A couple of weeks ago I had the opportunity to return and see my friends in the Netherlands, and I’d like to share some observations from the Lean Thinking in Healthcare Symposium I attended over there.
But that conference was on Friday. I arrived in-country on Monday morning at 7:30am. By 10:30 am I was in sterile scrubs in an operating room observing a knee replacement operation. (I was told of this agenda while on the way there, at about 9:30.) I’ve got to say it was quite an interesting experience, and here is my public, if belated, thanks to Dr. Jacob Caron, who graciously brought me into his domain. Thanks, also, to his patient for allowing me into this bit of her life as well.
The experience was fascinating, and enlightening. Here is the core value-add of a long and complex process as the patient is moved through the various stages of treatment. And at that core, things are organized, quiet, efficient. Of course it is nothing like an O.R. on television. Drama is the last thing a real-life surgeon (or patient, for that matter) wants in the O.R.
The work flow of instruments caught my eye. We all know that the surgeon asks for the instrument he needs, and the O.R. nurse hands it to him, usually anticipating his request.
But there is a return flow as well. As the surgeon is done with an instrument, he puts it down as he asks for the next one. The O.R. nurse then quickly picks it up, wipes it (if necessary), and re-orients it so she can pick it up quickly when it is needed again.
None of this is really surprising with a little thought. I imagine the tight circle around the patient is organized pretty much the same way in every operating room in technologically advanced countries. In manufacturing, we use the “like a surgeon” analogy to describe how team members who directly add value should be supported.
Later that afternoon, I was touring the ward where the orthopedic surgery ward with the supervisor.
They are working on kaizen, they have an Problem – Improvement board and do a decent job keeping track of things that disrupt work.
“No time” seemed to come up a lot as a reason for the nurses. And, from what I know of the workload of hospital nurses, this is not a surprise either.
But where does their time go?
Let’s consider that nurses are the front line. Yes, the physicians get the attention, but aside from cases like surgery, it is the nurses who actually deliver the care to the patient. In other words, though the physicians design the care, it is the nurses who actually carry it out.
So here was my question / challenge to the audience at the conference:
No operating room in the developed world would ever tolerate a situation where the surgeon had to go look for what he needed to deliver care to the patient. The surgeon’s world is fully optimized so she can devote 100% of her attention to the patient.
Yet, in those very same hospitals, all over the world, we tolerate – every day – conditions where nurses, who are also primary care providers, spend too much of their time fighting entropy, looking for what they need, improvising, dealing with interruptions – all of the things we would never tolerate in the O.R.
Why the disparity?
I think this is just another version of a burning platform. The surgeons HAVE to be that precise and everyone knows they have to be. If they aren’t, the consequences are going to be immediate and incredibly negative almost every time they make a mistake. The nurses can probably make 5-10 mistakes without having a serious negative consequence. They absolutely need to be better but the urgency isn’t as high.
I have a very similar experience in our facility. Single piece flow and inventory control was historically a “won’t work here” topic (of course). But there just happened to have always been a stellar example of it that never required any lean focus in order to happen. In our explosive areas, there have always been very strict inventory control regulations for obvious reasons. No one wants to have large piles of senstitive and energetic materials sitting around. When you aren’t clean, precise, and consistent, people die. The effects are immediate and they are obvious.
When the lean tools were introduced to this area, they were absorbed almost immediately with very few hiccups. For the most part, the tools weren’t all that out of the ordinary. They refined things that they had always done. They have to be good, so they are.
On the other side of a wall (a rather thick reinforced wall..), the world is completely different. The natural burning platform doesn’t exist so it has to be created.
Urgency is all relative of course and it is all about perception.
“Why the disparity?” is a great question. I think Kris nails it.
However, I would edit ‘The nurses can probably make 5-10 mistakes without having a serious negative consequence’ – replace ‘mistakes’ with ‘time wasting delays/interuptions’. If a nurse makes a mistake, it can have significantly negative consequences. If a nurse’s task is delayed, the consequences are typically not as consequential.
I still return to the core message: The vast majority of the care is actually delivered by the nurses. Outside of a few exceptions, the nurses are the value-adding element in health care.
In production, we spend a great deal of effort to ensure the direct-value-adding team members have what they need, where they need it. We ensure they have a way to let us know the second they detect an issue, so we can intervene, correct the situation, and restore the normal pattern of work.
Surgeons get this kind of support in the O.R. But in their day-to-day interaction with patients, the vast majority of the people delivering care do not.
The reasons, I think, have more to do with tradition than anything else. Nurses have traditionally been expected to figure things out and work the system. Many times it does not occur to them that they are doing things that should not be necessary.
As for the errors and omissions – yup. Nurses make life-and-death decisions all day. They are exposed to probably hundreds of opportunities to make errors through the course of their day, many of which could be designed out of the work. Most of the time they get it right, and most of the rest of the time they “catch” things before anything bad happens. But this is a source of constant, and unnecessary, stress, and one of the reasons the profession has such a high burnout rate.
Tradition or perception, they both come down to the way people think about things. Current perception is that nurses time and focus isn’t as important as a surgeons. Your contention is that this is a flawed tradition. I agree.
A bit of trivia… it was Frank Gilbreth (early IE) who observed in operating rooms that surgeons spent more time looking for instruments than they did performing the procedure. Gilbreth suggested a “surgical caddy.” It took more than 15 years for the AMA to accept this as a best practice.
There’s plenty of waste surrounding the O.R., typically. Lots of cases get delayed due to missing orders, missing lab results, missing instruments, slow room turnover, etc. So let’s assume surgeons are politically powerful in organizations… that doesn’t mean all waste is gone.
In the U.S., part of the dynamic is that hospitals try to keep surgeons happy especially if the surgeons are not employees… the surgeons CHOOSE (pretty much) where they bring their patients to.
Nurses, however, are employees so I guess the hospitals figure they will just tolerate the waste, or they can just leave.
I don’t think hospital leaders honestly WANT their nurses to have a lot of waste – they are just blind to it because they confuse motion with value and they aren’t on the gemba to see the waste.
I’m jealous that you got to see my friend Dr. Caron operate!