The Cathedral Hill Hospital (CHH) project is a 1.2 million square feet urban replacement hospital in San Francisco. Started in 2007, this state-of-the-art structure breaks new ground in design, construction, and operations. CHH’s Integrated Project Delivery Team has applied lean ideas, concepts, tools, and processes to develop this very complex project every step of the way. This paper compares and contrast initiatives set forth at CHH with the 13 principles proposed by Jim Morgan and Jeffrey Liker regarding the Toyota Product Development System. It explores the opportunities and limitations of experimenting and implementing LPPD ideas and practices in design and engineering.