The Nursing Shortage - A LEAN Perspective

The term "Nursing Shortage" is certainly not new.  As a matter of fact a Google™ search for it finds 680,000 matches.  The chart below from the Bureau of Health Professions, National Center for Health Workforce Analysis released in July 2002 is well traveled and shows the growing disparity between RN supply and demand.

The study projected a deficit of 800,000 registered nurses by 2020 with 44 states and the District of Columbia having a shortfall.  However, a review of these articles offers relatively few solutions as to how to fix the problem.  Perhaps the most notable exception is the Government's involvement with the Nurse Reinvestment Act in 2002 which makes nursing recruitment and retention in the words of Senator Barbara A. Mikulski "a priority on the federal checkbook". Even with government involvement, the gap continues to widen.  So what should we do? 

First a little background.  I am not a nurse and have only in the last several years become involved in healthcare.  My career as a manufacturing director and engineer has been focused on improving operations, but in my defense Henry Ford said "All our new operations are always directed by men who have had no previous knowledge of the subject and therefore have not had a chance to get on really familiar terms with the impossible."  In other words I bring a different perspective to the topic.  For the sake of this article I want to take a more fundamental approach that takes away some of the emotion and rely on lessons learned by other industries.

Fundamentally, whenever you have a lack of skilled workforce whether it be machinists, engineers, programmers, mechanics, or nurses there are three courses of action an industry can take:  1) Do nothing!  Hope the government solves the problem.  This has a long and storied past.  2)  Increase the number of people (nurses) by spending more money for awareness, training and pay.  However, with health care costs increasing by double digits each year this alone is not the answer 3) Improve the efficiency of the constrained resource (i.e. nursing). 

Once again I turn to Henry Ford who said "The very word 'efficiency' is hated because so much that is not efficiency has masqueraded as such.  Efficiency is merely the doing of work in the best way you know rather than in the worst way."

But how could it be possible to improve nursing efficiency?  Everyone is already pushed to the limit and we all want more time to be spent with the patient as studies have shown it translates into better patient outcomes (Aiken, 2000; American Nurses Association, 2000; Needleman, 2002).

In August 1945, Mr. Kiichiro Toyota, president of Toyota Motor Company at the time, said "Catch up with America in three years; otherwise the automobile industry in Japan will not survive."  Do you think they accomplished their goal?  Today Toyota leads the industry and such American icons as General Motors are in dire straights due in part to rising healthcare costs.

But how does this apply to healthcare and specifically nursing?  The key lies in a lot of hard work and focus on the fundamentals of process management.  These principles have more and more become known as "Lean Manufacturing" a term coined in Dr James P. Womack, Daniel T Jones' and Daniel Roos book, The Machine That Changed the World, based largely on their observations of the Toyota Production System. Lean principles can have a profound impact on any product or service to which they are applied and the healthcare industry is just beginning to understand the potential.

So what is Lean?  Lean is the essential method of removing "fat" or waste from a process. Waste can be defined as anything that does not add value for your customer - or anything for which the customer is unwilling to pay. The application of Lean principles and techniques enables you to remove this waste thus do more with less so that you can reduce costs and deliver greater value to your customers.  In the case of nursing, this means spending more time with the patient while at the same time increasing the nurse to patient ratio.  This is accomplished by increasing the percentage of a nurses time spent performing "value added activities" and less time on "non-value added activities" such as waiting for another function, searching for needed supplies or equipment, waiting in line to get a medication, gathering missing information or medications, and performing "non-nursing" functions such as stocking supplies.

A dressing change is most certainly a value added activity for which the customer is willing to pay right?  Well let's take a closer look. A specialty dressing change was analyzed to determine how much waste was in the process versus the true value added time.  This analysis showed that the total time to perform this specialty dressing change could be reduced from 16.7 to 11.3 minutes (a 32% improvement) by eliminating not the value added portion of the process, but rather attacking the non-value added activities as shown in the chart below.

As can be seen, the Value Added (VA) portion of the process remained unchanged while the non-value added activities (E - Evaluation, MH- Material Handling, O - Other, PW - Pure Waste, RW - Required Waste, and WK - Walking) were targeted for improvement.  In this case, a great deal of waste in the form of searching for and gathering the needed supplies was discovered.  By implementing the Lean principle of a visually managed supply replenishment system that presented supplies to the nurse at the point of use, the improvements were realized.

A multitude of  procedures were analyzed which included dressing changes, medication administration, report, transcription, and even access time to the nutrition room.  By performing a detailed analysis and applying Lean Principles, a time savings of 15-72% could be realized.

But that is just the beginning.  Once all the procedures are known assignments can be made utilizing the new information that ensures the work load is equally distributed between nurses.  Furthermore, performance measures can be implemented that ensure the new standards of care are being met and issues are made visible so real problem resolution can begin.

That sounds like a lot of detail and hard work and it is, but that is what Toyota and other leading manufacturing companies have done.  The implications for nursing are obvious.  More time for patient care, and maybe just maybe closing the gap between RN demand and supply.

Brian Dapp, Chief Operating Officer, AveraOpEx