Getting Started with Lean in Nursing


    By Dean Bliss:

    One of the big challenges we have as Lean people is to get beyond presentations, classes, and posters, and get to the real work done by the real workers.

    At our hospital system, we're learning a technique from a group called Rule 4 Consulting that is an intriguing approach to the problem. The technique involves using the “rules in use” that were defined by Steven Spear in the 1999 HBR article “Decoding the DNA of the Toyota Production System” and applying them in a systematic way to directly to a workplace – in our case, an inpatient care unit.

    The rules in use can be found summarized here via google books.

    One of the key features is lots and lots (and lots) of direct observation, which results in a few things.

    One, the observers develop the skills to “see” and to quantify what they are seeing (learning to see what we call “waste” in lean — we talk about learning to see with different eyes.). Two, the staff gets comfortable with the observation process. Three, the staff starts to be able to “see” problems in their work, which they previously either didn't notice, or simply worked around. And four, the staff begins to identify suggestions for how the work can be done better – in other words, problem solving at the front line.

    A simple example: When the food trays come to the floor, they frequently don't have salt and pepper, since they must be ordered by the patient. The nurses have to run to the supply area to retrieve the condiments – on one day, there were 3 requests within a one hour timeframe. Each time the nurse made a trip to the supply area, which took time away from her other duties. When we first discovered this, their reaction was “yeah, we have to do this once in awhile – no big deal”. Now they see running to get salt and pepper as a workaround to the problem. We did an A3, and talked to patients, nurses, and the dining service people, and started to get to the root cause. Nothing has been solved yet, but the recognition is there from the nurses that there is a problem that can be solved.

    We're only about four weeks into the process, so we have a long way to go, but I see this as a possible way to get to the core of improvement work – problem-solvers at the staff level. And I think this process has the potential to take us to places we haven't been before in terms of improvement.

    I can't wait to see how things progress. It's exciting stuff. I'd be happy to follow up in a few weeks as we progress.

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. That key feature that you describe as “lots and lots (and lots) of direct observation” has always been for me the most effective approach to team-based problem-solving. When I was inexperienced w/ Lean and didn’t have command of any other Lean tools, I could always just go “stand in the circle” and be confident that I would help the team solve a problem. I imagine Taichi Ohno would say that this is Lean in its purest form. Here’s why:

      1) It’s simple (all you need is a notepad, pen, and comfortable shoes)
      2) It adheres to the ‘genchi genbutsu’ principle
      3) It adheres to the ‘respect for people’ principle

      Great stuff!

    2. You're right. Lots & lots of observation not only helps you learn how work really happens; it helps staff learn to see their work in a different way. Documenting your observations by drawing them and reflecting those drawings back to staff keeps everything open and safe. And, as Michael noted, it honors their work. It is a great privilege to learn by observing staff. Work as observed is almost always different from work as espoused.

      Thanks, Dean!


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