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Streamlined processes

Lean management model can help nurses implement cost-cutting measures and improve quality of care

Monday August 11, 2014
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Lean management can be a tool for not only cutting costs but also for improving outcomes. Its roots lie in manufacturing — more specifically, the Toyota Production System. In healthcare, lean management is being applied to processes ranging from patient flow through the hospital to supply inventory. “Lean looks at streamlining processes to highlight and eliminate waste,” said Manimegalai Murugavel, RN-BC, DNP, NE-BC, CSSGB, patient care director at Inova Mount Vernon Hospital in Alexandria, Va.

As director of acute care services at Saddleback Memorial in Laguna Hills, Calif., part of MemorialCare Health System, which has been using lean management for eight years, Brandi Cassingham, RN, MSN, said although it’s a new mindset for those in healthcare, a key part is assessment — consistent with the assessment phase of the nursing process. “So often with nurses we want to jump in and fix it instead of stepping back to analyze the problem,” she said.

Lean management’s use in going past analysis to solutions is what makes it valuable for nurses and organizations, say RN leaders.

Value of lean for nurses

Why should nurses care about lean management? “Lean management gives nurses the power to change the environment where they work so they can deliver safe, more effective patient care and contribute in a meaningful way,” Joyce E. Johnson, RN, PhD, NEA-BC, FAAN, an experienced nurse executive and healthcare consultant in Frederick, Md., said. She added nurses are well-suited to lead lean-management teams.

Unfortunately, too many nurses equate waste elimination with doing more with less, so overcoming misconceptions is an important step for the process to work well. “You go to nurses who are fraught with frustration and you say, ‘Let’s start from scratch. You identify how it can work best; we’ll modify the environment based on your needs,’” Johnson said. “It takes time, and building trust is critical.”

Education and communication can help overcome misconceptions, Cassingham said. “When we first started, staff thought lean meant getting rid of people,” she said. “That’s not it. We want them to work smarter, not harder, and make their jobs easier.”

Lean fast facts

Three Lean Management processes —-

~ Identify waste
~ Perform root cause analysis
~ Solve root cause and repeat cycle

Types of waste LM addresses —-

Overproduction: Produce only exact amount customer wants, when they want it
Transportation: Eliminate movement of materials and information that doesn’t add value to products
Motion: Avoid unnecessary movement of people
Waiting: Eliminate delays, long setups and unplanned downtime of machines, processes or people
Underused people: Use people as efficiently as possible
Non-value added processing: Eliminate more work or higher quality than is required by the customer
Defects: Eliminate issues caused by defects — e.g., equipment defects or incorrect information
Unnecessary inventories: Avoid having excess and unused products and materials

LM terminology —-
Value stream mapping: Identifies current processes in detail
Kaizen: Continuous improvement to create more value with less waste; small, incremental changes lead to big improvements
Gemba walk: Direct observation of work (processes); no preconceived ideas as to solutions
True north: What team members should want to accomplish
Kanban board: A tool for visualizing, analyzing and organizing workflow
FMEA (Failure mode and effect analysis): Disciplined approach used to identify possible failures (and frequency) of product or service
5S visual management: An acronym for Sort (clean work area); Set (arrange items so easy to find, use and return); Shine (clean and care for equipment and areas); Standardize (make all work areas similar); Sustain (make process natural and instinctual through education, communication and employee involvement)
Six Sigma: LM is part of Six Sigma, which focuses on improving outcomes, using various analysis techniques

Source: Wisconsin Manufacturing Extension Partnership, wmep.org


Lean in action

Once staff learn about lean principles, they’re ready to put them to work. When Robert Wood Johnson University Hospital in New Brunswick, N.J., wanted to redesign the way care was delivered in its ED, the team turned to lean management, starting with their inventory. “Our inventory was disorganized, there were expired supplies, and the distance between where we worked and where the supplies were kept was inconvenient,” Katherine Baron, RN, BSN, CEN, interim assistant director of the ED and former staff nurse, said. Baron said they reviewed the periodic automatic replenishment inventory — or the ideal amount in inventory to meet needs but not overstock — in the regular storeroom and how to get the supplies closer to the patient. The staff-led team devised a system consisting of a local cart for most frequently used supplies, located in each ED pod (grouping of three patient rooms), and a regional cart of less frequently used supplies, located in the nurses’ station. “Every cart looks exactly the same and is set up exactly the same,” Baron said.

