By October 31, 2012 30 Comments Read More →

The Invisible Waste in Healthcare Leads to Visible Harm to Patients

In a car assembly plant, they do a pretty good job of ensuring that no assembly line worker has to do 70 seconds worth of work in a 60 second job cycle. It’s basic Industrial Engineering and, well, it’s relatively easy since automobile assembly is pretty repetitive – especially compared to an inpatient unit or an ICU in a hospital.

On an assembly line, if one worker (or more) has too much work, the line will fall behind (if they have an “andon cord” to pull to signal for help or stop the line) or defects would be pretty obvious. If a worker were forced into cutting corners, a missing door or a missing bolt is pretty apparent. But, in a hospital, the waste is invisible and the cost is much higher.

Like I said, it’s relatively easy to “balance” an assembly line for cars or engines. The work elements (install this bolt or tighten that bolt) are pretty highly engineered and we know how long they take. If a car plant has to produce a car every 60 seconds, they’ll make sure that each worker has less than 60 seconds’ worth of work at their station (or less than 60 seconds’ worth of work if they want things to flow well).

In a hospital, it’s more difficult to know what 60 minutes’ worth of nursing work is for an individual nurse.

  • Different patients have different needs, given their acuity and condition on a particular day – so there’s more work content (giving meds, checking central lines, etc.) for different patients or even within different hours. We can’t predict or schedule what will happen in a given hour.
  • The times for different tasks (such as starting an IV) can be pretty variable.

If a nurse has different tasks to complete in an hour that, say, add up to 70 or 80 minutes’ worth of work… they can’t be in two places at once… they can’t “stop the line” and pause one patient’s life while they care for other patients. If the work isn’t well designed or there is too much waste in the system (and if nurses don’t have a way to call for help or backup, the way an assembly line would), then it’s inevitable that corners will get cut.

The nurse can only be doing one thing at a time. If there’s 70 minutes of work to do in an hour, decisions get made about what tasks get skipped or delayed. We need to reduce waste (essentially freeing up time) or add staff (something that’s not very practical in this day and age). Reducing waste is preferable to “throwing people at the problem.”

Studies show that med/surg nurses only get to spend 30% of their time with patients at the bedside. They are running around searching for supplies, working equipment, and medications. They often spend more time charting and fighting the EMR system than they spend with patients. Systems and methods and processes evolve instead of being designed. The focus might be on tasks instead of the design of a 12-hour nursing shift. There’s too much waste.

Instead of a door being missing from a car (obvious), maybe hands don’t get washed properly. Maybe a patient doesn’t get checked on during rounding the way they should. Maybe a central line dressing goes unchecked or a call light doesn’t get answered… so an infection develops or a patient falls. Under time pressure, corners get cut and bar codes all get scanned as a batch or two patient identifiers don’t get used… so the wrong medication is given.

The waste (the process problems and the steps that get skipped, the corners that get cut) can be invisible, but the harm is done. The harm (the preventable harm) impacts patients and their families. These problems occur at most hospitals, it seems.

Instead of reacting AFTER a patient is harmed (often in a punitive way), we need to make sure the work is achievable (in a proactive way). Don’t give a nurse 70 minutes of work to do in an hour. You say there’s too much variability to plan this precisely? Then, if we accounted for the variation and the patient truly comes first, then nurses would have idle time more often… a nurse “not doing anything” is far more visible than a patient who is about to be harmed because of corners being cut.

This isn’t the nurses’ fault. This is a system problem. It needs to be fixed with solid Industrial Engineering and Lean methods. Instead of saying “there’s too much variation” and “every patient is unique,” we need to plan workloads better. We need to eliminate waste so patients can get ALL of the care they need and deserve.

Would you buy a car that was missing parts because the assembly line workers “didn’t have time?”

How do we make the healthcare waste visible so we can prevent harm? How do we create an “andon cord” that allows nurses to ask for help, without shame, and actually get them the help they need when they can’t do it all? How do we change the culture so nurses ask for help instead of just toughing it out?


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30 Comments on "The Invisible Waste in Healthcare Leads to Visible Harm to Patients"

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  1. Michael Lombard Michael Lombard

    Wow, Mark. One of the best posts I’ve read in a long time. I completely agree with your assessment of how variability in healthcare presents difficult challenges. Even if more of the work was automated to reduce variability (not my suggestion per se), we’d still have a human as the “product” and all the associated variability. Difficult challenges…that can be overcome through continuous improvement.

