Archive for category: Lean Six Sigma

Using Lean and PDSA to Reduce Employee Injuries


For many aging services providers, employee injuries are a costly reality of the workplace. In addition to workers compensation costs, however, employee injuries can cause scheduling challenges and lower worker morale. Lakeville Management, a small regional provider of assisted living and memory care communities, decided to tackle employee injuries as part of their commitment to deepening their respect towards employees.

To begin, administrators held several small focus groups to solicit information about the current safety culture, the employee injury reporting process, and barriers to implementing changes. With this initial information, the leadership team was able to construct a company-wide survey and identify opportunities to improve their processes.



The company safety committee (composed of multi-disciplinary representatives from each member community) first examined their current incident reporting process, which was used to report both actual injuries and near misses. Staff reported that the process was somewhat difficult, and, as a result, very few employees bothered to submit near misses. In addition, by examining the type of injuries that occurred most frequently, the committee decided to focus education and interventions on muscle strains, which accounted for almost 60% of all employee injuries.

The committee began by mapping out the incident reporting process. By dialoguing with supervisors tasked with completing parts of the process, the committee identified pain points, unclear forms, and burdensome back-and-forths. Using this knowledge, the committee tested several process and form updates, refining methods after 30 day trials in a single community.

The organization also created a temporary contest to build awareness about the value of near-miss reporting, including incentives for reporting near-misses and a transparent process in each community where near misses and interventions were displayed on a visual control board located in the staff break room. Staff were able see the results of reporting dangers before they led to injuries and could weigh in on interventions to help ensure that proposed changes were realistic within work routines.



After six months of work and four rounds of the PDSA process, Lakeville reevaluated the incident reporting process ease and short-term results. Supervisors reported that the updated processes were much easier to follow, and the leadership team noted a strong increase in the number of near miss reports. After twelve months, the results were dramatic: almost $200,000 in avoided worker compensation costs, 63% fewer lost days, and 15% fewer modified work days. In addition, managers at Lakeville became accustomed to including a review of staff injuries and near misses as part of their daily work, increasing accountability and awareness for the importance of worker safety to the organization.


Learn more about how Lean can help your organization improve performance, including reducing the number and severity of costly employee injuries, here.











Using Plan-Do-Study-Act to Remove Alarms from a Skilled Nursing Home


Since the late 1980’s, nursing homes nationwide have taken dramatic steps to reduce the use of physical restraints among their residents. For many, this meant replacing lap belts and limb ties with bed and pull-tab alarms. These alarms attempt to alert staff to a resident about to fall, although studies of their effectiveness are inconclusive, at best. Many professionals now consider alarms to be unneeded, anachronistic, and disruptive to a resident’s wellbeing and quality of life—although removing them can be challenging, as Greenville Manor discovered.


When administrators at Greenville first proposed the idea of removing alarms, staff, family members and even some residents worried about the effect on resident safety and security. Although they were excited about eliminating the alarms to improve the atmosphere in the nursing home, the administrative team decied to utlize a Plan-Do-Study-Act (PDSA) cycle to test whether alarms could safely be removed without jeopardizing residents. A small, interdisciplinary team convened to work on the problem. By talking with staff and residents, and conducting online research, the team determined a number of root causes behind resident falls. The team also examined the process by which a nurse added an alarm to a resident’s care plan, and noted that very little investigation typically occurred. By organizing fall causes in a Pareto chart, the team was able to target the top 3 reasons and develop an education program to address those causes.


The team developed a test plan to remove an alarm from one resident and measure the results. After two weeks of no increased falls, the test was expanded to include seven additional residents (one nursing section). The team met frequently to analyze fall data and check in with staff involved in the test pilot. During the test, an alarm was discovered on one of the residents. The team quickly investigated and discovered that one of the night shift employees had been absent from a recent team meeting and did not receive the pilot notice in her mailbox. After correcting the issue, the team made a note to follow-up with a night shift focus group to talk about communication challenges and ways to better communicate between shifts.


