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Integrating Lean with shared governance

Huntington, Kelly, BSN, RN, CPN; Goodyear, Caryl, PhD, RN, NEA-BC, CCRN-K

doi: 10.1097/01.NUMA.0000544460.58581.c6
Department: SHARED GOVERNANCE SPOTLIGHT: Executive Extra

Kelly Huntington is the assistant nursing department director at Children's Mercy in Kansas City, Mo. Caryl Goodyear is a clinical practice specialist for the American Association of Critical-Care Nurses in Aliso Viejo, Calif.

The authors have disclosed no financial relationships related to this article.



Shared governance, or shared decision-making, is an important part of empowering nurses to take ownership of their practice. Lean is an approach to healthcare delivery that improves efficiency, eliminates waste, and delivers value to our patients and families. One of its foundational aspects is the recognition that frontline staff members are empowered to identify issues, solve problems, and take pride in improvements that impact positive patient experiences. This is where shared governance and Lean have a common goal: empowering staff to take accountability for owning practice issues and challenges to achieve the goal of improving the patient experience. Lean tools can be integrated into the hospital-based shared governance structure and processes to help reach practice solutions.

In this article, we'll give you a better understanding of what it means to be Lean and explore the utilization of Lean tools to improve shared governance.

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Think Lean

Lean was derived from the Japanese manufacturing industry during the late 1980s.1 When applied to the healthcare industry, Lean is defined as “an organization's cultural commitment to apply the scientific method to designing, performing, and continuously improving the work delivered by teams of people, leading to measurably better value for patients and other stakeholders.”2 At its essence, Lean is meant to improve efficiency by eliminating waste. As part of the Lean culture, frontline staff members from all disciplines who are involved in supporting or providing patient care implement the changes to improve efficiency.

To incorporate Lean, we must first think Lean. There are four key pieces of essential Lean thinking:3

  1. Mutual trust. This is a shared belief that you can depend on each other to achieve a common purpose. Sometimes this can be a challenge to create, but once established it's foundational to the success of a team.
  2. No problem is a problem. Never be satisfied with the status quo. Always ask, “Can this process be performed better?” Seek to find problems that perhaps haven't been raised to a level of awareness. Once found, find solutions to fix the issue.
  3. Lead as if you have no power. As a leader, empower others to own the problems and solutions. Don't use power as a force to do what's needed.
  4. Build people first. Always ask “What can I do to help you?”

Using these four aspects of Lean thinking, leaders empower frontline staff members to create solutions to improve their environment. These same aspects can be applied to supporting the structure and processes associated with shared governance. Unit councils need mentoring to see problems, fix issues, and feel empowered to do so. In this case, the leader's job is to coach staff members to build their leadership skill set.

See Table 1 for six principles essential to creating a culture of improvement and empowerment, both key to shared governance and Lean.

Table 1

Table 1

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Attitude of continuous improvement

The thought of always looking to improve how we perform our everyday work may be considered a change for us as nurses. The act of problem-solving is a major aspect of continuous improvement. The nurse needs to understand the problem before diving into a solution. A problem is the gap between what should happen and what's happening. Lean tools to help with problem-solving include quick hits, big issues, and situation target proposal (STP) boards. The goal of these platforms is to move problem-solving from leadership to the front line.

Quick hits are problems that are resolvable at the unit level in less than 3 days. These problems are those that block the flow of patient care or when something in the environment isn't quite up to the current standard (such as something is broken or in the wrong location). If the problem is resolvable but only with collaboration beyond the unit or it will take longer than 3 days, then it's named a big issue. Daily management systems or huddle boards are used to identify problems and categorize them into quick hits or big issues. (See Figure 1.)

Figure 1

Figure 1

STP boards are used when a standard doesn't exist yet for a problem or there's a new idea for improvement. (See Figure 2.) Staff members submit ideas for improvement and, if accepted, work on the process of cultivating them. The STP approach challenges staff members to define the problem (situation), identify what should happen (target), and describe how it should be done (proposal). The board is used as a visible display of problem-solving and tracking of process improvement.

Figure 2

Figure 2

Typically, the Lean process and tools are owned by all local employees who work on a unit or department, such as physicians, dietitians, pharmacists, nurses, and respiratory therapists. Select members of this multidisciplinary team are asked to run the huddle board and participate in STP prioritization meetings. When working on problems and issues, employees responsible for leading the boards can immediately recognize that a solution to a problem with nursing practice can be owned by the nursing unit council. The unit council's role is then to solve the problem and monitor the improvement response.

For example, one unit noted that healthcare providers didn't have any distraction activities or items for adolescents receiving painful procedures. This problem was discussed at a huddle board meeting and it was determined that developing a distraction toolkit should be owned by the nursing unit council.

Unit councils can use Lean techniques when categorizing their work in improving practice. Quick fixes by unit council members can be noted, big issues may need to be studied in further detail to understand who else may need to be involved, and the STP board can be utilized to guide the process of creating a practice standard when one isn't available.

The following is another example of the integration of unit councils and Lean activity. The intensive care nursery unit council at our hospital completed an American Association of Critical-Care Nurses healthy work environment assessment for all multidisciplinary staff. As part of the response to the survey data, the unit council posted three new ideas to the STP board to address communication/collaboration issues. Their idea was that owning a healthy work environment belongs to all disciplines on the unit, so all disciplines should be involved in working toward solutions.

