Lean Would Be a Solution for What These Nurses Complain About


In my time working with hospitals, I've always been very sympathetic to front-line nurses (and other staff). They are far too often overburdened and undersupported. Work is often more difficult than it needs to be — too much hassle and not enough time with patients. Nurses are forced to jump through hoops, fighting through bad systems, yet they too often get blamed when things go wrong.

It's no wonder that 1 in 5 nurses choose to quit their job in their first year. And, far too many get fed up, leaving this important profession early in their careers.

This article posted anonymously on AllNurses.com has over one million views in the month since it first appeared:

Hospitals Firing Seasoned Nurses: Nurses FIGHT Back!

It's an “Open Letter to Hospital Administrators.”

From the letter:

“I have seen staff cut to the minimum, while patient acuity and nurse to patient ratios increase. I have seen support staff break down in tears because they have not been able to do their jobs properly. I have seen staff pushed to their breaking point, all the while administration stays in their offices, or in the meetings, determining yet more ways they can cut our resources.”

This is where Lean management is an alternative to traditional healthcare management styles and approaches. Lean leaders get out of their offices and get to “the gemba,” or the actual workplace. Managers and leaders would see if nurses are stressed out and frustrated and, in a Lean culture, staff would feel supported and everybody would work together to improve systems and processes — to free up time, reduce stress, and improve patient care.

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A Lean culture makes sure employees aren't overburdened – whether they are building trucks, writing software, or caring for patients.

The letter continues:

“I see ways in which we are constantly blamed for declining patient satisfaction, increased patient falls, late medication administration, all the while we are asked to do more with less. I have seen you fire experienced staff and hire less experienced, cheaper, staff. I have seen that new staff break down because they have no resources, no experience to draw from and I have seen patients suffer from that inexperience.”

Lean leaders wouldn't blame employees for poor results. Lean leaders take to heart what was taught by W. Edwards Deming — that senior leadership is most responsible for quality and for the systems and processes that lead to quality.

Lean leaders don't get mired in cost cutting mode like traditional hospital management does. Instead of firing people and replacing them with cheaper replacements, Lean leaders would embrace their employees' experience, viewing them as partners instead of seeing them as just a cost.

“I see you develop a culture of fear, where our jobs are at stake, and threatened at every turn. Yet, you still look to me for solutions.”

Lean leaders have also embraced another of Deming's teachings – the idea that management must work to eliminate fear from the workplace. Staff who fear for their jobs or are beaten down from being blamed for the hospital's problems aren't going to be willing to participate in “Kaizen” or continuous improvement.

The author of the letter also complains about being told to “do more with less.” If management means “work harder,” it's hard to see where that's possible. Lean leaders work with staff to reduce waste and make work EASIER, which allows nurses and other staff to focus more on patient care. Lean managers focus on helping people do more (more work that's rewarding instead of frustrating) instead of focusing on “the less” — or fewer resources.

I don't know what organization ever cut their way to greatness.

What does the letter suggest?

“My answer to this is simple. It is time to get real and start valuing your employees.”

Valuing your employees, to a Lean leader, means making sure they have the right staffing levels – for nurses AND for important support staff. Valuing your employees also means respecting them and including them in improvement efforts.

“We need to stop the assembly-line mentality of medicine and return to the service mentality.

Yes we are a business. But any business that has ever done well has not done well by decreasing the services to people or by mistreating its staff.

While some people associate Lean with “turning the hospital into an assembly line,” Lean has proven to be the best alternative to nurses being frazzled, overworked, overstressed, and not able to deliver quality care. I've seen bad assembly lines where the complaints were the same as these nurses' complaints.

I've also seen Lean assembly lines that represent everything these nurses want – a proper workplace, the ability to do quality work, proper staffing levels, respect, and the opportunity to have their voices heard. Lean organizations have a better leadership style and culture. That's our aim with Lean healthcare… a different culture and management system that better supports the staff so they can provide better patient care. This approach, not traditional cost cutting, leads to better financial results.

I suggest you read the article and the comments, which include a number of nurses who say they warn their management about patient safety risks that result from bare-bones staffing levels, to no avail. Many claim age discrimination and say the hospitals like hiring young nurses at the lowest end of the pay scale because they're less likely to speak up. If that's true, it's shameful.

One comment says:

“The hospital I work at has weekly ‘mandatory' lunch with CEO and HR director, this topic was recently brought up and the response was that it was ‘lazy nursing' that was causing low patient sat scores, it was lazy nurses that were complaining and lazy would not be tolerated…”

Lean leaders would never blame “lazy workers” for the problems in an organization.

What do you think of the article and the situation in hospitals? What hope do we have of creating more Lean leaders and more Lean cultures?

Chasing Lean tools, training front-line staff, and running a few projects here and there is not making enough of a difference. I'm not surprised. We need to do better.