At Inova an initiative on applying a care delivery model identified work overlaps among disciplines. Teams were able to streamline work to eliminate the overlap. “Now we have a standard workflow for every discipline, starting from the director level and cascading down to the front-line staff,” Murugavel said.

Many organizations like Inova use a creative solutions board to track issues that need lean management. “Any staff member can bring an issue to the board,” Murugavel said.

A team and front-line staff tackle the issue and work without preconceived solutions in mind. “We start by observing the processes from days to weeks, gathering data,” Murugavel said. The next step is to understand the data and then devise countermeasures to address problems.

Cassingham cites patient flow value stream as an example of how lean management works. “Value stream is the flow of tasks, processes or activities that occur from the time a customer requests a product or service to the time it’s delivered,” she said.

At Saddleback, staff examined everything that occurs during the patient flow value stream, defined as beginning with the time a physician requested a bed for a patient and ending with the patient’s discharge. Patients undergoing procedures with predictable lengths of stay, such as orthopedic procedures, choose a discharge date and time during their preoperative visit. “It’s the hotel concept,” Cassingham said. “You know the date and time you are going to check out.”

The team worked with physicians to define an algorithm that ensures medical equipment, transportation after discharge and other needs are arranged ahead of time.

In addition to these longer projects, Cassingham said daily problem solving is an integral part of lean management. “We post current metrics on a board and have daily huddles around that,” she said. “If we seem to be off track, we can figure out what we can do differently.”

The practical benefits of lean management are touted by those using it. “Organizations have reported to us that the costs of education and time to work on projects will be recouped through improved processes,” said Barbara Buturusis, RN, MSN, director of surveyor management and support in the division of accreditation and certification operations at The Joint Commission.

At Inova, applying lean principles helped improve staff productivity by 75%, resulting in significant cost savings, Murugavel said.

Power to change

One challenge of lean management is sustaining change. “You have to hard wire change for the long haul,” Johnson said. “Underscore that lean isn’t just a process or product change, it’s a totally different way of doing business and requires constant change.”

Baron said RWJUH has used lean management for a variety of projects, including staffing, which resulted in increased staff and the addition of different shifts.
If an organization doesn’t have an overarching lean management program, which is often the case at smaller facilities, Johnson said nurses still can apply lean principles. “It can start with little wins at the unit level,” she said. “Once staff see small changes being made based on their input, they feel empowered.”

The process also is seen as an outlet for creativity. “Lean management is about valuing people and challenging traditional ways of thinking,” Cassingham said. “It unleashes the potential that staff has as far as making improvements, makes the hospital a great place to work and improves patient care.”

Staff leadership is essential for successful lean management, along with an interdisciplinary approach, Baron said. “Our ED operations committee includes staff nurses, nurse aids and unit clerks. Although our director and head nurse participate, initiatives are staff led. Everyone loves being a part of it.”

BENEFITS TO SURVEY PREP

The Joint Commission
Lean management helps organizations improve outcomes — thereby improving their performance on surveys — and sustain those improvements over the accreditation cycle.
More than 40% of surveyors are trained in process improvement, and surveyors conduct about 17,000 accreditation visits per year. This expertise allows them to help organizations leverage the most benefit from tools such as lean management.

Magnet Recognition Program
Surveyors look for evidence of a process improvement plan that includes assessment, pulling together teams of people to create solutions, implementing solutions and sustaining change. The American Nurses Credentialing Center can’t endorse a particular model, but lean management is one of several process improvement models that is being used by many organizations.
Monitoring must not only be part of the implementation step, but it also must continue to ensure the change becomes part of the organization’s culture.
Organizations need to have at least two years of data to demonstrate sustainability.

Sources: Barbara Buturusis, RN, MSN, The Joint Commission, and Linda Lewis, RN, MSA, NEA-BC, FACHE, American Nurses Credentialing Center (which owns the Magnet Recognition Program)



Cynthia Saver, RN, MS, is a freelance writer. Post a comment below or email editor@nurse.com.