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Generally, nurses and other healthcare providers are outcomes focused. Patient and family perspectives may be different. In this case, the burden of healthcare can be monetary or nonmonetary (such as wait times, the distance it takes to get from point A to point B, or the pain of a procedure).2 Patients and families may ask themselves if going through a procedure is worth the pain and inconvenience.

Identifying waste is one way to create value. Using Lean's eight types of waste is a way for unit councils to recognize and categorize current waste under the nursing umbrella. (See Table 2.) To help identify steps in a process where value isn't being achieved, a value stream map or process map can be used to provide a visual of where extra steps may be eliminated.

Table 2

Table 2

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Unity of purpose

All healthcare institutions have the purpose of serving patients and families. Most hospitals have mission and vision statements to guide healthcare providers' work. These statements should unify the work of continuous improvement. At our organization, we're partnering with consultants to create a system with the highest safety, reliability, and empathy while providing timely access to care at the lowest cost.4 Yearly goals can help target this focus and provide a foundation for measuring outcomes. Unit or department goals should align with the overall goals of the hospital.

For example, the following may be areas of focus for a perioperative area:

  1. Increase engagement in safety improvement with the goal of achieving one implemented safety STP per person.
  2. Improve OR utilization to at or above the national benchmark.
  3. Reduce operating expenses (salaries, supplies, and equipment only).

Unit council goals should be set each year with the aim of aligning with unit-specific goals. These goals can improve clarity in achieving the hospital's mission and vision. Unit councils should strongly consider establishing a financial impact goal. Healthcare institutions must be on the positive side of a profit margin to provide care for patients and families.

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Respect the front line

As discussed earlier, Lean's goal is to empower frontline staff members to challenge everyday processes and create new ways to improve their daily work. Ideas and solutions trickle up to leaders who are in the position to coach, mentor, and support staff members in their improvement work.

In a typical leadership structure, ideas and solutions originating from top leaders are trickled down to frontline staff. Shared governance and Lean flip the pyramid, putting emphasis on the flow of new ideas and solutions from the bottom up.2,3 The assumption is that frontline staff members are closest to the process, so process improvement ideas should stem from them.

The unit leader's focus is on helping the flow of ideas and solutions move from the front line. The first step is to make sure that the team understands customer needs, organizational priorities, and how everything fits together. Next, a Lean leader spends time on the front line to understand how the work flows and if there are barriers to improvement.5 Gemba, a Japanese term meaning “actual place,” is used in Lean to mean “going where the work is.”1 When a leader does “gemba time,” he or she is on the unit experiencing the daily work barriers and issues facing frontline staff. Using gemba time, the unit leader can serve as a resource for problem-solving.

Unit councils can also serve as a resource for solving nursing practice issues. It's the frontline staff members who live these problems every shift. When confronted with an issue or problem that unit council members don't know about, they may want to employ the gemba philosophy and investigate by going where the problem is occurring.

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Huddle boards, metric boards, and STP or idea boards are all visuals to promote a culture of transparency and improve communication and collaboration. These boards create a gathering spot for staff members to discuss issues that need attention. The boards organize relevant information and relay daily readiness and performance trends on key metrics.

Unit council communication efforts can be enhanced by utilizing visual displays of work, goals, and achievements. There's no such thing as overcommunicating. Nurses and other frontline staff members are busy and may sometimes need different forms of communication to remember important details.

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Flexible regimentation

The goal is to take work that's nonstandard, transform it into standard work, and then keep improving it to get a perfect process.2 Regimentation is creating a standard process for executing a task based on the best evidence. The meaning of flexible in this case is the continuous effort to enhance the standard process.2 Patients and families deserve to receive the same information and experience the same level of care, no matter the tenure of the nurse. With the implementation of standard work, this consistent experience can be achieved.

Examples of standard work are developing a script for post-op follow-up phone calls or creating a gastric tube discharge toolkit with a scripted job aid and checklist. Confirmations are performed by leadership or peers to ensure that standard work is being followed. If variation is noted, the goal is to identify why and question if a change in the process needs to occur.

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Empower to improve

Shared governance and Lean improve value for our patients and families. Nursing practice, safety, and quality are key elements of focus for shared governance and Lean activities. Both empower frontline staff members to create solutions to problems and issues that impact their ability to improve outcomes. This type of engagement can also improve job satisfaction and retention as these activities advance a healthier workplace.6,7 Nursing shared governance focuses on the practice and outcomes of nursing, as well as the patient experience. Lean engages the whole team in identifying and solving problems based on an attitude of continuous improvement. Leaders of both shared governance and Lean become mentors and teachers, allowing the frontline team to be the driving force behind improvements.

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1. Lean Enterprise Institute. What is lean?
2. Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc. 2013;88(1):74–82.
3. Shook J. Thinking fast and slow and Lean with John Shook. Lean Enterprise Institute. 2018.
4. Joan Wellman and Associates, Inc. Lean principles. Presentation at Children's Mercy Hospital, Kansas City, MO. July 14-15, 2015.
5. Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. 2nd ed. Boca Raton, FL: CRC Press; 2012.
6. Brunges M, Foley-Brinza C. Projects for increasing job satisfaction and creating a healthy work environment. AORN J. 2014;100(6):670–681.
7. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016.
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