The transition from fee-for-service to value-based reimbursement is driving many healthcare systems to fine-tune processes and work waste out of the system. In the search for quality improvement tools there has been much buzz surrounding lean, touted for its ability to remove waste from processes. Many have tried lean and, failing to achieve any sustainable benefit, are learning that applying lean principles to healthcare can be quite difficult. The lean approach isn’t a magic potion. Sustainable change will never become real without a committed organization dedicated to making it a reality. Lean, or any quality improvement tool, works in healthcare only when it is part of a larger initiative driving real cultural change.