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There are several different improvement models that can be used to guide quality improvement and safety efforts in healthcare. This article focuses on the Lean approach.


Henry Ford was one of the first individuals to apply some of the basic principles of Lean to Ford manufacturing in the early twentieth century. He did this by moving from handcrafted materials to mass production including the assembly line process and standardization of tasks. Toyota later adapted, refined, and improved upon the initial approaches by Henry Ford, introducing concepts such as standard work (most effective way of doing something), developing error-proof processes and attention to customer value (Barsalou, 2013).

What is Lean?

Lean is a quality improvement approach with a focus on what’s important to the customer and eliminating waste in the form of effort, time, cost or materials. This is done by streamlining processes and keeping steps that are value added, and removing any that don’t add value to either a product or service. For example, ThedaCare healthcare system integrated the Lean approach into the redesign of their patient rooms by moving supplies, medications, and electronic-record-keeping systems into patient rooms. As a result, nurses were able to spend 70% more time with patients (Catalyst, N., 2018). 

Lean Tools

Lean methodologies value multidisciplinary team input, and can be employed through the use of several tools including value stream mapping, standard work, 5S process, Just Do It’s, and the A3.  Value Stream Mapping is a process in which a team maps out the steps in a process to identify and eliminate any areas of waste, inefficient flow, or errors (AHRQ, 2020). This is done using a visual tool which allows the team to see the process and identify ways to streamline and make it better. Once this is done, standard work can be created, representing the best way of doing a process, with all the steps laid out including who does what. This is shared with staff and becomes standardized practice.  

The 5S Process is a tool that can be applied to the work environment to improve organization and cleanliness. It includes the following steps: 

  • Sorting- necessary items and removing any items not needed 
  • Set- organize items 
  • Shine- keep area clean 
  • Standardize- the area 
  • Sustain- this effort (Kelly et.al, 2018) 

A simple project example includes organizing items that are used together in the same area within a clean utility room. For example, organizing all the intravenous start supplies such as needles, heplock, tegaderms, IV tubing, IV solution, and blood tubes in one area. This eliminates the time wasted in searching for supplies. Just Do its are used with problems that have known and simple solutions and require minimal effort.. For example, staff are not aware of a new process that has been implemented; the solution is to provide training on that new process. 

Finally, A3’s are used for larger projects that require multidisciplinary input and take more time to implement. The following abbreviated example describes the use of the A3 approach. 

A3 Applied to Improving Obstetric Triage

Opportunities for improvement related to the timely triage of obstetric patients were identified by nursing staff. In this setting, triage occurred on the labor unit, and care providers assigned to triage could also be caring for patients outside of triage. 

Data review showed the average length of stay for triage was greater than the average in comparison to similar units. Literature review showed that for similar size and structure units, the average length of stay was 2- 2.5 hours. A multidisciplinary team was pulled together to help identify the problems and engage frontline staff in the process.  The A3 approach was used to fully evaluate the problem and develop countermeasures.

    • Identify the problem- Length of stay in triage was greater than the average for like size/structure units. 
    • Identify the gaps– Audits were completed to determine causes for long triage times.
    • Establish a target– Knowing there would be circumstances that warrant longer length of stay (i.e.extended monitoring s/p motor vehicle accident, rule out preeclampsia) a target was set for 3 hrs length of stay for for the majority of patients, with a focus on term labor patients being evaluated in a timely manner.
    • Determine root causes– Audits identified the most consistent cause for increased length of stay related to medical care providers having responsibilities outside of triage.
    • Develop countermeasures– A business plan was created and showed the need for a dedicated nurse and provider model in triage.
    • Put countermeasures in place– After budget approval, a certified nurse midwife was hired to cover triage during peak times. A dedicated nurse was assigned to triage for all shifts.
    • Monitor process and data- length of stay continued to be monitored and showed a significant reduction in length of stay related to dedicated provider coverage in triage. 
    • Standardize processes that work (Kelly, et.al., 2018)

In summary, Lean is a model that engages frontline staff in quality improvement. It offers a range of simple to complex tools, with a goal of streamlining processes through elimination of waste based on what’s important to the customer.

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide


Barsalou, M. (2013,November). History of Lean Manufacturing. Retrieved from https://www.qualitymag.com/articles/91504-history-of-lean-manufacturing

Catalyst, N. (2018). What Is Lean Healthcare? Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0193

Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2018). Introduction to quality and safety education for nurses: Core competencies for nursing leadership and management. Springer Publishing Compa

 Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS

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