How to mobilize an entire nursing unit

A recurring question is how you can mobilize an entire team, unit or department to work with lean. Too often, I see small groups of enthusiastic people who are wondering how to get the rest involved. One element you can use is a training for the entire unit. For the department of Orthopaedics this seemed to work well.

Recently, the department of Orthopaedics organised one evening and one day training in the Lean principles and tools for the entire care unit (60 nurses). They were very well prepared! Four months before the training day, they started to prepare and work towards it. All three departments (secretary, nursery department and outpatient clinic) got a digital camera in November to photograph improvement points or irritations (based on an idea of Neruosurgery, see previous blog), which provided more than 50 photographs of concrete waste or unsafe or unpleasant situations. These pictures have been printed on A3 size and laminated. At the training a reward was given to the person with the most striking picture. These pictures were used as starting points for improvements. Smart, because in this way you directly got 50 points of improvements provided by the people themselves on which they want to work.
 
They also made a movie for the training. They have put the process in scene from the moment that the OR calls for a patient to come for surgery until the patient is ready to leave the nursing department. This process takes 15 minutes, because the patient must change clothes, visit the toilet, medication is given and the bed prepared. The movie showed a lot of types of waste (that were actually not put in scene, but really happened). Employees recognized these immediately. A few examples:

- Cotton balls were out of stock when the medication needed to be prepared, new cotton balls had to be taken elsewhere
- No IV pole available on the bed, had to be taken out of another room (and there the problem will start again with the next patient)
- No ‘parret’ or parrot on the bed (so that the patient can pull himself up in bed), this parrot was also removed from another bed in another room (where it will be gone for the next patient)
- The nurse had to walk up and down several times to get something which she could also get at the same moment. For example a glass of water for medications, OR clothing and bellovac medication.
- Nurse had to wait for the patient that went to the toilet. This could have been done parallel with other activities
- A call came in from the OR that they had forgotten to give the patient some medication.
 
All in all, the conclusion was that the activities can be done in half the time, seven or eight minutes. And this would save seven or eight minutes many timee a day. It became clear that filming a work process is a wonderful trainings tool.
The training itself was designed as follows:

Evening show: The whole care unit came together from 7:00 p.m. to 10:00 p.m. to learn more about the principles of lean thinking and a first exercise was done to apply the principles to their own practice (what is value, what is waste, what processes do you work in?). The introduction of lean thinking was done by Dirk van Goubergen, who put on a great show. At this evening also the prize for the most striking picture was presented.
One week later: “a day practicing with lean thinking”. We arranged this day by ourselves in the hospital (1/3 of the group, all disciplines together, one week later again 1/3 of the group and a week later again).
- Start interactively with post-its: what would you like the care unit to achieve with lean thinking?
- What is value and what is waste? A discussion about values in practice
- How to recognize the seven forms of waste? An exercise with a video recording with a practical (non-healthcare) example and participants are asked to call out any time they see a form of waste. After the video the group thought of improvements to increase value and effiiciency.
- How to analyze a process? The movie of their own process was used in groups of 5 or 6 participants. Create a (simple) process description and indicate where value is created. What types of waste do you see? What are ideas for improvement.
- Each team selects a problem and applied the A3 method:
1. What is the problem?
2. What is the current state/practice?
3. What causes the problem?
4. What is the ideal state/practice?
5. Then (!): What are possible countermeasures?
6. Concrete agreements how to test and evaluate a countermeasure
 
- In the afternoon the A3 method was applied again, but this time on a picture that the participants themselves created. A new element here is that in each team one person observes the team dynamics and whether or not the A3 method is applied appropriately and this person’s task is to appoint where the team can improve. Most mentioned points of improvement were not to jump to solutions, but to understand the problem first. Another point of improvement is to listen more carefully to each other.
- The group was then split into two sub groups:
o One group went to analyse the daily rhythm of the department: what do we at what time and which activities come in between other main activities? What is the busiest moment and are we able to perform those activities in another way or at another time? The group became enthusiastic, especially when regular rountines were questioned. At one point there was even asked why patients have to conform to the rhythm of the department rather than the other way around. They actually started an experiment on this subject, which will be discussed into more detail in a later blog.

o The second group went to a workplace to look how this place could be better organised using the visualization tool. To their surprise, a lot of concrete ideas were created.

- The training ended with a discussion of what had been learned that day and what the participants would remember at home. Besides a number of concrete actions created with the A3 method, the following aspects were mentioned: it is surprising to see how much room for improvement there is, it is nice to do this together, it is important to first understand a problem before we think of solutions, organising workplaces better (with visualisation) and to make a day rhythm more suitable for the patient.

Since the training, all kinds of things are happening: a photo board has been made on which three pictures are placed of waste and the way they are being improved, improvement boards are used (see previous blog), and the management is asking itself how to give more structure to all improvement initiatives. These are the better problems to worry about!

P.S. My gratitude goes to Nieki Peerbooms for translating my Dutch blog