To sustain improvements, organizations need a strategy to engage and standardize the work of frontline managers. Leader Standard Work (LSW) is a Lean concept that ensures standard work processes and practices are in place and consistently followed.1 This approach is a driver for leadership success through continuous process improvement and is applicable to all leaders regardless of their organizational level. Standardizing a leader's work allows for enhanced organizational performance while creating time for the leader to focus on important activities. Standardization of work permits a leader to spend their time more efficiently. Leaders can devote time to other tasks including coaching and performance accountability, thereby raising the performance of their team.
Healthcare organizations are often challenged with improving processes to be more efficient with a goal of improving the quality of patient care to meet benchmarks without increasing costs. When process variations are removed, waste is reduced, efficiency is improved, and teams can deliver safer care with improved patient experiences.2 Lean principles, adopted from the Toyota Motor Company, have been successfully used by healthcare leaders to change culture and sustain improvements.3-5 Healthcare leaders have also used other processes including the Deming cycle (Plan, Do, Check, Act), which are often short, time-limited cycles to keep departments involved in continuous process improvement.6 LSW supports leaders in increasing their impact by adjusting the way they think and manage, thus building performance consistency. To effectively transform an organization's culture and gain process sustainability, 3 key LSW components should be incorporated into leadership training: calendar alignment, visual management tools, and leader walks.
LSW Step 1—Calendar Alignment
Calendar alignment ensures a leader has enough time built into their schedule to be a leader and complete other LSW components such as leader walks, known as Gemba Walks.7 Grouping of required reoccurring meetings to specific days and times creates added capacity to allow focus on other things in the leader's view.8 When this concept is introduced, many leaders feel this is not necessary as there is a perception that calendar alignment takes time away from other activities. Providing a thorough explanation of the step of calendar alignment including examples of a balanced, aligned schedule will help identify the benefits and support buy-in. Grouping meetings and administration duties to specific times and days promotes work-life balance with increased job satisfaction. When leaders have a repetitious, consistent schedule, frontline staff become accustomed to this and learn to expect it, allowing them the opportunity to regularly engage with their leaders.
LSW Step 2—Visual Management Tools
Leaders need visual management tools such as checklists or flow diagrams when identifying areas for improvement and when conducting their leader walks (Supplemental Digital Content 1, https://links.lww.com/JONA/A911, and Supplemental Digital Content 2, https://links.lww.com/JONA/A912). These checklists or diagrams contain detailed steps of a process and are an important reference tool for a leader when conducting observations, coaching, and holding people accountable to follow a designed process.
LSW Step 3—Leader Walk
A leader walk is time set aside in 1- to 2-hour blocks each week by nurses and physicians and other leaders. It is often helpful for the medical director and nursing director walk together in a care setting, providing them the opportunity to make the same observations but from different perspectives.9 Leader walks also provide leaders an opportunity to have an in-depth knowledge of process details. During the leader walk, time is spent observing any process specific to the department, watching for variability, obtaining feedback from staff on how to improve, and coaching staff on expectations.
An example of how these steps have successfully been implemented to drive change, along with details of the implementation and methodology, is available in Supplemental Digital Content 3 (https://links.lww.com/JONA/A913). In this emergency department (ED) example, median door-to-provider times improved, left without treatment rates dropped, and overall median length of stay decreased.
The adoption of LSW principles in the ED in this organization resulted in rapid and sustained change in patient care metrics. While many departments may have initiated processes to effect change, the results are not often sustained. LSW in this organization has resulted in cultural change that has led to sustained results across the entity. For example, leadership presence during leader walks has empowered nursing staff and providers to be an active part of the changes and provide valuable input. These techniques have been essential during the pandemic and ensuing leadership challenges. Through leadership presence and the incorporation of LSW, the culture of a department and hospital can be changed and begin to embrace process improvement.10 Adopting LSW principles can be a powerful method for shifting culture toward consistent processes improvement and sustaining change. Leaders must be willing to dedicate time to be educated and understand existing processes and the changes needed from their perspective.
Implications for Nursing Leaders
These tools can be integrated into existing workflows and can be utilized by all levels of nursing leaders. This can improve team dynamics and may positively influence other aspects of patient care. Engaging all levels of frontline providers for input into process changes through LSW can increase staff satisfaction, improve efficiency, and patient throughput, as well as impact patient satisfaction.11 Including leader walks as a consistent leadership behavior offers increased presence and gives frontline staff an increased sense of support.
LSW represents a framework for helping leaders and organizations implement sustainable change to improve efficiencies, leadership effectiveness, and ultimately patient care. Through the 3 key concepts of LSW, calendar alignment, visual management tools, and leaders walks, leaders can rapidly implement dramatic and sustainable change at all levels. Hospitals and nursing leaders should consider LSW as a tool for implementing change and positively affecting culture and outcomes.
The authors thank Margaret Kohl, MBA, for assistance with site data reporting and Jayne Faber, BSN, RN, for assistance with the Supplemental Digital Content.
1. Barnas K. ThedaCare's business performance system: sustaining continuous daily improvement through hospital management in a Lean environment. Jt Comm J Qual Patient Saf
2. Kane M, Chui K, Rimicci J, et al. Lean manufacturing improves emergency department throughput and patient satisfaction. J Nurs Adm
3. Holden RJ. Lean thinking in emergency departments: a critical review. Ann Emerg Med
4. Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc
5. Aij KH, Rapsaniotis S. Leadership requirements for Lean versus servant leadership in health care: a systematic review of the literature. J Healthc Leadersh
6. Dombrowski U, Mielke T. Lean leadership—15 rules for a sustainable Lean implementation. Proc CIRP
7. Soliman MHA. Gemba Walks the Toyota Way: The Place to Teach and Learn Management. 2020.
8. Örtenblad A, Putnam LL, Trehan K. Beyond Morgan's eight metaphors: adding to and developing organization theory. Hum Relat
9. Netland TH, Powell DJ, Hines P. Demystifying Lean leadership. Int J Lean Six Sigma
10. Kueny A, Shever LL, Lehan Mackin M, Titler MG. Facilitating the implementation of evidence- based practice through contextual support and nursing leadership. J Healthc Leadersh
11. Fay L, Carll-White A, Real K. Emergency nurses' perceptions of efficiency and design: examining ED structure, process, and outcomes. J Emerg Nurs