Nurses Are Leading Change and Advancing Health With Lean Methodology

During her September 8, 2020, presentation for the inaugural ONS Bridge™ virtual conference, “Leadership Tools for Success: Lean Methodology for Process Improvement,” Anna Liza Rodriguez, MSN, MHA, RN, OCN^®, NEA-BC, of the Vanderbilt-Ingram Cancer Center in Nashville, TN, explained that lean methodology is one promising approach to process improvement.

Rodriguez explained that lean methodology, which is the concept of efficient manufacturing and operations that grew out of the Toyota Production System in the mid-20th century, has been adapted to the healthcare setting in recent years.

When applied to health care, Rodriguez said, lean methodology can help to improve patient outcomes, increase patient and staff satisfaction, and reduce costs. Effective implementation of lean methodology requires adequate organizational support and interprofessional collaboration.

Rodriguez identified various lean methodology tools that may be used in process improvement. For example, different types of waste in health care can be identified using the acronym DOWNTIME:

• Defect: resources spent making errors, identifying errors, or fixing errors
• Overproduction: caused by doing more than the customer needs at the current time
• Waiting: delays because of resources not being ready or available
• Not clear: problems caused by staff being unclear about the best way to do a task
• Transportation: excessive movement of patients, supplies, and/or specimens
• Inventory: having too many or too few materials, medications, or supplies on hand
• Motion: excessive movement by service providers
• Extra processing: use of redundant or excessive processes

In addition, the 5S methodology is a process for maintaining a clean, well-organized workplace:

• Sort: separate the necessary from the unnecessary by removing superfluous tools, equipment, and procedures from the workplace.
• Simplify: Put everything in its place and organize material, preferably with the help of visual aids.
• Sweep: Visually identify potential problems and deal with unsafe conditions or damaged equipment early in the process.
• Standardize: Define how a task should be done, effectively communicate the process, and document process changes as they occur.
• Self-discipline: Ensure that everyone adheres to policies.

The lean methodology process itself also involves five steps.

First is understanding the patient’s definition of value. Rodriguez suggested using empathy mapping or collaboratively creating a visualization to articulate what is known about a particular type of user, including what they say, think, do, and feel. 

Second entails selecting, observing, collecting data, mapping, and evaluating a process. Current state mapping involves creation of a flowchart that illustrates and analyzes the steps involved in a process. After mapping a process from beginning to end, critique its current state to identify areas of waste and opportunities, Rodriguez said, and ensure representatives from each discipline are included in the analysis.  

Third is identifying the ideal state and brainstorming solutions to get there. Future state mapping, a process by which this ideal future state is identified, is useful during this step, Rodriguez said. Fourth involves deploying an improvement plan, and fifth is pursuing perfection, with 30-, 60-, 90-, and 180-day reports to track progress.

Lean methodology has already been used successfully in the healthcare setting:

• Quality and safety (e.g., reduction in central line–associated bloodstream infections, which decreased patient deaths from these infections and was associated with a substantial cost savings)
• Patient wait time (e.g., reduced patient waiting time for nonemergent orthopedic surgery from several weeks to hours)
• Patient flow (e.g., reduced late surgery starts, reduced rescheduled procedures, increased cases per month)
• Patient satisfaction (e.g., substantially improved emergency department patient satisfaction)
• Finance (e.g., bottom-line benefit)

 According to Rodriguez, implementation is often most successful when leadership is aligned, institutional culture is supportive, lean methodology tools are integrated as part of a comprehensive management system, and patients are assigned priority.

Lean methodology is needed to achieve true, sustainable transformation, she said.