After one month, the team determined that removing the alarms had actually resulted in a slight decrease in the number of falls in that section. (Later, the team learned that this result was not uncommon in communities that were successful in removing alarms.) The team decided to move forward with expanding the pilot, but to adjust the communication plan to ensure all staff and other stakeholders received adequate notice of the change.


At the next all-staff meeting, the team shared the results of the test, and solicited reactions from other team members. Staff who were involved in the pilot, along with the project team, responded to questions and helped to allay remaining fears about removing alarms throughout the community. Over the next three months, successive neighborhoods removed alarms while staff carefully monitored fall data. A community-wide party celebrated the removal of alarms, and a record of the before and after fall data was prominently displayed in the staff conference room.

Confusion as a Major Waste in Healthcare

Identifying and eliminating waste is a core part of Lean work. In traditional Lean literature, there are seven or eight “wastes” identified:

  • Defects
  • Overproduction
  • Waiting
  • Transportation
  • Inventory
  • Motion
  • Excess processing
  • (Non-utilized talent)

In her book A3 Problem Solving for Healthcare, Cindy Jimmerson makes an argument for confusion being a primary waste. Certainly, confusion leads to many of the other wastes, especially defects, waiting and excess processing, and in my own learning and understanding of Lean, I’ve felt more comfortable sticking with the traditional listing. This highlights one of the challenges with Lean: at its core, it’s a changing methodology and set of tools, rooted in a philosophy of respect-based continual improvement. So when we translate the principles to other settings, such as healthcare, Lean itself begs to be adapted and changed as needed. So, is there something more about the waste of confusion, especially in healthcare, that warrants an examination of its place in Lean healthcare thought? After a recent client visit, I’m more inclined to say yes.

It’s common to run across confusion in healthcare, and especially in long-term care. Policies and procedures are oftentimes outdated and impractical, notes reminding staff of one task or another riddle work areas, and it doesn’t take long before you overhear a staff member say something like, “I don’t know what’s going on around here.” In some cases, the confusion is so overwhelming, we actually turn a blind eye to this fact, and begin operating from a survival perspective where it’s assumed that no one knows what’s going on, and you merely hope to make it to the end of your shift without a significant adverse outcome occurring.

As I watched staff operate during this site visit, however, I saw a number of cases where confusion acted as a primary waste. For instance, when residents would move rooms, someone would cross out their room number (originally written with a Sharpie) and write the new room number above it (usually with a pencil). In some cases, the new room number had yet to be written on the chart, though the chart itself had been moved to the new unit. I would watch staff looking back and forth through the chart rack trying to find someone’s chart, sometimes finding it and sometimes giving up and writing a note of a piece of paper to file later.

In another case, a nurse remarked how she didn’t know what was happening on her unit because she hadn’t worked there for a week and the previous nurse had left without giving report. In response, she was just taking issues and concerns as they came, rather than addressing anything proactively.

In both cases, it’s easy to see wastes and potential for wastes present: defects, inevitably bound to occur by picking the wrong chart or missing crucial information; waiting, or, perhaps more accurately, time wasted searching; motion, for sure, as staff would walk back and forth several times trying to find the right chart; excess processing and non-utilized talent, both from doing unneeded work (but that the staff member didn’t know was unneeded) or extra work, such as writing something down and then later rewriting it in the chart.

As I watched the staff working though, I wondered if recognizing confusion as a primary waste would be more helpful in understanding the root causes and, ultimately, being able to address them. After all, I think most of the staff innately understood how confusing their workplace was, and how much effort they wasted because information wasn’t clear, available or accessible. While most staff can understand how defects, waiting, inventory, ect. can apply in the healthcare setting, it usually takes some explanation and translation. It’s also worth considering how Toyota originally identified primary wastes, as the language is very much rooted in a manufacturing mindset. This isn’t to say Toyota’s vocabulary isn’t applicable anywhere else– it is– but rather is there a better way– a Leaner way– to better target and resolve the waste present in healthcare.

So, should confusion be considered a primary waste? Should we talk about nine primary wastes, or reduce one as Cindy proposed? This is certainly a topic worth more consideration and discussion as healthcare continues to adapt and refine Lean applications.