    I think you ask a highly insightful question: “How do we make the healthcare waste visible…?” I think your implication is that by exposing waste, we are more likely to do something about it. I agree.

    To make waste visible, I think we need something against which we can contrast it. We need to be able to see the gap between our current state and the ideal state. We need to be able to differentiate between the care we provide and perfect patient care. Wouldn’t it be helpful if everybody from the bedside nurse to the physician to the senior leader could all agree that a particular activity was clearly value-added or non-value-added?

    To get to that point in our thinking, there are a couple of key ingredients:
    1) No Blame…when something is deemed to be non-value-added, we can’t jump down the throat of whoever is associated with that activity
    2) Objectivity…we have to take emotion out of it and be able to accept that highly “valuable” or prized activities can still be technically non-value-added
    3) Theoretical…healthcare professionals are some of the best pragmatists in the world, able to come up with the good solutions for the many difficult situations that arise daily, but we need to be able to put pragmatism aside and think about what might be possible theoretically
    4) Conceptual Framework…we need a clearly defined algorithm for determining whether an activity is value-added or not

    If these elements are in place, we have a fighting shot at developing a shared understanding of what is value and what is waste. If we have that shared understanding, does it guarantee that waste will be exposed and eliminated? No, but it probably can’t hurt.

    • Mark Graban

      Thanks, Michael.

      I agree that exposing waste gives us a chance to eliminate the waste. Fear is such a big barrier to people being open about risks to patients (not theoretical risks, but very real very practical risks) and being open about waste. If staff fear being punished or managers fear being shamed for the waste that’s there, then we can’t start the improvement process.

      I hope that variability is viewed as challenge to work through as we improve, rather than being an excuse or a reason why we can’t even try to improve.

  2. Michael Lombard Michael Lombard

    Taking the shame out is key. We have to have a more impartial view of waste, risk, and variability. Instead of looking at problems as evil, we should look at without judgment and just acknowledge their presence. That puts us in a better mindset to objectively solve problems in a no-blame manner.

    But how do we go about creating this mindset in our organizations?

    Like acquiring a clinical skill or mastering a lean tool, it requires a combination of awareness, education, training, coaching, mentoring, and above all, practice. We often think that it’s enough for leaders to just model the right mindsets, and that surely helps, but let’s put a little more structure around how we engrain the right mindsets.

    What would that structure look like? I’m interested in seeing how such structures might vary from one place to the next.

    • Andrew Bishop

      Of course it’s not terribly useful in the short term, but in the long haul, hiring and promotion based on individuals capability in these areas is important, since some of these capabilities are pretty deep in personality, I think. In healthcare, education, training and mentoring processes are critical, too, since they establish the pool available for hiring. That is a long row to hoe! Many stories of shaming and humiliation in the training pipeline, I’m afraid. Finally and possibly most practical as a “next step” kind of thought, the structure and application of the improvement drill, (Toyota Kata) as laid out by Mike Rother provides a way for people to explore the uncertainty of exposing uncomfortable problems with out judgements. It’s a structure that is all about “creating a mindset” as you put it. Is anybody working explicitly with Rother’s kata in healthcare?

  3. Sean O'Donnell Pharm D says:

    The best way to minimize waste and fraud is to put more of the healthcare spending dollars in the hands of the consumer. We need high-deductible plans with health savings accounts and catastrophic insurance. This will empower individuals to spend their money more wisely and also will drive down the premium cost of the insurance portion of their healthcare plan. Two Wall Street Journal pieces below explain design and success stories.

    ( LINK 1 )

    ( LINK 2 )

  4. Sean O'Donnell Pharm D says:

    With more ” Consumerism ” as it is sometimes called, external pressure from the consumer ( who now has a greater financial stake in the matter ) will subtly ( the invisible hand ) put the right type of pressure on healthcare providers to attack their own internal wasteful behaviors. This is evident in all sectors of the economy where the consumer pays in a direct manner for a product or service.

  5. Mark Graban

    I was writing about “visible harm” in the headline… but the more I think about this, the more I realize a big part of the problem is the harm being invisible in many ways (infections, VAP, etc.). A fall might be visible but might be blamed on a number of factors other than poor process.

  6. Sean O'Donnell Pharm D says:

    I love reading your site. You guys are on the mark with your lean approach to healthcare and other sectors. The “Lean” way of thinking would work well in the “Consumerism Model”.

