clinic to sustain and improve on its performance. In the State of the Clinic 2025 address, CEO Tom Mihaljevic MD, recognized the efforts of staff in improving uniform safety, quality, and patient experiences in Ohio, Florida, London, and Abu Dhabi, and then challenged associates to make further gains by leveraging lean methods: 

“Let us reach more uniform excellence this year. There are several opportunities to continue improving safety performance and patient experience. We should communicate often through tiered daily huddles and daily plan of care visits. We should further standardize anything repetitive in our work and use safety checklists. Lastly, we can embed lean management into the fabric of the Cleveland Clinic. Lean is a skill used to solve problems in the process of care delivery. It results in solutions made by the team for the team, which improve patient outcomes, eliminate waste, and reduce costs. By being lean we can focus on creative efforts to innovate in more ways.” 

The Clinic’s lean journey began humbly in 2006 with the creation of its initial process improvement team, which relied on a variety of tools and approaches, including lean, six sigma, and project management, and largely focused on discrete projects, said Lisa. In 2012, the Clinic committed to building a culture of improvement rooted in lean methods and reached out to Mark Reich, LEI Chief Engineer Strategy, for guidance. This eventually led to the development of the Cleveland Clinic Improvement Model (CCIM) in 2014.  

Lean is a skill used to solve problems in the process of care delivery. It results in solutions made by the team for the team, which improve patient outcomes, eliminate waste, and reduce costs.

–Tom Mihaljevic MD, CEO, Cleveland Clinic

“We realized that the core questions teams needed to answer to build a culture of improvement were quite consistent: alignment (‘What matters most?’), visual management (‘How are we doing today?’), problem solving (‘What gets in the way?’), and standardization (‘Do we always do it the best known way?’),” said Lisa. CCIM is built around those questions, which align with LEI’s Lean Transformation Framework. 

“I am a big believer in the Lean Transformation Framework, and I try to be very disciplined and rigorous in saying, ‘What is the problem we’re trying to solve, what’s our true value-driven purpose?’” said Lisa.  

Since the advent of CCIM, the Clinic has continued to embrace additional lean concepts, such as tiered huddles, which were piloted in 2018. Then new CEO Tom recalled being bothered that he did not know what was happening every day in the Clinic and pushed for 15-minute tiered huddles. “People would typically come to me and say, ‘Oh, we had a bad week.’ Or ‘We had a bad month.’ There’s very little that anyone can do with that information,” he told Becker’s Hospital Review.  

Caregivers who provide direct patient care in every department, ward, or hospital now “huddle” every morning. The huddle identifies both what is important for the day as well as existing problems, which if not solved by the huddle team are escalated up to the next huddle tier. “The format is the same,” said Tom. “It’s only 15 minutes long, with the teams of caregivers speaking about what is important for their work that day. It always starts with quality, safety, patient experience, environmental care, infrastructure, and anything that needs to be addressed for caregivers’ patients and their fellow caregivers.”  

The Clinic found that having a pre-existing system for addressing challenges — including a well-established culture with regular check-ins, formal reflection about precedents, and mechanisms for responding to “defects” as they occur — can generate tremendous benefits, wrote Lisa and John Shook, LEI Senior Advisor. This was certainly the case as COVID emerged and Clinic leaders sought to leverage problem-solving capabilities to help deliver on what matters most: keeping their patients and caregivers safe. Amid the pandemic, this meant developing processes to test and vaccinate an entire population while keeping testers and vaccinators safe.  

By the end of 2020, the Clinic had performed more than 300,000 tests, with few cases of COVID among caregivers and no caregiver cases traced to patient testing. Standard work was used to build testing sites at other Clinic locations and at other healthcare providers. In 2021, the Clinic then turned its attention and problem solving to safely distributing a flu vaccine to millions of patients and tens of thousands of caregivers during a global pandemic.  

Clinic staff have revisited and reinvigorated some lean practices following COVID, including the tiered daily huddle system, kaizen system, problem-solving capability and awareness. Reflection and PDCA at the enterprise level is unusual, said Josh Howell, LEI President. “In my experience, the combination of humility, commitment to learning through practice (not just benchmarking others), and a willingness to change (even systems they’re known for publicly) is rare in the lean community.” 

Achieving broad organizational objectives, especially under extreme challenges, and a desire to keep improving even after substantial gains have been made cannot happen unless leaders are aligned and working as one. Complete commitment and collaboration can be difficult under far less trying conditions. Lisa shared three keys to getting leadership engagement/buy-in/support: 

• Don’t ask for “support” or “buy-in” because “these terms are vague and subjective. Instead, we make our requests clear, specific, and purposeful.” 

• Once there is clear, specific commitment, determine how to engage and define the specific, tangible actions to be taken in the work. Lisa and her continuous-improvement colleagues start this conversation through the left side of the A3 — the purpose. “Why are we even talking about this? Why is this an important problem to solve?  What is the target condition? What do we know about the current state? What is the clear, specific ask to them to help forward your A3?” 

• Don’t ask for anyone to “support” something they haven’t yet had the opportunity to experience, understand, and critically evaluate. “We want our leaders to make good commitments, and that can only be done when they understand what they are committing to and why. It would be unwise to agree to support something I don’t understand, and I would not ask that of my leaders.”  

Not everyone in a large organization, such as the Clinic, may always want to get involved with an improvement effort. “I think a lot of [CI] people just get stuck and stop and say, ‘Why aren’t they doing what we want them to do,’” said Lisa, arguing that she and her CI staff need to work to get beyond that. “You can’t stop there. You really have to listen and understand where they’re coming from.” She added that working through those situations ultimately makes CI staff more impactful lean leaders and gets more problems solved and more people developed. 

Chad Cummings, Vice President of Lean Transformation & Continuous Improvement, at the Clinic, said developing people is an important component in getting everyone involved in continuous improvement. “If we want to make a change in our culture, we have to really think about what behaviors, right behaviors or correct behaviors, we want to drive, but even prior to that thinking about routines. Do we have the right routines in place that help to establish those behaviors. And to establish those routines you have to build capability in people. You have to give them the knowhow of what good looks like.” 

In the areas where lean is deeply rooted, the daily practices that we rely on to ensure high quality and safe care have not skipped a beat. We now know we can sustain our way of working even through challenging times.

–Meredith Foxx, Chief Nursing Officer Cleveland Clinic

Gradually the integration of a lean culture, including behaviors and routines, into daily leader standard work has helped to sustain the Clinic’s lean transformation and continuous improvement culture. “It’s been interesting to see how, even during the pandemic, in the areas where lean is deeply rooted, the daily practices that we rely on to ensure high quality and safe care have not skipped a beat,” said Meredith Foxx, Chief Nursing Officer at the Clinic. “We now know we can sustain our way of working even through challenging times, and I believe that’s because people see the value lean brings to their work.” 

Dr. Lisa Yerian will deliver a keynote address at the Lean Summit in Houston on March 12-13. 

Learn more about the Cleveland Clinic’s lean transformation: 

• “The Escalator of Issues” article by Jim Womack 
• “On the Job Podcast: One Pathologist’s Path an interview with Dr. Lisa Yerian of Cleveland Clinic” 
• “What are the Three As of the A3?” article by John Shook and Dr. Lisa Yerian 
• Mark Graban LinkedIn post praising Dr. Lisa Yerian’s approach to lean reflection