Leader Standardized Work

Standardized work is not only designed to guide line staff; it works equally well—and is equally important—for leaders, too. Standardized work for leaders consists of developing routines for rounding with purpose (going to the gemba) and other activities where you check in on the status of current tactical and strategic goals.

A purposeful, daily stand-up meeting is a good start to standardized work. It should consist of sharing census changes, resident concerns, staffing issues, safety incidents, future events and successes to be celebrated. Once you have started building a culture of continuous improvement, consider adding a minute of reflection. Ask the team, “How did yesterday go?” and “What can we do better today?” The idea of building upon each day keeps work from being routine and helps staff to engage in the process of making small improvements all the time. A stand-up meeting should start on time consistently and last no more than 10 or 15 minutes. For issues that require more than a minute or two of discussion, have a smaller group break off afterwards to discuss rather than occupying everyone’s time.

Developing a daily checklist that incorporates current goals is another way to standardize oversight and accountability. A daily checklist helps to reinforce priorities, communicate the intended direction of the organization, and connect to the drivers that will lead to the desired goals. The questions need to be customized to your current goals and priorities to be effective. Generally, improving resident quality and experience are top concerns of most organizations, as are employee staffing and performance issues. If there is significant construction, reorganization or major initiatives rolling out, these items should be integrated into the daily checklist.

Here are two examples of daily check sheets for an administrator and DON:

Administrator Daily Check List




Sometimes, questions may seem formulaic or unnatural. Don’t worry. If staff know that they can count on a response, they will be happy to share struggles and challenges. Also, by asking questions like, “Have there been any falls in the last 24 hours?” or “Are all assessments up to date?” staff will understand the importance of these items to your work and to the organization’s overall success. Questions should change over time as priorities and goals do. The important thing is to develop a daily routine that can help keep your organization on track.

The Basics of Lean: The PDSA Cycle

One of the most basic foundations of Lean is the PDSA cycle, which guides virtually all improvement approaches. Dr. Edwards Deming is credited with developing the Plan-Do-Study-Act (PDSA) cycle of continuous quality improvement based on his learning from Walter Shewhart at Bell Labs. The cycle is also know as Plan-Do-Check-Act (PDCA), the Shewhart cycle, or the Deming Wheel. It’s based on the scientific method:

1)  Form a question
2) Make a hypothesis
3) Predict the outcome
4)Conduct a test or experiment
5) Analysis the results
(Repeat steps 2-5 as needed)

The PDSA cycle begins with an opportunity for process improvement (OPI). This is a problem, an error, or an area you’ve identified as needing improvement.


In the planning phase, clearly identify the problem, develop an understanding of what the future state should look like (once the problem has been removed), and conduct a root cause analysis to determine the likely cause or causes of the problem.

Once the likely root cause or causes have been identified, identify solutions or countermeasures that can be tested. (Lean prefers the term “countermeasure” over “solution” because most systems and processes are complex enough that there is rarely a solution; instead, countermeasures to likely causes of problems are put in place to bring about success. In addition, thinking about countermeasures as opposed to solutions encourages a mindset of continuous improvements to a process rather than a goal to reach and then forget about.)


In the do phase of the cycle, test out the proposed countermeasures. It’s usually best to try solutions in a limited area, such as one neighborhood or department, so you can make modifications or adjustments before rolling it out to the whole community.


After implementing countermeasures, collect data and analyze the results of the pilot tests. Were the countermeasures effective? Is the problem better? Worse? The same? Different changes can require different timelines for checking on their effectiveness, but generally 30, 60 and 90 day marks provide a good place to check on the status of countermeasures.


If countermeasures were found to be effective, incorporate any improvements or learning from the pilot and roll out the countermeasures to other appropriate areas. If the pilot didn’t produce the desired result, begin the cycle again. Perhaps a root cause was incorrect or missing? The implementation wasn’t complete? Area staff weren’t involved effectively?

The key to the PDSA cycle is to work methodically through challenges, experiment with and evaluate changes, and act on the results.

PDSA is the basis for A3 thinking, a tool that grounds the improvement cycle in an easier to understand and follow process. By working through problems and their causes in a scientific, methodical way, we can develop effective countermeasures and build on prior success.

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