  7. Shannon Bettenbrock says:

    Great post, Mark! I can’t wait to share it with clients and colleagues! This capacity/demand issue that you describe is also present in other healthcare settings, notably physician practices. Because of hidden wastes, value-added tasks that benefit the health of individuals and communities go undone. As a result, health status suffers- Preventable diseases occur or increase in severity, unnecessary hospitalizations occur…the list goes on. Caregivers blame variability in “patient compliance” and ever-increasing regulatory demands for these undesirable effects. Communities, patients, payers blame physicians and their staff. But as you noted, this is really a systems issue. I don’t think that the burning platform for improvement is as visible in the “outpatient” medical practice environment, but there are forces like increased quality-reporting and consumerism (as Shawn mentioned) that should help bring it to light! To look at the big picture, we have the in-hospital system, the medical practice system, other healthcare services, and the interactions of all of these in delivering healthcare…a complex system of systems. I agree with you that industrial engineering and lean methods are the key to improving the system, large or small, to ensure health and safety.

    • Mark Graban

      Thanks for the comment, Shannon. These same pressures and capacity-demand mismatches can be found in laboratories, radiology, pharmacies, etc.

      The problem is when people are pressured into cutting corners, skipping steps, etc. to make work fit into the time available. There’s a lot of harm that can result…

  8. Andy Hoort says:

    GREAT post!

    As a nurse who has been trying to proselytize Lean to my peers for years this post hit home for me. Instinctively I think all nurses understand these concepts, they just think there is no changing the beast. Unfortunately, the number of ??? marks in your post might lead one to believe they are right.

    Give me some hope! Who are some of the health care organizations to benchmark in nursing variation measurement and tracking?

    • Mark Graban

      Thanks, Andy.

      On the “hope” side — Virginia Mason Medical Center in Seattle has done GREAT work in this area. They claim taking patient bedside time from 30% (the typical start) to over 90% (a claim I am a bit skeptical of, not having been to their bedside, but I trust them). They were featured recently on PBS News Hour:


      ThedaCare (in Wisconsin) has also done amazing work in the redesign of inpatient care, letting nurses take a lead role in increasingly team-based care (with MDs and RPhs).

      Big challenges… I have discouraging days sometimes when I see so much waste and so many fundamentals that are lacking (training, basic process, etc.)… but improvement is happening. Maybe I’m just impatient that it’s not happening overnight.

  9. Al Norval says:

    Agree Mark.

    When we look at work in an automotive factory, not only is it less variable but more of it is value added meaning there is less waste in the work.

    In Healthcare, the work is variable and a much lower percentage is value added to the patient meaning there is more waste in the work.

    I’d suggest that reducing the waste in the work will make the system more stable. To do this we need to make the invisible waste – visible so we can problem solve it.

    • Mark Graban

      Thanks for the comment, Al.

      You spurred a slightly different thought… on an auto assembly line, the assembly workers (those adding the value) aren’t expected to go run and fetch their own parts, etc. The non-value-adding work is offloaded to support staff (material handlers, etc.) so the assembly workers can focus on the the product and the value adding work.

      Why do we force nurses to do so much non-nursing work, such as running to fetch supplies, equipments, meds, etc.???

      There are nurse assistants, techs, housekeeping etc. — but maybe we don’t have enough of them to truly support the nurses.

      Same goes for doctors in the ED… why are they spending time charting when they could have a scribe who types for them (typing faster and getting the doctor back to the patient sooner)?

      Part of the variation of healthcare work, I think, is the lack of proper separation between patient care and support work.

      I think if nurses spent more time being nurses, pharmacists spent more time being pharmacists, etc. then the whole system would be better off.

  10. Andy Hoort says:

    Your case in point: Nurses at my hospital caring for 3-5 patients…

    1) Call in orders for patient meals.
    2) Hand deliver lab specimens to the lab five floors down.
    3) Wheel their own stable patients to tests and procedures throughout the hospital.
    4) Pickup medications from the pharmacy three floors down and in a different building.
    5) Search for missing supplies/equipment and obtain needed supplies from central distribution five floors down.
    6) Answer call bells and phones and direct them to the correct nurse/patient.
    7) “Strip clean” rooms after patients are discharged.

    Not a one of these requires a nursing degree to complete. However, they do account for the bulk of my day and most of my headaches (ie variation) and also prevent me from providing valuable education, comfort, and attention to signs/symptoms of deterioration in health.

    • Mark Graban

      That’s exactly the problem I was thinking of, Andy. Are there ever any discussions of offloading those tasks to support staff? I’m pretty certain that increasing labor in a few support roles would actually reduce cost overall for the hospital, but that’s sadly a difficult case to make.

