Reader Question: Support and “First Responders” for Healthcare Professionals


Here is a new reader question from Steve Palmreuter in Michigan. He raises a topic that I've been thinking about lately, so I'm happy to share it with you (with his permission). You might remember Steve as I blogged about a news story in 2009 that highlighted his shift from manufacturing to healthcare and we've communicated a number of times and I actually met him when I spoke at a Michigan Lean Consortium event a few months back.

His email begins:

We have begun experimenting with a concept we borrowed from manufacturing that we're calling the “facilitator” role.   I've heard it called many different  things in manufacturing; team leader, line leader, zone leader, facilitator, etc.   I'm sure you're quite familiar with the concept.

What we find is that our nurses on the front line continually use their workarounds because there's no structure in place to help with solving these issues.   As a result, the workarounds just become “the way it is” and we come to accept it as part of the process rather than viewing it as waste or a problem.

The facilitator role is one where an Rn facilitator supports 4 front line Rn's on an inpatient unit.   The job is twofold:

  1. serve as first responder to  potential delays in patient care
  2. apply PDCA thinking to resolve the delay   issues or other observed wastes.

We're making progress in our experimentation and have learned a great deal about how to do this; however, I'd love to springboard off someone else's  learning curve.   Do you know of anything which has been written (books, articles, etc.) on this topic?

Here is my response back to Steve…

That's one thing that was painfully clear when I recently visited Autoliv in  Utah with a group of 25 healthcare leaders from around N. America —  Autoliv has  WAY better support structures and support staff in place to react when
front-line associates have a problem, compared to most hospitals. And they have the mindset to  really fix the system, not just workarounds in place. Pull an “andon cord,” put up a simple flag – the system should provide support to those doing “value added” work (in this case, nurses, RTs, etc.).

I've recently talked to some Seattle healthcare people who were incredibly  impressed with  that similar support and response when they visited Japan to learn from their best manufaturers. Virginia Mason has  tried to  put in a “Patient Safety Alert” system to move closer toward that ideal of giving people support and help when and where it's needed, instead of relying on monthly metrics.

But  you're right, a typical charge nurse doesn't operate like a team leader  in a  Toyota plant. I think we can change that in healthcare, it would require a concerted effort from a healthcare organization.

I've personally helped some hospitals learn structured PDCA responses to problems so that manager support doesn't become a different level of workaround. The manager can't be chief fire fighter. Using the A3 methodology or a structured “idea card” that prompts PDCA thinking (problem statement, countermeasure with hypothesis, measurement, and followup) can be very helpful.

I would love to hear your thoughts and experiences here as well — leave a comment!

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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. There is definitely read across between sectors in this instance. From experience I have found one of the biggest hurdles to overcome is the shift from reactive to proactive when it comes to dealing with problems. The simple answer is that it comes down to time; problems require thinking to solve to root cause. Systems will only become efficient when time is given to think about the changes required.

    What tends to happen is that without the investment of time problem solving never gets past problem containment (workaround) at best and in many cases firefighting repeat problems becomes a resource niche.

    Very early in a transformation it has to be recognised that without the investment of time for problem solving very little system progress is made. The pressure to cut costs is craved when the reality is that costs will probably have to rise before they fall.

    How often have we been asked to coach problem solving to hear the reply, “I haven’t got the time”? It’s a paradigm that needs to be shifted to enable the change in culture so creative solutions are needed. If we could flick a switch it would be easy but the transition to A3 thinking has to run alongside the traditional response in the form of a clear support structure. As these don’t usually exist then they have to be created and in an environment that has usually focused on cost cutting before the last resort of Lean then the paradigm lies with senior leaders.

    Once this backing is in place and PDCA understood the people who add the value will create the solution.

  2. Great topic. We need to find a way to provide the support structure that caregivers need, or Lean could fall by the wayside like so many other improvement methodologies. Coincidently, a discussion about “patient flow coordinators” is going on at the “hme” Yahoo listserv.

  3. I have been thinking of something along these lines. So often we think of the “nursing team” instead of the “patient team”. I think having a RN “team lead” needs to ensure the problem is identified as a patient problem and not a RN problem. While this is mincing words, it says a lot culturally.

    The patient team is the attending, RN, and all other support services. You will get more value from a “team lead” once the team is defined.


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