A Lean Guy Listens to NPR – Waste & Problems in Healthcare


Coming this week — blog posts and tweets (follow me or hashtag  #HCsummit12) from the 2012 Lean Healthcare Transformation Summit on Wednesday and Thursday. If you are going to be there, please say hello!'

Looking back a week… the weekend of Memorial Day weekend, the NPR “most emailed stories” email that arrives each Sunday featured not one but two stories about waste and problems in healthcare. I think will resonate with Lean thinkers in and out of the profession.

The two stories I'll cite and comment on:

In the first story, the theme is nurses not being available for patients.

…the Robert Wood Johnson Foundation and the Harvard School of Public Health finds that one-third of hospitalized patients say nurses weren't available when needed, or didn't respond quickly to requests for help.

NPR didn't exactly go to the “gemba” to find out why or look for a root cause, but they surveyed nurses via Facebook (an unscientific survey, but a way of reaching those on the front-lines of patient care).

They heard:

…nurses telling us they get no breaks, no lunches, barely time for the bathroom.

The nurses are afraid. They are afraid that something bad will happen to their patients and they are afraid to speak out for fear of retaliation from their hospital leaders.

Another nurse comment:

There have been shifts where I've driven home at the end of 12 hours, and I'm gripping the steering wheel, and all I can think of is, what happened during my shift? Did I miss anything? I've run ragged; I didn't get a break; my knuckles are white. And what can we do to make this situation better for both the patients and the nurses?

The NPR piece is surprisingly quick to present the perspective that we don't have a “nursing shortage” — but rather, there is “a shortage of nursing care.”

A few years back, I heard a great Lean leader, Fred Slunecka, now COO of Avera Health, say basically that there wasn't a shortage of nurses and other staff — there was just too much waste in their processes.

Instead of hiring more people, we can reduce waste and provide better support to nurses. I've been to the gemba a lot, and you see nurses (and other staff) scrambling around looking for things. They are “hunting and gathering” for equipment, supplies, medication, information, and people.

Hospitals need to provide better support systems for nurses and other “value adding” front-line staff. Nurses need to know that the things they need to do their work will ALWAYS be there, where needed (closest to the point of patient care) and in the quantities needed.

Hospitals using Lean, like Virginia Mason Medical Center (read their book), have DOUBLED the amount of time that nurses have available for patient care at the bedside. By improving processes (through projects and small daily kaizen), we can essentially double the amount of NURSING CARE provided without hiring more nurses. Everybody wins – patients get the care and service they need and nurses are less stressed and more satisfied.

It's a shame that nurses and patients are so frustrated. It doesn't have to be that way.

Another nurse raised the issue of quality and safety:

I've thought, before, that the day that I come home and look back, and realize that I made a mistake because the demands exceeded any reasonable capacity on the part of a nurse, that's the day that I never want to be a nurse again.

More time at the bedside correlates not just to higher patient satisfaction, but to things that are really important like reducing falls and other patient harm. Frantic, harried nurses are more likely to make errors involving medication and other errors that can also harm patients.

In the second story, NPR collected stories from patients who are generally dissatisfied with their care. There are a lot of stories of high charges due to not having insurance, then there are stories related to the delivery of care.

One was a case of a patient getting double testing (and double BILLED) by two parts of the same health system that couldn't talk with each other in a single evening:

It started when he woke up one night with alarming stomach pain — “like shards of glass traveling through me,” he says. Doctors at a nearby urgent care center ran a bunch of tests but couldn't figure out what was wrong, so they sent him to the hospital.

Even though the hospital was part of the same system, the doctors there weren't alerted that Dasenbrock was coming and his records weren't transferred. So he had to fill out the same questionnaires and repeat all the same diagnostic tests, as he was doubled over in pain.

A CT scan showed a nonserious ailment that needed only simple treatment — lots of fluids — and Dasenbrock went home. But two days later he got two bills totaling thousands of dollars.

“I laid the two bills next to each other and it was literally word for word, letter for letter and line item by line item the same charges … for all the tests I had gone through,” Dasenbrock says. He ended up having to pay for the duplicate tests.

There was a story about miscommunications and bad processes that harmed an elderly inpatient:

Last year [the patient] fell and broke three ribs. He was admitted to the hospital, and his mental state began to deteriorate by the second day. “He wasn't even coherent by the third day,” Bronicki says.

Brown, a retired engineer who taught physics, was mentally fine before the hospitalization, Bronicki says. So it wasn't normal for him to be so confused.

But she says the parade of doctors who saw him seemed to assume “that was his natural state, given his age and condition. We would have to convince each new doctor that saw him — tell the story of his Parkinson's, explain that this was not his normal, that he was normally functioning, talking, coherent.”

A neurologist finally figured out what was wrong. Different doctors had prescribed different pain medications, and the drugs were interfering with Brown's Parkinson's medication. That caused his mental deterioration and made his limbs rigid.

After the medication was straightened out, Brown improved. But Bronicki and her sisters felt they had to maintain a constant vigil at his bedside to prevent another medication error.

In this case, it's unclear (to me as a non-clinician) if this adverse event was truly an error. Was medication interaction known (and therefore should have been preventable) or was it the type of thing that's hard to anticipate? That patient's family regrets taking him to the hospital for something (broken ribs) that only required TIME to heal.

The article rightfully points out that there is a lot of high-quality care that many patients do receive. But, there's far too much room for improvement… and I'd emphasize the problem is bad systems, not bad people.

p.s. Also check our their general story on the poll about people's (dis)satisfaction with healthcare quality.

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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. I’m glad to hear there are some Lean folks that are drawing the medical Value Stream all the way through to the Patient’s bill. As a backend revenue operations guy, I see billing errors and hear many complaints from Patients. I don’t feel enough has been done to investigate and eliminate this waste (though I’m trying). A word for the clinically focused improvement folks: I understand that clinical rules and is the key interaction in the revenue stream. I get it. Just bear in mind that you can give your patients the best experience from admit to discharge, healing them safely, and leaving them happy; but in a month when they get their bill and it’s confusing or doesn’t line up with their expectations or recollections – all that value you added is quickly forgotten. Don’t forget to involve the backend: leverage our claims data and interactions with Families to better inform the front line improvement planning. Thank you, Franklin

    • There are not just the billing errors that irritate patients, but then also the billing errors (or medical coding errors) that leave money on the table. I’m sure you might see a lot of that Franklin. From what I’ve heard and seen, this can be a multi-million dollar opportunity for a hospital – avoiding coding errors that would prevent them from rightfully getting paid for the work that they do. The whole value stream can start up front at referral and pre-authorization time… it’s a complex value stream involving doctors, the hospital, insurance, patients, etc.

      • Well put Mark, thanks for the reply. I am a Coding Supervisor and see many of the opportunites you mentioned. Beyond patient complaints and revenue loss due to coding errors (great point!) there is a form of error-proofing that we’re hoping to implement through Provider and Staff education: Compliance. Just because we get paid doesn’t mean the services were medically necessary, documented appropriately, or coded correctly. Equal defects that can create wastes, and all great avenues to explore on our Lean journey.


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