  11. anonymous says:

    I’ve seen first-hand how maddening invisible waste is to a Lean “expert” transitioning from manufacturing to healthcare. As someone who facilitates improvement, I also feel bad setting care providers and other staff up to fail by giving them duties that can’t consistently be completed in the allotted time. I especially feel bad when I see better designed service delivery models at hotels, grocery stores, and even some fast food restaurants. Some of this problem is the tradition of healthcare but the major culprit in all of this is leadership.

    Obviously there are opportunities to eliminate waste at the point of service. This can and should be done. It takes no leadership to command nursing floors to do 5S. 5S can help, but only to a degree. Beyond that, we have seen organizations like ThedaCare blow up the nursing care delivery model so that ”excels at work-arounds” isn’t part of the job description. This takes real leadership.

  12. Heather

    I think adding more support personnel is an excellent option to reduce waste. It is more cost effective for the company as they are able to pay entry level techs less than they would be paying an additional RN or MD. In today’s job market – this option also positively impacts our economy by employing a greater number of people in the community.

  13. Ben Panton says:

    Hi Mark
    Just wanted to thank you for a really clear and well articulated article. I enjoyed reading it and the follow up comments it generated. I will use the questions you raise for discussion and prompts with my Operating Theatre colleagues as we go through a redesign process.

  14. Jamie Voster says:

    Great article Mark.

    I think in any industry it’s difficult for some to ask for help. We do a daily huddle every day, one of our topics is “Support Opportunity” this is a great way for each of us to get the help we need without feeling like we’ve “failed” or can’t do our job. It’s an opportunity for others to help. Since we’ve implemented our daily huddle, at least 2 times a week, we have the opportunity to help our co-workers. It’s a great feeling!!

    • Mark Graban

      Thanks for sharing that, Jamie!

      At one hospital I worked with, the CNAs (techs) did a similar huddle twice each shift. They asked who needed help and they reassigned (balanced) workloads on their own. They managed this on their own, without any direct intervention by the manager or other leaders.

      The same idea was then presented up to the nurses, who said no thanks.

      I think sometimes the higher you go in an organization (or in education level), the less likely (or the more scary) it is for somebody to ask for help. Needing help because the workload is too high or because you forgot how to do something shouldn’t be viewed as a sign of weakness or as being a bad employee, but it (sadly) often is.

      That’s a big part of the culture that needs changing.

  15. Ken says:

    I have a vision that as we move into computer charting a team leader could monitor when care is falling behind in real time. At that point additional resources can be dispatched.

    • Mark Graban

      Ken – even better would be leaders actually out in the unit being able to communicate with their nurses and staff. At some hospitals, the nurses put red/yellow/green flags on their computer carts to serve as a visual signal that they need help… I’d tend to rely on things like that (simple and observable) rather than having somebody stuck behind a desk monitoring computers. Maybe we can do both.

    • anonymous says:

      To Ken, Monitoring (or seeing) when care is falling behind would be the holy grail for healthcare. ThedaCare has done well on a number of fronts with this, but “seeing” abnormal isn’t always possible. I suppose if it was, then House (tv program) would be half hour instead of full hour episodes. The nature of the human body is that there is a large amount of variation. The culture and tradition of healthcare is largely ungoverned by standards. So…. how does the traditional lean manager manage in such an environment?

      My approach would be to make visible what you can, develop standards where possible, focus on developing leaders and staff because they will be the eyes and ears for improvement much more than in manufacturing, and be very, very patient. Oh, by the way, patience is not an attribute shared by many in senior positions.

  16. Paul Akers says:

    Mark that was a great question. My take, create a culture that can see waste, then eliminate the waste through small tiny continuous improvements…no magic bullet.

  17. I am originally from automotive sector, and now, I have transferred over my credentials to the healthcare side, as six sigma black belt, I ‘ve realized that there is this waste of non-underutilized talent so prevalent in healthcare.These are the 8 forms of waste:

    8 Forms of Healthcare Waste
    Not utilizing the creativity and talent
    of all employees
    Extra processing
    Of all these, the “Non-uder(un)utlized talent” is also the most visible one in Healthcare. When I was doing a project in Surgery, I’ve realized that some of the tasks the nurses can be fulfilled with the help of a Nurses Aid.They include:
    1. Draw Labs
    2. Send Urine Samples
    3. Change Patient into surgical attire
    4. TED hose/SCD sleeve
    5. Surgical Clippings-All these functions does not require clinical expertise.

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