For success, Lean requires facilitywide commitment

Otherwise, it may not increase care time

A lot of hospitals and other healthcare organizations have been talking about Lean management and the Toyota process. Indeed, there have been dozens of academic studies related to its techniques in the last couple of years alone. But just because people are using the management model pioneered in manufacturing, and although many report robust financial savings from projects implementing it, does that mean that patients are getting better care?

Maybe not. A study in the April issue of the Journal for Healthcare Quality looked at 34 articles related to Lean management and the Transforming Care at the Bedside initiative to see if such projects lead to more time for direct patient care.1 After all, Lean is all about removing waste and improving efficiency. It would follow that projects designed with Lean techniques would probably result in more time for nurses to take care of patients. But that’s precisely what author Tiffany Brackett, RN, and her colleagues didn’t find. Indeed, all but one article found that even if there were positive effects from the Lean projects, they didn’t show any increase in time spent by nurses caring for patients. There may be increased safety or some other beneficial outcome, but given the strong, proven relationship between direct nursing care and patient outcomes, what does it mean that Lean doesn’t lead to more of that?

“I know that everyone in healthcare agrees that if you want to improve outcomes, then we need to spend more time with patients,” says Brackett, performance improvement and patient safety coordinator at MedWest Health System in Clyde, NC. “Caring, communicating, and helping prevent complications — that’s what we do.” Many organizations have spent a lot of time and money hiring consultants to figure out how to achieve that. “For the last several years, I’ve heard all about Lean and Lean projects. We have invested a lot of money to train a few people in Lean practices. We have done time study and step studies and moved supplies. But it hasn’t really changed anything. The reason I wanted to look at this is because everyone was talking about Lean, but I wanted to see the proof that it worked for nursing.”

She suspected that what might work in radiology or a lab where there was little variability probably didn’t translate well to nursing, where every patient and every case is different. “Reducing variation is certainly a good thing, but you don’t have a standard patient. Every case is individual, and if you have a patient who is awake and alert, well, you can’t ‘Lean’ that patient.”

Some things might save dollars, but “if they are using Lean to say that they are going to save us time so we can do more patient care, well, it doesn’t work.” She found one study that reduced the time nurses spent on documentation, but the little time saved didn’t translate to more patient care. And even when efficiency was obviously increased — think of projects that move supplies closer to the patient — it doesn’t provide the nurses with enough extra time to spend with patients. Brackett wonders if the savings accrued to some of these organizations even begins to pay for the time and financial investment in Lean training.

What does work is more support staff. As hospitals dealt with fiscal crises and the economic downturn, many let go ancillary staff that handled many tasks that now fall to nurses. Rehiring them, says Brackett, would allow nurses to go back to caring for patients. “It’s the ultimate conundrum: how to give more time at the bedside without more resources.”

There is one exception to what Brackett and her colleagues found in their literature review: Virginia Mason Hospital in Seattle. For the last 10 years, the hospital has been on a journey to remake itself as a Lean organization, from top to bottom. And that has paid off. For nurses at the hospital, the Lean method has led to more time spent in direct patient care.

What is different there, says Brackett, is the level of investment the organization made in Lean. It wasn’t just a few people, or just a project here and there. It is a top-down remake of the hospital, from C-suite to housekeeping. Everyone at every level of the organization is invested.

Leader of the pack

For nearly 30 years, Dana Nelson-Peterson, DNP, MN, RN, the administrative director for ambulatory nursing services at Virginia Mason, has seen the practice of nursing change. But one of the biggest changes she has seen has been in the last eight years. The decision to adopt the Toyota production model and make it their own has led to “a considerable turn-around in the amount of time we spend at the bedside.” While not a randomized controlled study, the Virginia Mason case study that Brackett looked at related the transformation of a nursing unit that more than doubled the time nurses spent on direct patient care by cutting out waste and inefficiency.2

Janine Wentworth, RN, the administrative director for patient care, came to the hospital just before the management transformation started. “All the units had different standards in how patient care was delivered. The Virginia Mason Production System helped us standardize the work so that it more consistent. There is less searching and no more trying to figure out what the sequence of work we do on this unit is because it’s different than that unit over there.”

From 35% of time spent at the bedside to 78%, from more than 5,800 steps per shift to just under 900 — they are significant accomplishments. And they continue to measure the impact of their changes. “We measure at set intervals,” says Nelson-Peterson.

The cultural shift over the last decade is a complete turnaround, Nelson-Peterson says. “It has permeated every level and every process, from interviewing and onboarding of new staff to orientation. If you are in a leadership position, you got through Lean certification. Leadership then does presentations on our model through the Virginia Mason Institute. They tell the organizations who come here looking for a silver bullet that there isn’t one. This has to be an overall change in how you do business, and a complete commitment to it.”

Executive leadership doesn’t sit on their laurels after certification. The CEO, the COO — they run workshops for others, says Wentworth. All physician section heads go through a course on the Virginia Mason Production System so they can learn to lead “kaizen” or continuous improvement meetings. All section chiefs and physician executives go through Lean training, and residents have an elective option to participate in kaizen events. “They are eager to do so, and many choose this residency just for that,” Wentworth notes.

The hospital has become a magnet, not just for employees, but for other organizations that use Virginia Mason as a template for how to make Lean work. And it will take a significant investment to do so. While there isn’t any lump sum figure that either Nelson-Peterson or Wentworth can provide for the cost of transforming Virginia Mason, they do give an idea of the time commitment leaders have to make.

Nelson-Peterson spent a year going through certification, which was like an additional quarter-time job along with her regular work. She is a kaizen fellow, which required another 18 months of in-depth learning. And she spent more than three years in the kaizen promotion office.

