Debate about Lean at SF General Hospital – Hire a Consultant or More RNs?
Happy June, everybody! Summer is here. We've actually had a delightfully long spring here in San Antonio, which means the temperature hasn't really been above 90 yet, which counts as cool (and comfortable for us).
Speaking of California, I recently saw this article about San Francisco General Hospital: “Toyota work methods applied at General Hospital.”
We've Got Two Choices
The article talks about “staffing levels being dangerously low,” but that equation has two levers to pull:
- Increase the number of nurses (above the mandated California state ratios?)
- Reduce waste to free up time so nurses can spend more time with patients
Only one of those approaches is affordable and sustainable – reducing waste.
“Nurses often work through their breaks, and they stay after their shifts to get charting done,” said David Fleming, a registered nurse who has been at SFGH for 25 years. “I think nurses are getting the job done – but they're at the edge.”
It's not right, for a number of reasons for nurses to not get their breaks… they are fatigued, which can lead to more errors, and their happiness and satisfaction level goes down.
Also, nurses who barely have time to get their work done (a common problem that I've seen at A LOT of hospitals) aren't going to have the time to help improve anything.
From the article:
But does “driving out waste” translate to staffing cuts? “It certainly hasn't happened here,” Nazeeri-Simmons responded when asked about that. Instead, the consultants have helped management to “right-size services to meet the demand,” she said, noting that wait times in urgent care had been significantly reduced as a result. Decisions such as using a portable X-Ray machine that eliminated the need for patients to walk ten minutes across the hospital grounds had dramatically reduced wait times, she added.
“We need to make sure the staff are working to the highest of their capability,” she added.
No, driving out waste should mean better patient care. If a hospital is truly following the example of Toyota, they will put quality and safety first. The best Lean hospitals have “no layoffs due to Lean” commitments.
Spend on More Nurses or Consultants?
Somebody leaked a copy of the $1.3 million Lean consulting contract signed with Rona Consulting (disclosure: Mike Rona wrote the introduction to the 1st edition of my book Lean Hospitals and they are a customer of KaiNexus).
As we saw with Saskatchewan (with a $40+ million contract), there's often controversy about spending money for Lean help. Critics often say, “You should just use that money to hire more nurses.” Or, they'll say “Lean is common sense… why should a consultant be needed to figure out how to improve? It's just common sense!”
Spending money on Lean (including my services as a consultant) should lead to a long-term positive return many times over. My bias is clear and out there for everybody to see — spending money on Lean consulting and education is an investment… granted that the hospital and their leaders are taking the right steps to capitalize on that investment.
If Lean was truly just “common sense,” then it would be more common, eh?
The short-term argument is that there aren't enough nurses to provide safe care:
Nato Green, who is representing nurses as a negotiator on behalf of public employee union SEIU 1021, described the staffing levels at SFGH as “unsafe and unsustainable.” There are currently 90 vacancies for nurses that haven't been filled, he said. That's a 14 percent vacancy rate, Green noted — typically substituted with traveling nurses, temps, and overtime labor.
It begs the question, then, “why are there vacancies?” Traveling and temp nurses are expensive… are there factors that prevent SFGH from filling the open positions? I'm sure it's not a matter of not trying or a matter of being cheap, especially since patient safety is affected by being understaffed.
The hospital aims to use Lean to not just improve efficiency, but also to improve patient care and safety:
Heidi Gehris-Butenschoen, a spokesperson for Rona, said the goal of transforming work practices under the Toyota Management System is to improve patient care. Asked whether the consulting tends to affect staffing levels, Gehris-Butenschoen said, “That's really up to the hospital. It's definitely in our workshop not something we focus on. The Toyota system is not about cutting heads at all.”
Again, I think the only sustainable way is reducing waste and letting nurses make the best use of their time. Unions generally have a financial incentive to have more dues-paying members.
Patients Aren't Cars – Of Course, They're More Important!
There's an old, tired argument that gets trotted out by a nurse:
“We are not taking care of cars on an assembly line,”
he said. “When it comes to another human being's body, I don't know that faster is necessarily better.”
Of course patients aren't cars. That's all the more reason that we need Lean management and a Lean culture in healthcare. Using these methods to help prevent scratches on the side of a truck door… that's relatively trivial.
Sadly, nurses and patients typically don't get that level of support for quality and safety… and that's where Lean helps. It's not about turning healthcare into an “assembly line.” It's about treating patients with the respect and providing the care they deserve. Taking care of the nurses means they can take better care of the patients.