“At first glance, you could say that applying manufacturing processes to health care is cold or impersonal,” Holly Dowling, RN, BSN, OCN®, clinical nurse educator for ambulatory hematology/oncology at Beth Israel Deaconess Medical Center in Boston, MA, says. “However, when you are goal oriented and your goals are all about providing the best, safest, and most efficient patient care, it makes sense.”
Although car assembly has very little to do with patient care, in an effort to improve quality and efficiency, health care has turned to the automotive manufacturing process for inspiration. Hospitals across the country have begun to embrace the philosophy known as Lean, a concept developed by the automotive giant Toyota.
WHAT IS LEAN SIX SIGMA?
Lean Six Sigma is a model that has been used in business to help streamline processes, decrease waste, and improve quality. The healthcare industry has adopted Lean for a variety of reasons, including decreasing wait times, reducing mortality rates, lessening lengths of stay, cutting costs, increasing efficiency and quality, and decreasing errors.
Main Principles for Implementing Lean Six Sigma
- The patient comes first, and all employees commit to that concept.
- Staff understand and know how the work gets accomplished.
- The process must be flexible to decrease problems in the long run.
- Managing and improving the process flow and eliminating waste creates additional savings, decreases medical errors, and improves quality of patient care. More steps means increased risk of complications and slowing of the work.
- Keep the focus on the problem and eliminate distractions.
Toyota’s Lean revolves around a culture of reducing waste and increasing value and efficiency. For nurses, efficiency has historically been equated with staffing cuts. But Lean efficiency means putting the patient first by improving how resources are used and providing value.
Can Lean Really Work in Health Care?
Elaine Stenstrup, MSN, ACNS-BC, AOCNS®, clinical nurse specialist at the University of Minnesota Medical Center in Fairview, says it can.
“I was concerned at first that the approach was going to take away the clinical judgment from the bedside nurses and that their voices would not be heard. But all of the departments involved with patient care participated.”
Interdepartmental participation is a key component to Lean, because patients often interact with different areas for their treatment, and many departments tend to be interdependent.
Using Lean in Patient Care
“We needed to eliminate the time wasted looking through multiple supply closets to locate items for a procedure,” Dowling says. “Our outpatient infusion area stored patient supplies in six different locations. Some were supported by the distribution department to maintain periodic automatic replenishment (PAR) levels and monitor for expiration dates, but others were not. Complicating matters further, we also had special order products that were not monitored, meaning when they ran out, no one knew to order more.”
Holly Dowling, RN, BSN, OCN®
Stenstrup’s challenges were similar. “Our goals were to Lean our supplies to save money and increase staff time with patients. For example, we decreased to 5 kinds of tape instead of 12. Having so many different dressings and tapes on different units resulted in uncontrolled inventory. We also did not have a good system for our bedside carts: no standardized set up, no PAR levels, and no one designated to maintain them. So we performed time-flow studies to diagram the paths nurses took when caring for patients. The diagrams showed we were spending a lot of time retracing our steps to obtain supplies.”
One key to successfully implementing Lean is having the right people at the table. “I was involved in some decision making for clinical supplies,” Stenstrup says, “but we had bedside clinical staff representatives who were more involved from start to finish. They continue to be the unit champions when a new product or process needs to be addressed.”
Dowling adds, “Teamwork between nursing, practice assistants, and distribution managers is critical.”
Because implementing Lean often requires paradigm shifts, education is also paramount. “Training included an overall review of the concepts of Lean and processes needed for each aspect of the project,” Stenstrup explains.
Dowling adds, “I was asked to participate in a large three-day event for another Lean project that provided background for this one. I also attended classes offered by the hospital on a regular basis. There are now so many departments using Lean that we have a regular forum where the work is presented.”
Implementing Lean in Today’s Healthcare Environment
Going Lean requires paradigm shifts, yet embracing change in even the most progressive hospitals can be difficult. People may be resistant, and projects may not go as planned.
“We were initially concerned that our patient supplies would be taken away, or that normal workflows would need to be altered,” Stenstrup confesses. “It also required a change in thinking about standardizing products—and even standardizing patient care in some instances—instead of having all of our personal preferences met. At first, our PAR levels were either underestimated or overestimated. There were also times when processes put into place by other departments caused a break in our workflow. However, nursing leadership brought the issues through the appropriate channels to fix the problems.”
Dowling brought the entire staff into the implementation process. “To facilitate staff participation, we broke down carts in an empty patient room. This allowed them to see what changes were made and give timely feedback.”
Her advice for integrating Lean into the healthcare environment? “Always keep your eye on the goal.”
Stenstrup adds that nursing’s voice must be heard throughout the process. “Local nursing leadership needs to ensure the champions are at the table in all discussions. The champions should be staff who have an understanding of the unit’s patient care and will be able to professionally voice consent and concerns with the Lean process.”
Find Information on Quality With These Web Resources
Agency for Healthcare Research and Quality
Reaping Lean’s Results
“Using Lean has saved nursing time and has reduced frustration trying to find or order items that should be easily available and in one location. In the end, I think everyone was pleased,” Dowling says.
“We have seen less waste in the products we use for patient care,” Stenstrup adds. “One example is that we no longer bring extra supplies to the bedside for central line dressing changes, which used to result in throwing the extras away upon discharge. We now have a designated place for what is truly needed, so there’s no more hunting for supplies. The time savings was noticeable, lessening the number of steps needed for patient care. And we created a template for the bedside cart stockers to show them where the special items were to be placed.”
Lean is not a one-time tool used to get something accomplished but rather is a continual way of thinking, of improving the machinery to make it run smoother and provide a better patient experience. Stenstrup sums it up: “Be flexible, unafraid, and involved as much as possible. It is a very new way of thinking in the clinical world.”
For more information in promoting quality in your practice, view the archived ONS Quality and Safety in Oncology Nursing E-Conference sessions until November 8, 2013.