Nursing’s Journey through the LEAN Process

In 2008, under the new leadership and direction of Dr. Narendra Kini, President/CEO, Miami Children’s Hospital began a journey of transformational change which included the adoption of LEAN principles as a methodology for continuous performance improvement. LEAN, based upon the success of the Toyota Production System over 50 years ago, focuses on the elimination of waste while adding value to a process. (Zidel, 2006)

There are key operational terms which form the basis for utilizing LEAN, among them is the concept of value added. Value added is what the customer or patient says is important to them about the service being provided. Dr. John Kenagy, vascular surgeon, stated in Forbes magazine that nurses spend a third of their time in patient care and two thirds of their time hunting, documenting and clarifying.” (Fisher, 2000) Nurses understand “value-added” from both the customer view and as a provider of care. For example, as a customer, the nurse may rely upon receiving the right supplies from the Materials Department at the right time to provide and deliver care to the patient. In this case, the value-added nature of these services is from the view of the nurse’s eye. On the other hand, when providing value to a patient, the nurse must recognize and understand the patient’s perception of what adding value means to them. Another term is “non-value added” which is fairly evident and otherwise known as a process which does not provide value or “waste.” LEAN recognizes many forms of waste, including defects, over production, inventory, motion, not utilizing people, extra processing, transportation and wait time. In identifying opportunities to eliminate waste, known as “muda”, it is the first step in creating value. LEAN is about “making value flow from beginning to end based on the pull — the expressed needs — of the customer/patient.” (IHI Innovation Series, 2005)

For nurses and hospital personnel, examples of waste may or may not be easily identifiable, however, eliminating the waste should be very desirable. For example, a form of “motion” waste might be trying to track down a chart, vital signs equipment or an instrument in the OR which is time consuming and frustrating. “Wait time” waste is any time that a parent or patient waits for a test or results or to make an appointment with his/her treatment. Wait time waste from the nurse’s perspective as customer might be waiting for a result or medication to be delivered. Defects could include medication errors or mislabeled specimens. These forms of waste include a cost to the customer in both financial and quality terms.

At Miami Children’s Hospital, the nursing and hospital staff has begun to understand and utilize LEAN processes to improve their clinical practice. Value stream maps have been created identifying “kaizens” (opportunities for improvement creating more value and eliminate waste) which continue to provide the framework for continuous improvement. GENPACT, Inc. has provided the guidance creating enthusiasm, building organizational knowledge and generating momentum for adoption of a LEAN culture. In a time when safety is paramount and preventable medical errors are a prime concern along with a flailing economy, LEAN is a methodology which makes just makes healthcare sense.