This Nurses Union is Wrong About Lean
There’s a weeklong nursing strike going on at Allina Health in Minnesota: Seven-day nurses strike starts at five Twin Cities hospitals. The main issue is health insurance coverage for the nurses, it seems.
One reason for higher health insurance costs is rising healthcare delivery costs… one reason hospital costs are higher than they’d otherwise need to be is due to a lack of Lean thinking, teamwork, and leadership in many organizations. The lack of real cost reduction (through the elimination of waste and the improvement and redesign of processes) leads organizations to “squeeze” people through benefits, pay, and jobs. It’s a negative spiral that leads to, among other things, poor labor relations (it could be called “poor management relations).
Disclosure: I previously did some consulting work for Allina Health, coaching some of their employees, leaders, and staff in some “Kaizen Kickoff” workshops at various sites, where we introduced a working continuous improvement system into departments, including nursing units. Everybody was wonderful and there were no objections from nurses or the union.
The MNA seems to dislike executives (and their paychecks) more than they dislike Lean… but they’ve staked out a position that Lean is bad and they’re going to stick by that, it seems.
The union does bring up a good point in the video… far too often, people err by timing the value-adding work instead of focusing first on eliminating all of the waste, delays, and non-value-added time that surrounds the work. Timing people is fine if you have THEM participating (see my post) and if the goal is to figure out how to make work easier and results better… the goal isn’t to pressure people to work faster.
But, they disingenuously mock up a patient on an assembly line as the voice over from the Lean video says specifically that Lean is not about turning patient care into an assembly line. Sigh. The Lean model IS about better patient safety… not just cost. Again, if an organization is only focused on cost or the bottom line, that’s not really Lean.
The article talks about something I’ve long decried… nurses and other healthcare professionals NOT getting proper breaks and lunch times. This leads to fatigue and errors and dissatisfaction… hospitals need to figure out a way to provide staffing and coverage so people can actually sit and eat.
“There is a problem with nurses not getting their breaks,” Olson said. “We now have a break room in almost every unit, because people don’t feel comfortable leaving.”
This is a common problem in hospitals… which is why my “vision for a Lean hospital” from Chapter 13 of my book Lean Hospitals includes this basic (and legal) right to have a proper break:
There are also other issues in the strike related to how to set staffing levels. Setting staffing levels in a hospital is more complex than knowing how many production workers need to be assigned to a line. A car factory is a repetitive and highly engineered environment in a way healthcare is not (yet Lean still applies, of course).
Allina wants nurse staffing determined by computer, based on patients’ electronic records. The union objects to removing charge nurses’ judgment from the staffing equation. Charge nurses consider factors not documented in a chart–family and psychosocial issues, the intensity of nursing required, the experience and skill of particular nurses.
Besides, Swehla points out, the computer data may be out of date. “Nurses do first and chart later, because it’s more important to take care of the patient,” she said. “The input into the computer about a patient’s conditions may happen two hours after you’ve delivered the care. They’re deciding staffing in real time with this program–but we’re not charting in real time, because we don’t have the time.”
I could certainly see room for judgment in a standardized scheduling and nurse assignment process… and that could still be “Lean.”
Actually being able to chart in real time would be better, too, and something I’d hope to see happening more in a hospital that practices Lean.
But back to the “All In” article, it says:
“The approach will sound familiar to anyone who watched the “lean production” craze sweep auto manufacturing. Quality and savings are achieved by standardizing work into rote steps. Skill and individual judgment, which introduce unacceptable variation, must be ironed out.”
There’s another dubious definition of Lean. It sounds more like “Lean As Misguidedly Explained,” or L.A.M.E.
Yes, standardized work is an important aspect of Lean. But, remember… Toyota has long said that standardized work should be created by (and improved by) those who do the work. I’ve never hear anybody in healthcare call for the elimination of “skill and individual judgment.” Yes, “unnecessary variation” can be bad, but not all variation is unnecessary or harmful.
“Only those motions that produce quantifiable results–services the hospital can bill for, health outcomes it can tally up–count as productive. That leaves out, say, brushing a patient’s hair, comforting a family member, or mentoring a younger nurse.”
I’ve never heard anybody in healthcare say that any of those activities in the last sentence should be eliminated. For quite the opposite view, remember the “Loving Care” approach of a Dutch hospital that focuses on freeing up nurse time so they can be more caring and loving… the MNA sounds like they would support that approach… an approach that sounds more like “Real Lean” than some of the “Fake Lean” cost-cutting efforts that hospitals try to pass off as Lean.
“Any downtime is waste. In auto plants, lean managers pushed to keep workers busy 57 seconds out of every minute. (Of course, this dramatically increased injuries like carpal tunnel.) Nurse productivity, according to Health Catalyst, can be measured in nursing hours per patient day. That ratio improves when you burden nurses with so many patients that they start skipping breaks to keep up with care.”
In the typical hospital, nurses are already busy for something like 80 minutes out of every hour. Nurses and hospital employees are already getting hurt too often. If you see a Toyota plant, it’s not “management by stress,” as the unions like to call it. Doing a well-engineered 57 seconds worth of work on an assembly line that’s paced properly and ergonomically correct can less stressful than scrambling to do work that might take 45 seconds one time and 75 seconds another time (especially when workers in a non-Lean environment get yelled at for falling behind).
Lean isn’t about overburdening nurses, eliminating skill, or being cold to patients. Lean is the best solution I’ve ever seen for the problems the MNA complains about. It’s a shame that hospital leaders can’t get the union on board with working together to solve these important problems that matter for nurses and patients. Why hasn’t Lean been more a part of the solution instead of being a point of argument?
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