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. From LinkedIn:

    John Lee: “We need to stop the assembly-line mentality of medicine and return to the service mentality.” Much of this has to do with the documentation and “quality” mandates that are foisted upon providers by payors. Often this leads to placing an increased technology documentation burden on the nurses. Technology should be used to reduce, not increase, the burden on the nurse. A very common example is the quite common habit of requiring the nurse to reabstract data that already exists in EHRs. The data is already there: use it without increasing clicks for the nurses.

    My reply:

    John – I agree those are problems to solve that some “solutions” haven’t been a huge help. But those problems shouldn’t be described as “assembly-line mentality.”

  2. RE: “We need to stop the assembly-line mentality of medicine and return to the service mentality.”

    This statement is commonly given by employees across all types of work and has resulted in well-deserved criticism of managers over many decades. The way in which managers bring improvement to work is focused narrowly on the immediate business need and therefore almost always neglects the evolutionary needs of humans when it comes to work. This is why most workers resist Lean or other systems of management that seek to improve worker productivity and reduce costs.

  3. Also from LinkedIn:

    Laura Burns: If every hospital CEO, Administrator, and executives started their career as a nurses aide and worked their way up the ladder their way of managing would be way different. How can someone with a business degree tell nurses, ancillary staff and physicians how to do their jobs when they’ve never spent one single second doing patient care. It’s easy to sit behind that desk and bark out orders when it all boils down you have no idea what it takes to do what we do day in and day out. I challenge every hospital executive to don a pair of scrubs and work side by side one person in every single direct patient care position! I bet your perspective will change and quick!

    My response:

    Laura, I agree that it’s bad for any leader to sit behind their desk and bark orders or blame people. Even if an executive started out as a nurse, I’ve heard people complain that things have changed so much in 20 years that the nursing leaders no longer understand what today’s nurses have to do. That said, getting into scrubs once in a while sure would make a big difference, for many reasons!

  4. More from LinkedIn:

    Peet Wiid: Hi Mark, once again a great post! It is sad (and disturbing) to see how the overarching culture in many healthcare institutions has changed from serving people with respect and care, to barking out demands, pushing people to breaking point, and hence creating a “sick” and toxic environment for staff AND patients. The need for Kaizen leadership, based on humbleness and respect for humanity, is required more than ever before.

    Anastasia Sayegh: Sad, very sad situation in healthcare . It is a reflection of our CEO’s. For the situation to change our CEO’ s need to change. But change to achieve excellence is not meant for everyone it is for barely 10% of the population. Cause change requires courage, common sense and innovation, attributes rarely found combined in our Today’s hospital leaders.

    John Lee: Although not strictly “assembly-line,” IMO, the blog is referring to the constant attention to various surrogate markers that are the incentives that are used to quantify a healthcare CEO’s performance. Unfortunately, the person most often tasked with abstracting data to document such performance is the nurse. This is why (some) administrators are wont to replace experienced (expensive) nurses with inexperienced (cheaper) nurses. To their eyes, such staff are commoditized data collecting workflow automatons

  5. Great article, thank you for sharing.

    I am sure a lot of readers can connect with the emotional frustration of these nurses. While the stakes my be less perilous, I’m sure many people can relate to their own workplace when leadership and front line employees can’t agree on one problem to fix together. Sadly, their “solutions” to the problem that they see individually may end up harming one another.

    Cost is a problem in our healthcare system. Perhaps a focus on stability, safety, and patient-centered care could help solve some of the problems associated with high costs?

    This letter should sit in every doctors’ waiting room as a reminder to make healthy decisions and avoid hospitalizations until they can solve these problems.

  6. Yes, this nurses letter is spot on. I worked as a nurses assistant for 13 years and even though my title says I assist the nurse however the title is misleading. I would watch nurses run around trying to do their job however I could NOT assist them because I could not, set-up a feeding tube, hang an IV, change a soiled wound dressing, ect; better nusring assistants would help relieve nurses of work load and it would increase patient care and outcome significantly and honestly there needs to be some type of “compassion test” to see if a person is caring enough to be in the medical field. There are way to many nursing assistants who are in the field just for the pay check and have zero compassion for the plight of another human being and this alone results in poor patient care, deteriorating a patients condition further and the nurses getting the blame. Nusring assistants are the foundation of patient care and this foundation is very broken.

    • Katherine – Thanks for your comment. Since there are many tasks that nurse assistants cannot help with, one thing I usually ask nurses and a team to look at is:

      How many tasks are being done by nurses that COULD be done by nurse assistants? Often, nurses are doing things out of habit… tasks that a nurse assistant could help with, which frees up nurses to hang an IV, etc.

      Have you seen an organization that you work at do that sort of analysis?

      What are nurses doing?

      1) Tasks or care that nurses MUST do (can only be done by nurses)
      2) Tasks or care that are better if nurses do it, but could be done by others
      3) Tasks that are done equally well by anybody who is trained (meaning the nurse should not take time to do these tasks unless completely necessary


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