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Lean Team Members in Nursing

Renewal through leadership for nurses in the lean team leader role.

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Developing nurses into Lean team leaders empowers them in every facet of their professional lives, from their relationships with the physicians they support, to their interactions with supporting departments in the hospital system and, most importantly, to the level of care and attention they can devote to patients. Further, the administrators who manage in a Lean team leader structure have an expanded team of knowledgeable, frontline go-to people who can solve problems as they arise and assist in communicating vital messages to the rest of the staff. This article will discuss the Lean team leader role and its successful use in the orthopedic program at Children's Hospital of Wisconsin (CHW) in Milwaukee.

Lean - the term commonly applied to the principles and tools of the Toyota Production System - has gained prevalence in healthcare over the past decade. Author and consultant Aneesh Suneja works to improve healthcare systems with Lean and lead the initial Lean transformation in CHW's orthopedic program.

Lean Team Leaders in Healthcare

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The Lean team leader is typically a nurse who moves into a lead role within the care team. She is an expert in the clinic processes and usually supports one physician. The role does not include hiring, firing or taking disciplinary action. Rather, the team leader is primarily accountable for patient flow.

Flow is a term used by Lean practitioners and means that the thing moving through a process (in this case, a patient) never stops moving. In the orthopedic clinic, patients were stopping - and waiting - in the waiting rooms, exam rooms, radiology and at casting. Physicians were also stopping to look for information needed to see a patient, to dictate clinic notes or return phone calls, or to see which patient in the clinic was to be seen next. Other staff members felt like they never stopped - they ran ragged all day long. But to improve patient flow, all parts of the process must be working together without role confusion, redundancy, errors or waste. The team leader is the person specifically accountable for looking at the care process from beginning to end, finding those sources of waste and leading the effort to remove them.

Part of that responsibility is data collection. The team leaders track critical performance metrics important to their care team, allowing them to continually evaluate and monitor the clinic's performance and set new problem-solving goals based on trends in the data. Using data to drive problem-solving removes conflict and personality clashes around critical issues and focuses the team instead on clear and commonly held improvement goals.

At CHW, the team leaders report feeling more valued and involved in the clinic, and more comfortable talking frankly with the doctors about issues affecting the clinics. Reflecting on the change, Team Leader Tracie Brasch, RN, noted, "I feel more respected. As far as decision-making and what I think is important to providing the best care, I feel as a team leader my input is as important to that of the nurse practitioner, physician assistant even to the doctor. I know they all value my opinion."

Managing in a Team Leader Organization

Program Administrator Terry Schwartz manages the orthopedic program differently with the team leaders in place. First, she uses the team leaders to relay and help explain information about issues facing the organization to the rest of the staff. "The team leaders help to get messages out to the rest of the team. As the program has grown with the building of other satellite locations, they are the bridge to the staff," she said.

Secondly, she encourages the team leaders to develop a broader view of the orthopedic program and the rest of the healthcare organization. While the team leaders began by looking only at their physicians' clinics, Schwartz instituted monthly meetings when ideas and data could be shared among all areas of the program. The team leaders are routinely challenged to see the bigger picture as they evaluate the impact on all clinics of solutions they have implemented for one. Schwartz relays information about the organization's direction so the team leaders have a broader context in which to consider their action planning.

Brasch added: "We share good ideas to make a program rather than six different practices. Now I feel more responsible for the satisfaction of the cast techs, clinic assistants and secretaries - the whole picture. That's made a huge difference, and it's a huge satisfier for the physicians as well."

This broader perspective is further developed through the team leaders' work with supporting departments in the hospital. Schwartz has encouraged each team leader to learn more about a particular supporting function. Brasch is now the program's liaison to central scheduling and radiology, and has problem-solving efforts to remove errors and rework caused by miscommunications.

For example, schedulers are often invited to listen to calls with Brasch on the nurse line to work out issues with orthopedic scheduling protocols. This has reduced the number of patients who wind up in the wrong type of clinic with the wrong provider. Brasch and the radiology techs developed a standard order sheet that reduced errors and delays caused by variation in the way the physicians wrote orders. The networking and trust cultivated by these exchanges helps solve problems efficiently between departments when issues arise.

The team leaders' leadership skills and cross-functional relationships have helped support the growth of the program. For example, when data showed a need for the physician's assistant and nurse practitioner to begin holding clinics for new spine patients, the team leaders worked with central schedulers to develop educational materials and attract patients. This cross-functional, data-driven improvement has increased the capacity of the program and reduced the time to next appointment by nearly half.

Empowerment Leads to Renewal

Examples like these illustrate the empowerment of the nurses who are team leaders in the orthopedic program "As the team leaders have developed, I've been able to increase their scope of influence," stated Schwartz. "I use the monthly meetings as coaching sessions about key initiatives and strategic plans for the organization. The team leaders review and discuss these complex issues, and that discussion helps them solve daily, frontline problems in ways that are in line with the organization's overall direction. That's powerful - frontline nurses in a lead role who understand the organization's long-term direction and can use that understanding in daily problem resolution."

Developing the nurses into team leaders has benefited the doctors, who are free to focus on the patient interaction. It has benefited the administrator, who has a team of knowledgeable, motivated leaders taking on the daily problems and reaching out beyond the boundaries of the program. It has benefited the patients, who experience coordinated care in a calm, competent environment. Most of all, it has benefited the nurses, who are empowered and engaged, and growing into true leaders. Brasch said her expanded responsibilities and ability to do more is "rewarding work. I go home saying 'Wow. They really trust me and believe that I can make it better.' I feel like I'm actually nursing again."

Aneesh Suneja is the president and founder of FlowOne Lean Consulting LLC in Milwaukee, and the co-author with his wife, Carolyn Suneja, of Lean Doctors: A Bold and Practical Guide to Using Lean Principles to Transform Healthcare Systems, One Doctor at a Time and the new Lean Doctors Workbook: An Application Guide for Transforming Outpatient Clinic Systems With Lean (available at http://asq.org/eye-on-quality/). Tracie Brasch is a team leader and Terry Schwartz is the program administrator for the orthopedic program, both at Children's Hospital of Wisconsin, Milwaukee.




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