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).

I'm headed off to Los Angeles tomorrow for the 5th annual Lean Healthcare Transformation Summit. Let me know if you'll be there, too!

Speaking of California, I recently saw this article about San Francisco General Hospital: “Toyota work methods applied at General Hospital.”

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We've Got Two Choices

The article talks about “staffing levels being dangerously low,” but that equation has two levers to pull:

  1. Increase the number of nurses (above the mandated California state ratios?)
  2. 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.

Before Lean:

“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.

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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’ve been following mark for a long time. And my open mindlessness allows me to fully understand that lean works. However I am an LPN employed by sunrise health region in saskatchewan and it’s devestating here how lean is being implemented. It’s coming from the top down. No employee input is being asked of or considered. The administration is dictating to us what works and we must implement it. If we don’t like the change we haven’t given it enough of a chance. The employees are being blamed for lean not working here in saskatchewan. At times we are punished for it too. Regardless I totally agree it would work if it was a collaborative effort to improve efficiency but like I said it’s failing here due to the circumstances of administrative dictation and patients are feeling the brunt of that.

    • Hi Erica-

      Thanks for your comment. I’d say that Lean works… but there are far too many situations where something is called “Lean” when it doesn’t really resemble the engaging, collaborative approach of Toyota.

      I’m going to blog tomorrow about this video from a California eye clinic that Toyota helped with:

      Watch this video and you see what Lean really looks like:

      1) Solving problems that matter for patients and staff
      2) Engaging people in the problem solving and improvement process
      3) The smiles and pride that results from working together to fix things

      It really should be a collaborative effort to improve efficiency AND improve quality. It goes hand in hand.

      Lean isn’t about top-down mandates. Employees who disagree with a top-down driven change should NOT be labeled as “resistant to change.”

      I’m sorry to hear about your situation, Erica.


  2. In my own organization a pilot nursing unit dramatically eliminated waste, returned more time to nursing care, improved patient satisfacation, and reduced hospital acquired conditions via application of Lean concepts. A corporate mandate just came down that requires this unit to cut RN staffing by 15%. The problem with Lean is that very few administrators involved don’t understand or care to understand process management and independent of that, no one can defend what the “right” amount of nursing staff should be.

    • Mandates like that, made from a distance, are the antithesis of Lean.

      “Farming looks mighty easy when your plow is a pencil and you’re a thousand miles from the corn field.” – Dwight D. Eisenhower

      It’s sad that most hospitals base staffing decisions based on spreadsheets, consultants, and benchmarks instead of truly understanding the work and how its done. Staffing based on benchmarking is a race to the bottom… everybody will end up understaffed and patients will suffer.

  3. Hi Mark

    Whether or not Lean or for that matter any improvement method succeeds, depends on the managers not screwing it up later with new cuts. What the nurse above are seeing is not, but in fact dishonest fraud. Recently I have had to spend some time in a local ER due to an injury, this hospital has been quietly using Lean to improve their services, and I can honestly say it has been working, they are doing a better job than they use to. The nurse and doctors are I feel much happier, and you hear nurse discussing improving their skills, through taking extra courses, and training, instead of listening to them complain about how they are treated.

    This hospital got a new CEO a few years ago he spent and still does spend time with all the various work groups, either working with them or just shadowing them to see what issues they face (after all he is not a medical person). Because of that his people feel they can talk to him about problems and they work together to get them fixed. He has his people so well motivated that even the admitting staff will call up and inform the ministry when their computer system isn’t supplying information they need by default, so they do not have to waste extra time constantly changing one setting. This hospital never even discusses Lean, all they talk about is improving their service. I congratulate him and his staff, as from what I have seen they are now using their nurses to actually look after patients, instead of as errand boys and paper shufflers, and the care you get is a vast improvement over what it use to be. Over the last four days, I have witnessed a vast improvement, in how everything is being done at Windsor Regional Hospital. Lean works when everyone works together, and management doesn’t use the gains as a means to cut their budget.

  4. Hi Mark,

    I saw your post today from three years ago and agree with the previous comments that senior leaders and managers often do not understand process management nor do they understand the value of bottom-up continuous improvement by engaging front-line staff with improvements to improve quality of care and reduce waste.

    At the same time, I also think there needs to be significant stretch level goals made by senior leadership which provide the right environment for transformational care delivery. Too often, many of the lean deployment efforts have focused so much on “point” improvements within the value stream which limits the ability of leaders and front-line staff to transform care delivery across siloed departments.

    Lastly, I think organizations that can build comprehensive value streams while engaging physicians, nurses, and front line staff will be better able to design systems of care which provide the highest value (high quality, safe care, exceptional service at the lowest cost.) Lean coupled with systems engineering principles can be powerful driving forces to transform care delivery.

    • Thanks for your comment. I think the “significant stretch goals” can help prioritize and drive larger improvement projects (breakthrough, transformation, redesign) while we are still engaging every single employee in smaller incremental improvements.

      It’s not a matter of which type of improvement to do… they need to (and can) co-exist. There’s more need to prioritize larger, more strategic improvements (in keeping with a strategy deployment methodology, if it’s there). Smaller front-line driven improvements (kaizen) shouldn’t at all interfere or suck resources away from the larger initiatives.

      We have to improve and transform and then keep improving.


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