Since moving into healthcare in 2005, I've been surprised by a number of things in the hospital environment. The first time a skilled medical professional (a laboratory medical technologist) said, “they just want me to check my brain at the door” (true story), I was stunned. That's what GM assembly line workers said to me in 1995. It was sad then and even more heartbreaking to hear in a hospital in 2006.
Another thing that surprised me was the fairly common practice of “flexing” staff, including nurses. This typically means sending staff home early when the expected workload isn't there.
I saw a question on the online HME (Healthcare Management Engineers) group about flexing, asking in a non-judgmental way about hospitals' practices. After a few days of general silence on the rights and wrongs of the issue, I chimed in, saying (at the risk of sounding sanctimonious, I realize):
I'd argue that “flexing” should really be called something more brutally accurate like “sending staff home because we view them only as direct labor.”
There's such a lost opportunity in healthcare — nurses or other staff are sent home early… yet everyone says staff has no time for root cause problem solving or any continuous improvement efforts. There are studies that show that flexing really hurts morale because staff feel less than fully valued as professionals.
Toyota never sends hourly workers home early when there are parts shortages or other situations that mean there's no direct work to do. Supervisors engage their brains in improvement activities. Why can't we do the same with highly skilled nurses?
My source on the Toyota “never” statement comes from a discussion with John Shook. Has Toyota ever done this, sending people home early? Maybe, but my discussion with John:
Mark: “If a Toyota line were going to be down for the rest of the day, due to parts shortages or something, would Toyota send all of the production workers home?”
John: (without pause): “No.”
Toyota would train people or have them work on improvement activities. Their system supports that and people are trained how to do so.
It seems to have been taken as the new conventional wisdom in healthcare that being “efficient” means low cost, which mandates “flexing” and sending staff home early. I've tried challenging that a few times with hospital executives and I get a lot of blank stares. It's like I've grown a second head (one of which you are tempted to send home early for being unproductive… or maybe both of them!).
Now, I realize staffing to demand is a good thing. We shouldn't be always overstaffed. But we need SOME capacity and time for improvement, not just doing work.
Hospital demand and patient needs are hardly ever level loaded. It's hard to bring someone in to the laboratory for a three-hour morning shift and it might seem cruel to send a nurse home four hours early when her cost of commuting for that unexpectedly short day is just the same as a full shift.
I'm not opposed to staffing properly and I'm not opposed to cross-trained staff that can be shifted (“flexed”) to another department that needs additional staff based on patient needs. But, just sending people home early… that seems to violate the “respect for people” pillar of Toyota's management system. It also seems to violate the need to drive improvement into the workplace.
Many hospitals are trapped in this cycle (roughly, a “reinforcing loop” to the system dynamics crowd)
There's too much waste in the normal daily process, which interferes with proper patient care. For example, nurses can't quickly find needed equipment and supplies. But, there's no time for kaizen or continuous improvement activities. So things don't get fixed, better processes don't get put in place. Things remain broken (or get MORE broken).
When I teach hospital leaders about Lean improvement systems and employee suggestions, the first response is usually, “That sounds great, but we don't have time!!”
Maybe we would have time if we didn't rush to send nurses home the minute patient census drops. Maybe leaders are focusing too much on that sole labor productivity metric of Worked Hours Per Unit Of Service? We have labor productivity, but at what cost to quality, safety, and morale? How does length of stay suffer from this laser focus on labor cost?
Yes, I realize that labor costs are often 60 to 70% of a hospital's costs. I'm not saying to ignore labor productivity.
One follow up email on the HME discussion said this often happens:
- In the mid afternoon, patient census is low (after discharges), so RNs are sent home early (flex!)
- Then the ED has patients to admit, but there aren't enough RNs to admit them, so patients wait and care/admission is delayed
So you've saved a few hours of labor, but at what cost to the overall system? I'm sure the root of this comes down to measures and silos.
Imagine, instead, a world where RNs and Techs take time that's available when census is low to work on improvement work – little “just do its” or simple process mapping exercises. 30 minutes here, an hour there – you can actually get a lot done in small chunks of time if you do the following:
- Track improvement opportunities and staff ideas in a visual way (see my book or David Mann's )
- Train staff and managers on Lean principles and teach them how to analyze and improve work (see the “Job Methods” program from Training Within Industry, used in healthcare circa 1945).
- Train managers on how to properly interact with staff to encourage continuous improvement (see the “Job Relations” TWI program)
- Measure results (not of each individual improvement activity) but long-term measures of the department (and broader value stream) that matter.
The alternative to “send people home” shouldn't be “let them stand around.” We need to train and motivate people (or, as Dr. Deming would say, NOT de-motivate them) and allow them to drive improvement… that's how you break that cycle and start making things better in a workplace.
Who says it can't work in healthcare? Is someone reading this willing to challenge “flexing” in their own hospital – finding the leadership required to do the training so front-line staff can start doing this?
When I worked at GM, an old UAW guy didn't want to participate in improvement efforts as he said, “I was only hired for my back and my arms.” Isn't it sad if the same is sort of true for nurses, where their brains aren't used for continuous improvement? As one person said in the discussion, “The workload is more than just direct care.”
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