Multiple models guide quality improvement and safety efforts. This article focuses on the Lean approach, and describes one hospital's experience using Lean to improve obstetric triage.
What is Lean?
Lean is a quality improvement approach focused on what’s important to the customer and on eliminating wasted effort, time, cost, or materials. Lean is implemented through streamlined processes and keeping or eliminating steps based on their value-add.
For example, the ThedaCare healthcare system in Wisconsin used the Lean approach during the redesign of their patient rooms. They moved supplies, medications, and electronic-record keeping systems into patient rooms. As a result, nurses were able to spend 70 percent more time with patients (Catalyst, 2018).
History
Henry Ford was one of the first individuals to use basic Lean principles, at Ford factories in the early twentieth century. It’s how his company transitioned from individually handcrafted cars to mass production using assembly lines and standardization of tasks. Toyota later refined Ford’s initial methodology, introducing concepts such as standard work (the most effective way of doing a task), developing error-proof processes, and paying attention to customer value (Barsalou, 2013)
Lean Tools
Lean methodologies use tools such as value stream mapping, standard work, 5S process, Just Do Its, and the A3 process. Value stream mapping is a process in which a team maps out and visualizes the steps in a process to identify and eliminate areas of waste, inefficient flow, or errors (AHRQ, 2020). After mapping, standard work is created, showing the best way to do a task, with all the steps laid out, including who does what. The standard work procedure is shared with staff and becomes standardized practice.
The 5S process improves organization and cleanliness. It includes the following steps:
• Sort necessary items and remove unnecessary items
• Set items (organize)
• Shine the area (clean)
• Standardize the area
• Sustain the effort
(Kelly et al., 2018)
An example of 5S in action is organizing a utility room according to how items are used. Intravenous start supplies would be stored together since they’re always used together. 5S organization eliminates time spent searching for supplies.
Just Do Its are simple solutions for minor problems. They require minimal effort to implement. For example, if staff are unaware of a new standard procedure, the Just Do It solution is to provide training on the new procedure.
Finally, A3 processes are used on large projects that require multidisciplinary input and take time to implement. The following vignette regarding triage of obstetric patients describes the A3 approach.
Clinical Vignette
In this hospital example, triage occurred on the labor unit. Care providers assigned to triage could also be caring for patients outside of triage. Data review showed the average length of stay for triage was greater than the average for similar units. Literature review showed the average length of stay for units of similar size and structure was 2-2.5 hours. The A3 approach was used to evaluate the problem and develop countermeasures. A multidisciplinary team identified the problems and engaged frontline staff in the process.
• Identify the problem – Length of stay in triage was greater than the norm for like size/ structure units.
• Identify the gaps – Audits were completed to determine causes for long triage times.
• Establish a target – Knowing there would be circumstances that warrant longer length of stay (e.g., extended monitoring after a motor vehicle accident, ruling out preeclampsia), a target was set for 3 hours length of stay for most patients, with a focus on term labor patients being evaluated in a timely manner.
• Determine root causes – Audits identified the most consistent cause for increased length of stay was related to medical care providers having responsibilities outside of triage (attending deliveries, rounding on other units).
• Develop countermeasures – A business plan was created and showed the need for a dedicated nurse and provider model in triage.
• Put countermeasures in place – After budget approval, a certified nurse midwife was hired to cover triage during peak times. A dedicated nurse was assigned to triage for all shifts.
• Monitor process and data – Length of stay was monitored and showed a significant reduction in length of stay related to dedicated provider coverage in triage.
• Standardize processes that work
(Kelly et al., 2018)
In summary, Lean is a model that engages frontline staff in quality improvement. It offers a range of simple to complex tools, with a goal of streamlining processes through elimination of waste based on what’s important to the customer.
C-ONQS Practice Questions
A multidisciplinary team identifies that their unit has long length of stay times in their triage unit. The team reviews all the steps in the process from when the patient arrives to discharge. One area of inefficiency identified is the initial provider assessment.
The medical student is often sent in first to see the patient, who then relays information to the resident, contributing to a delay in the initial assessment by the resident. The process is then streamlined to remove medical students from seeing the patients prior to the resident in triage. This is an example of which Lean tool?
5 S Process
Just Do its
Value Stream Mapping
In this same project, a document is created which details all steps in the triage process, including what each care provider does and when. This is an example of which Lean tool?
A3 processes
Just Do its
Standard work
Answers:
c value stream mapping
c standard work
*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide
Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS
References
Barsalou, M. (2013). History of Lean Manufacturing. Retrieved from https://www.qualitymag.com/articles/91504-history-of-lean-manufacturing
Catalyst, N. (2018). What Is Lean Healthcare? Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0193
Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2018). Introduction to Quality and Safety Education for Nurses: Core Competencies for Nursing Leadership and Management. Springer Publishing Company
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