In a car assembly plant, they do a pretty good job of ensuring that no assembly line worker has to do 70 seconds worth of work in a 60 second job cycle. It’s basic Industrial Engineering and, well, it’s relatively easy since automobile assembly is pretty repetitive – especially compared to an inpatient unit or an ICU in a hospital.
On an assembly line, if one worker (or more) has too much work, the line will fall behind (if they have an “andon cord” to pull to signal for help or stop the line) or defects would be pretty obvious. If a worker were forced into cutting corners, a missing door or a missing bolt is pretty apparent. But, in a hospital, the waste is invisible and the cost is much higher.
Like I said, it’s relatively easy to “balance” an assembly line for cars or engines. The work elements (install this bolt or tighten that bolt) are pretty highly engineered and we know how long they take. If a car plant has to produce a car every 60 seconds, they’ll make sure that each worker has less than 60 seconds’ worth of work at their station (or less than 60 seconds’ worth of work if they want things to flow well).
In a hospital, it’s more difficult to know what 60 minutes’ worth of nursing work is for an individual nurse.
- Different patients have different needs, given their acuity and condition on a particular day – so there’s more work content (giving meds, checking central lines, etc.) for different patients or even within different hours. We can’t predict or schedule what will happen in a given hour.
- The times for different tasks (such as starting an IV) can be pretty variable.
If a nurse has different tasks to complete in an hour that, say, add up to 70 or 80 minutes’ worth of work… they can’t be in two places at once… they can’t “stop the line” and pause one patient’s life while they care for other patients. If the work isn’t well designed or there is too much waste in the system (and if nurses don’t have a way to call for help or backup, the way an assembly line would), then it’s inevitable that corners will get cut.
The nurse can only be doing one thing at a time. If there’s 70 minutes of work to do in an hour, decisions get made about what tasks get skipped or delayed. We need to reduce waste (essentially freeing up time) or add staff (something that’s not very practical in this day and age). Reducing waste is preferable to “throwing people at the problem.”
Studies show that med/surg nurses only get to spend 30% of their time with patients at the bedside. They are running around searching for supplies, working equipment, and medications. They often spend more time charting and fighting the EMR system than they spend with patients. Systems and methods and processes evolve instead of being designed. The focus might be on tasks instead of the design of a 12-hour nursing shift. There’s too much waste.
Instead of a door being missing from a car (obvious), maybe hands don’t get washed properly. Maybe a patient doesn’t get checked on during rounding the way they should. Maybe a central line dressing goes unchecked or a call light doesn’t get answered… so an infection develops or a patient falls. Under time pressure, corners get cut and bar codes all get scanned as a batch or two patient identifiers don’t get used… so the wrong medication is given.
The waste (the process problems and the steps that get skipped, the corners that get cut) can be invisible, but the harm is done. The harm (the preventable harm) impacts patients and their families. These problems occur at most hospitals, it seems.
Instead of reacting AFTER a patient is harmed (often in a punitive way), we need to make sure the work is achievable (in a proactive way). Don’t give a nurse 70 minutes of work to do in an hour. You say there’s too much variability to plan this precisely? Then, if we accounted for the variation and the patient truly comes first, then nurses would have idle time more often… a nurse “not doing anything” is far more visible than a patient who is about to be harmed because of corners being cut.
This isn’t the nurses’ fault. This is a system problem. It needs to be fixed with solid Industrial Engineering and Lean methods. Instead of saying “there’s too much variation” and “every patient is unique,” we need to plan workloads better. We need to eliminate waste so patients can get ALL of the care they need and deserve.
Would you buy a car that was missing parts because the assembly line workers “didn’t have time?”
How do we make the healthcare waste visible so we can prevent harm? How do we create an “andon cord” that allows nurses to ask for help, without shame, and actually get them the help they need when they can’t do it all? How do we change the culture so nurses ask for help instead of just toughing it out?
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.