Identifying and eliminating waste is a core part of Lean work. In traditional Lean literature, there are seven or eight “wastes” identified:
- 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 Policies and procedures are oftentimes outdated and impractical, notes reminding staff of one task or another riddle work areas, and it doesn’t take long before you overhear a staff member say something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.