The document discusses how lean principles from manufacturing have been applied with mixed success in healthcare. It argues that for lean to be truly effective in healthcare, it must be part of a larger initiative to drive cultural change throughout an organization. Specifically, healthcare systems should use two lean tools - value-stream maps and A3 diagrams - to improve horizontal processes, while also adopting principles like continuous process improvement and empowering frontline workers. Sustainable change requires long-term teams focused on clinical domains and organizational commitment to making improvements a reality.