How this Kaizen Prevents New Moms From Feeling Like They’re Being “Stabbed in the Heart”


I wanted to share a recent Kaizen improvement story that I heard from a hospital.

Great things can happen when we:

  • Listen to our patients
  • Take action to prevent similar problems
  • Get departments working together to coordinate care

Imagine you're a new mother and you're recovering in a room after your postpartum care. You've been cared for and visited by a few different OB-GYNs from the medical group, each one of them a top-tier clinician in their field.

Now, we're imaging, but this was a real situation. The mother was ready to go home and one of the doctors said, “OK, you're ready to go, so you and your baby can go home now.”

The problem? She had given birth to a 27 week-old preemie, who was in an incubator in the NICU. The NICU was a separate unit and the communication and coordination of care clearly wasn't as good as it should have been. Nor was communication good enough within the OB-GYN group. They were treating the mother's body, not the whole person, which included her anxious mental state, not knowing if her baby would survive to ever go home.

The mom later told the manager of the NICU that the OB-GYN's inadvertently insensitive statement made it feel like she “had been stabbed in the heart.”


The mom in this story was on maternity leave from being a nurse in that very NICU.

The NICU manager here said, “That was callous.” The hospital was not about creating callous or heart-stabbing moments for people. That wasn't fitting with their mission, vision, values, or purpose.

In normal circumstances, this story and this feedback might not have ever been brought forward. A mother who wasn't a nurse might not have thought to complain or speak up… the hurt might have just lingered.

If we're not aware of problems, they can't be fixed.

In this case, the hospital and the OB-GYNs were now aware that something bad had happened, that they had a problem. This creates an opportunity to improve – to fix systems and processes so that the same mistake isn't repeated.

In investigating the situation and talking to other mothers who were part of the unit's patient/family council, they learned that this bad situation was not a one-off occurrence. Similar things had been said to other mothers. Oops.

Preventing the Problem

What did the hospital do to prevent this problem from reoccurring?

They didn't hang a bunch of signs saying “Don't be callous!”

Screen Shot 2015-05-01 at 9.41.31 AM

I don't think signs or reminders like that are very effective. Nor do they look very nice. See my separate blog project on this, “Be More Careful!

Instead of lecturing physicians, they changed the process in a simple way. That's Kaizen.

What did they do?

First, they had a meeting with staff from both departments AND they included members of their patient/family council. Six months after childbirth, mothers and fathers are eligible to participate formally in their council where they get the “voice of the customer” and their ideas.

The group decided to create a subtle visual signal that could be used in the NICU. They decided to use a graphic of a teddy bear that would be laminated as a sign. That bear would be posted on the door of a mother's room if she had a baby in the NICU.

Of course, they had to educate the OB-GYNS about what this sign meant. This sign still required a reliance on human kindness and “not forgetting” to see the sign. But they thought it would help, even if it didn't completely prevent callousness.

They learned that, with the sign in use (in the “Do” stage of the Plan-Do-Study-Adjust cycle), that it was beneficial to more people than the physicians. ANYBODY entering the room – nurses, techs, dietary, housekeeping – could be aware of the bear and tread carefully or be sensitive to the mother's needs and concerns.

In the Study phase, the cross-functional and cross-departmental team assessed that the sign was helpful. Behavior and sensitivity had improved.

There was a similar story at another hospital that we shared in our book Healthcare Kaizen, a former client of mine. It was a very similar situation, as we described:

From chapter 1 of our book (which you can get as a free PDF):

At Riverside Medical Center (Kankakee, Illinois), housekeeping, dietary, or maintenance staff would sometimes face the awkward situation of entering a patient room to find a grieving family with a patient who had just passed away. During an initial Lean and Kaizen program, Darlene, a member of the housekeeping team, made a simple yet effective and beautiful suggestion to prevent that situation from occurring again. She created an angel sign, pictured in Figure 1.5., that could be placed on the door when a patient passed away. Ancillary departments were easily instructed to look for the sign so they could remain respectful of the deceased and their family. The sign was also a subtle way to maintain privacy and dignity for the families, because other visitors might just think the sign was a decoration.

Figure 1.6 Angel


The Need to Share and Spread

While Kaizen teaches people how to improve and how to problem solve, does everybody need to “reinvent the wheel” when we face similar problems in different departments or different hospitals? Yes, we want people identifying problems and solving problems, but we can learn from others. We can share ideas. That doesn't mean we should only copy what others have done.

But, if we have the same problem and somebody else's solution works, what wrong with “stealing shamelessly?” Nothing!

What matters is solving the problem.

If we copy or borrow somebody else's improvement, hopefully we can improve upon it and hopefully it inspires others to implement their own Kaizens.

At Franciscan St. Francis, they have a homegrown web database on their internet that makes it easy for people to search for Kaizens that have been implemented. They can share ideas across departments and across their three hospitals. They built their own system… KaiNexus was not yet on the market.

Our KaiNexus software, among other things, makes it easier for people to share and spread ideas. I wish we saw more of that across healthcare more broadly.

I wonder how many people who read Healthcare Kaizen copied specific improvements that were featured in the book in addition to developing a Kaizen process? It's OK to copy, but that shouldn't be the only thing we do.

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

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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. Hi Mark:

    Beautiful post, this one.
    Amazing how humans can learn and improve.

    Thanks for sharing this one. Good job!


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