How a NICU Nurse’s Kaizen Idea Became an Innovation That Helped Babies Everywhere: Franciscan Kaizen Video #7

Sometimes, continuous improvement sparks something bigger than anyone expected. In this story from Franciscan Health's NICU, a nurse named Kelly turned a heartbreaking event–a baby developing a pressure ulcer–into an inventive solution that made care safer, easier, and more human. What began as a small Kaizen became a patented innovation now used far beyond her hospital. It's a vivid reminder that when organizations empower people closest to the work, improvement doesn't just fix problems–it creates breakthroughs.

Today, I'll share the seventh video in a series of clips that I shot last October at Franciscan. See all of the videos here.

---

I think this video shows that opportunities for innovation are all around us if we keep our eyes open and look for problems to solve. I think this fits into the category of innovations that we find by implementing lots and lots of little ideas, as this Japanese hospital CEO said.

Summary:

At Franciscan Health's NICU, a nurse, Kelly, turned a heartbreaking incident–a baby developing a pressure ulcer on the back of the head–into an opportunity for improvement.

Frustrated that the existing mattress covers were stiff, unattractive, and difficult to change, she didn't blame anyone. Instead, she asked why staff resisted using them. Their answers–too heavy, too ugly, too awkward–became design criteria for a better solution.

Kelly went to a fabric store, bought soft, colorful materials with coupons, and organized a “sewing party” with coworkers. Together they redesigned the cover to make it easier to replace without disturbing the baby, while adding cheerful prints that parents and staff loved.

Her manager helped connect her with the hospital and vendor, and eventually the new design became the manufacturer's standard–helping babies in hospitals far beyond Franciscan.

Yes — the hospital filed for a patent on Kelly's redesigned NICU mattress cover.

This story captures the essence of Kaizen leading to innovation:

• Start small, with a problem that matters.
• Ask why it's hard to do the right thing.
• Engage the people who do the work.
• Improve the system instead of blaming people.

Kelly didn't just solve a problem–she made care easier, safer, and more human.

Transcript:

Here is a transcript of the video. Paula is the manager in the NICU.

Paula: I really want Kelly to share this one with you, because we're actually thinking about going for a patent on this, or submitting it at least to the company.

Kelly: First of all, we had a…I'm the skin care rep for the unit. We had a pressure ulcer on the back of a baby's head. That is a big-time no-no. We don't ever want that to happen. It was very devastating for that to happen.

I work with the skin team. I did a little bit of research and got ahold of the rep about the Z-Flo mattress. These are super, and you can fill them with air-infused fluid. They have no memory in it, so it does not push back against the baby's skin.

It was a perfect, wonderful positioner that we used. When we got it…We don't like change here.

Paula: Really?

[crosstalk]

Kelly: People don't like change.

Man 1: They all love change here.

Kelly: The mattress was kind of heavy. When we put it in these bags, when you put the mattress in these bags. We have them here. If you want to do a check on the baby, and they've been soiled…

[bell tone]

Kelly: First of all, the mattress cover that came with it…

[bell tone]

Kelly: We like pretty blankets. This is not pretty…

[bell tone]

Kelly: …and it's not soft.

[bell tone]

Even more than that problem…I need to shut that off…was that to put the mattress on, you would have to come pull this out here, so what happens to the baby in that meantime?

You put this on. You don't have to take it out to take the other one off, and it's very heavy, so like this. This is not working very well at all.

What I found was, I would get my baby's positioned really wonderfully, have this on, everything's great, protecting their skin. They're comfortable, parents love it.

I come in the next shift. It's on the side. One, it's getting dirty on the bedside tables. Two, the baby's not on it, getting the benefit from it.

I've got to ask staff, “What's the deal? Why don't you like this?”

“Well, it's a pain to change this. It's not cute. I don't like this, it feels like paper. It's not soft on the baby.” You really can't load blankets over it, because then you don't get the benefit of the mattress itself.

I talked to the rep and I said, “I really am thinking about making my own covers that are pretty.” She said, “Well, you have to use a thin fabric.” I said, “That's fine.”

I went to the fabric store and I found a lot of different cute prints, never [inaudible 2:57] it. I used coupons and got it on sale at JoAnn Fabrics. I found lots of cute baby prints because that's what our staff likes. It's nice and thin so they still get the benefit from the mattress.

Then I said, “I think we need to have a party where we can sew. We're going to bring our sewing machines, whoever wants to. We'll have a party, and we're going to design new mattress covers.” We looked at not just the way that it went on, not just the fact that we wanted to make it prettier. We wanted to see, “Was there was a better way for it to go on?”

We ended up designing…and people also like straps to go over the babies…so some of our other little positioners that we had have had straps to hold the babies in. We designed one that had straps, and the opening, instead of being at the top, ours were lengthwise in the back.

Then, what we can do is, if the mattress is dirty, you can roll the baby from side to side like you would an adult. You take the dirty side off, the baby's rolled over, then you roll the new one on. I'll show you what that looks like when it's on.

You don't have to take the baby off the bed. You don't have to take the mattress off of the bed. It's pretty. The parents love them and it's been a lot of fun.

At first, I was sewing a bunch of them at home myself. I don't have a lot of time. I'm working full-time and going to school full-time. Then, I started thinking, “What can I do to get more help in this?” I made a pattern and I put instructions with them. I had them in a little packet just like you would a pattern that you buy from a store. Then I was like, “Do you sew? Do you sew? Do you sew?” [laughs]

Paula: Anybody in the unit?

Kelly: Anybody in the unit. Anybody that would.

[crosstalk]

Kelly: My mom had never seen a Z-Flo mattress, but she sews a lot. So I made one cover and gave her to it with a pattern. She had started sewing them now, but she was, “Look, I at JoAnn's, I got some fabric on sale.”

I was really hoping that if the staff joined in and if they made them, they would take pride in it and want to put them on there, “Oh, that's the one that I made,” and want to be involved in it.

Then when you see the difference of the baby laying, all wrapped up and cuddly like this, in a nice mattress. They're so comfortable, the parents were like, “Oh my gosh. That's a huge difference.”

They love it. It's pretty. Do you know any baby that…They're not comfortable for so many different reasons in here. This has made them feel comfortable. It's soothing. It feels like they're inside the womb again, so it's a very comforting thing to them. I think the moms felt good about that, knowing that, “OK.” They all see them, and they're, “Oh my gosh.” They were so agitated, and then I see how they relax in here.

There were so many…I was really wrapped around this, that we were not just developing, getting it to prevent the ulcers, and then getting the staff to buy in. Designing the mattress, getting the fabric on sale, getting some donated…

[laughter]

Paula: …getting people to help clip coupons.

Kelly: Yeah.

Paula: 40 percent off at the store.

Kelly: Like I said, if staff thinks it's pretty, then they have some buy-in with it. If they made some, they're going to be more involved in using it. Then they know [inaudible 6:40] “I want to sew. I want to sew, too.” People like to do things…

---

Please scroll down (or click) to post a comment. Connect with me on LinkedIn.

---

Let’s build a culture of continuous improvement and psychological safety—together. If you're a leader aiming for lasting change (not just more projects), I help organizations:

• Engage people at all levels in sustainable improvement
• Shift from fear of mistakes to learning from them
• Apply Lean thinking in practical, people-centered ways

Interested in coaching or a keynote talk? Let’s talk.