Wentworth says that a typical rapid process improvement project will involve 10 people, all of whom are paid, and will take a week of their time. “Maybe that’s more than when it was a bunch of people in a bunch of committee meetings for quality improvement. They were all getting paid, too, but the outcomes weren’t as good.” Time spent in such activities is part of the non-productive time budget, and she says that she hasn’t seen an increase in that. Indeed, if anything, she is seeing better productivity with the hours everyone has. Nurses spend more time with patients without having an increase in nursing hours because they are more efficient. “More people are doing the right work for their position.”

Nelson-Peterson says that the organization didn’t jump from nothing to a complete Lean organization overnight. It was a journey. “We started with a couple people in the kaizen promotion office. Now there are 35 who are the leaders, working beside frontline staff. That is necessary to make this a whole organization process. You can have one unit, or one executive excited about this. But you can’t turn a ship that way. You have to have a shared vision and an organizational commitment to where you want to go.”

Wentworth says you have to build the structure for learning, and you should start with the top and work down. “That’s the right way,” she says. “Senior leaders stayed solid through the bumps on the road. Starting at the grass roots and working up, it’s harder to weather the storms that come with any big change.”

The journey isn’t over, either. When the teachers — senseis — come to Virginia Mason to check in, the learning continues, says Nelson-Peterson. “Just last week we had one here and we were pushed to consider new perspectives. Ten years into it, we are still babies compared to Toyota.”

One unit and growing

When people in healthcare talk about Virginia Mason and Lean, they talk in near reverential tones. They all know that the Seattle hospital is among those that do it best. But most organizations don’t have the means or the will to reinvent themselves completely. And while research may show that it takes a big commitment for Lean to be successful at the bedside, there are organizations that feel doing something on a smaller scale can still have a big impact.

At Barnes Jewish Hospital in St. Louis, the techniques have been used in a variety of projects across many disease states in the department of neurology. The most recent was a study related to door-to-needle time for stroke patients to get tPA.3 Jin-Moo Lee, MD, PhD, the director of cerebral vascular disease section, department of neurology at Washington University and Barnes-Jewish Hospital did a value stream analysis looking for inefficiencies in the process.

National guidelines say that tPA must be administered within four and a half hours of the onset of stroke, and earlier is better. Studies looking at door-to-needle time show a lot of variability in how fast this happens. The national average in 2011 was 80 minutes, but the experts say the average should really be 60 minutes, and only a quarter of the stroke patients in the U.S. were getting it that fast.

At Barnes Jewish, they were right around 60 minutes. After examining processes, including everything from routing of patients to how long lab results took, they were able to cut that down to 38 minutes. It’s been 18 months and the time has held steady. Even better, Lee says that the distribution of patients and when they get treated has changed. The people at the far end of the spectrum are getting help much faster than they used to. And while whether this translates to good outcomes is hard to tell given the relatively small number of cases, Lee says he has “no question that this is working.”

Brian Hoff, MS, the lead performance engineer at Barnes Jewish, is a Six Sigma Blackbelt who has helped multiple departments explore how Lean can improve what they do — radiology, the emergency department, and even the HR department have all created Lean projects. For nursing, they have looked at issues related to nursing stations, rooms, hallway clutter, and other environmental issues that waste provider’s time. For instance, a visual management supply replenishment system has made it easier for nurses to see at a glance what is in stock and what is running low. A discharge project that looked at the entire continuum of care, from inpatient to rehab led to changes in the way handoffs were made and streamlined the process so that patients had shorter length of stay. In addition, Hoff says that more patients were discharged directly to home, rather than to a rehab hospital.

It’s hard to correlate some of the benefits directly to the Lean elements of a project, but Hoff says he thinks in some cases, saving time and space here and there makes a big difference. In other cases, it might be a matter of seconds. Will that translate to more direct patient care? It’s hard to say. But he thinks that patients are benefiting from Lean regardless.

“I am a 100% believer,” Hoff says. “If you look at individual projects and actions, and you expect dramatic results, that’s not what it’s about. It’s about looking for waste — every person, in every job. Then you get everyone to keep an eye on the process and find a way to fix it. Over time, it adds up to big, big change.”

Virginia Mason has certainly taken it to the next level, but in the end, they aren’t as big an organization as Barnes-Jewish, says Hoff. With so much complexity — multiple sites and organizations, including a university, a hospital and BJC Healthcare — it’s too big. So they settle for bringing Lean into specific parts, like neurosciences and administration.

Success breeds interest, says Lee. “Some of our other departments are watching what we do. Pioneering success will pull other groups in eventually.”


1. Bracket T, Comer L, Whichello R. Do Lean practices lead to more time at the bedside? J Healthc Qual. 2013 Mar;35(2):7-14.

2. Virginia Mason case study on nursing time at the bedside:

3. Ford AL, Williams JA, Spencer M et al. Reducing door-to-needle times using Toyota’s lean manufacturing principles and value stream analysis. Stroke. 2012 Dec;43(12):3395-8. doi: 10.1161/STROKEAHA.112.670687. Epub 2012 Nov 8.

For more information on this topic, contact:

• Tiffany Brackett, RN, Process Improvement and Patient Safety Coordinator, MedWest Health System, Clyde, NC. Telephone: (828) 734-6983.

• Jin-Moo Lee, MD, Ph.D., Director, Cerebral Vascular Disesase, Drian Hoffepartment of Neurology, Washington University, St. Louis, MO. Telephone: (314) 747-1138.

• Brian G. Hoff, MS, Lead Performance Engineer, Barnes Jewish Hospital, St. Louis, MO. (314) 747-3000.

• Dana Nelson-Peterson, DNP, MN, RN, Administrative Director, Ambulatory Nursing Services, and Janine Wentworth, RN, Administrative Director for Patient Care, Virginia Mason Hospital, Seattle, WA. Telephone: (888) 862-2737.