Don’t 'Lean' on Me, Hospital Workers Say

Nurses and other hospital staff are already moving at breakneck speed, and then come the consultants. Some hospitals have decided nurses shouldn't be talking to one another. Photo: Jim West/jimwestphoto.com.

A sign in the newborn intensive care unit invited nurses to suggest changes that would speed up their work.

One popular suggestion: replace a sticky combination lock with swipe-card entry. But that would cost too much.

Instead, on a consultant’s recommendation, supplies were rearranged. Blue masking tape outlines now show where each item is supposed to go. A sign lists the “five S’s” of workplace organization (sorting, straightening, cleaning (shine), standardizing, and service). Each shift, one nurse is supposed to check them off.

“I don’t know how much they paid for this outfit to come and do this, but it hasn’t really helped my ‘workflow,’” said Eileen Prendiville, a nurse at the California Pacific Medical Center.

Too bad they didn’t spend the money to rehire the full-time medical assistant who used to restock supplies, Prendiville said. After they laid her off, “you’d have a sick baby and no supplies there. That would help the workflow much more, to have a real person come in.”

HERE COME THE CONSULTANTS

Prendiville isn’t alone with the consultants. “Factory Efficiency Comes to the Hospital,” glowed a New York Times headline in 2010. The story showcased how Seattle Children’s Hospital was using Toyota’s “continuous performance improvement” system.

Another Seattle hospital has actually branded its version of the Toyota method. Its spin-off institute offers $3,000-a-pop trainings in the “Virginia Mason Production System,” to help hospital administrators across the country “eliminate waste and increase value.”

Today’s hospitals are as committed to running lean as any factory. Highly paid consultants scrutinize hospital processes, measuring “metrics” such as staff-hours-per-patient-day.

Who could oppose improving quality or eliminating waste? “But they’re not talking about efficiency in how we provide care,” said DeAnn McEwen, a nursing practice specialist with the California Nurses Association. “It’s really about profits.”

In health care, 50 to 60 percent of operating expense is labor. So there is constant pressure to reduce staff.

“What it boils down to,” said John Borsos, secretary-treasurer of the National Union of Healthcare Workers, “is coming up with a way of dumping more work on people.”

NO DOWNTIME

Nurses and other hospital staff are already moving at breakneck speed. Judy Sheridan-Gonzalez, a nurse at Montefiore Medical Center and president of the New York State Nurses Association, saw a consultant’s time-and-motion study backfire.

They found “what we’ve been saying all along: we have no downtime,” she said.

In the ER triage area, even the 15 seconds while a chart prints out cannot be wasted. “You start taking vital signs, putting the armband on,” she said. “You’ll never see a triage nurse sit there. You never stop.”

But consultants get creative.

For instance, at each change of shift, the departing nurse traditionally gives “report,” explaining each patient’s situation to the incoming nurse who will take over. Nurses take this very seriously, McEwen said. After all, they have legal responsibility for the patient’s care.

“Often nurses would spend 15 minutes, to half an hour, to an hour of overtime, going over a detailed report,” she said. The practice makes patients safer—but to a time-motion consultant, it looks like “a bunch of nurses sitting around a desk.”

MEDICAL WASTE

If staff aren’t the problem, why are health prices skyrocketing?

  • consultants’ fees
  • insurance industry paperwork and bureaucracy
  • too many administrators
  • high salaries for executives and doctors
  • advertising, branding, and fancy new buildings—to compete with other hospitals for the most profitable slice of business
  • changing vendors and replacing high-tech systems every few years
  • poverty and inequality worsening our health
  • too much emergency care—because people don’t have access to good primary/preventive care
  • profits—for hospitals corporations, insurance companies, and Big Pharma.

So some hospitals have switched to group “rounding” report, where the manager, secretary, and all the nurses troop around to each room together. This allows the manager more control—to limit discussion, move things along, and avoid overtime.

Other hospitals “decided nurses shouldn’t be talking to each other at all, and implemented taped report,” McEwen said, where “you leave a phone message for the incoming nurse.”

VIDEO CARE

Technology underpins many management schemes for speeding up work.

Her emergency room switched to electronic blood pressure monitors, Sheridan-Gonzalez said, because they’re quicker than the manual kind. Trouble is, they’re more often wrong.

“Patients say, ‘Oh my God, it’s that high?’” she said. “I say, 'Try not to worry—these digital machines are not always accurate.'"

Another cost-saver is moving cardiac monitors off-site.

When a nurse on the floor watched heart monitor screens, McEwen said, she could easily discover a false alarm. And if the patient really took a turn for the worse, that nurse was one more person to help respond. Now, hospitals are consolidating heart monitors in another ward, where a lower-paid tech watches them.

In some cases, even doctor consultations are happening over video screens, Borsos said, and medical transcription work is being moved off-shore.

“Technology can be useful, but it should not be designed in a way that replaces the judgment of skilled workers,” McEwen said.

She believes a patient interviewed over phone or video is more likely to tell the provider what she wants to hear—especially if the patient is ashamed he didn’t refill a prescription or couldn’t afford the recommended diet.

Over video, the nurse can’t see swollen ankles, lay a hand on clammy skin, or smell an infection, she said. “If I had them in front of me, I could tell.”

EYES ALL AROUND YOU

Many hospitals have stepped up surveillance—with cameras everywhere, swipe-entry doors, and electronic tracking chips in the badges workers wear.

At one hospital, nurses stopped those chips with a single provocative flyer, comparing their treatment to zoo animals and convicts. They left the flyer in a nursing office by “accident.” Management panicked and called off the plan.

Another method of surveillance: the celebrated electronic medical record.

The electronic paperwork to discharge a patient is “eight pages of clicks,” said Betsy Prescott, a leader in the Massachusetts Nurses Association. “You get spoken to if you miss one thing.”

“Some of these floors can have 15-19 discharges a day,” she said. “You’re not taking care of the patient, you’re documenting.”

All this documentation helps the hospital track every item it wants to charge the insurance company for—and pin the blame for any problems on nurses.

Employers can track “when you log on, keystrokes, how long you are on a page, which pages you’re on, which pages you’ve never been to,” McEwen said.

STANDARDIZE

Standardization is a watchword of lean management.

Nurses at St. Charles Medical Center in central Oregon were justly proud of their Rapid Response Team—it had saved lives. But that didn’t stop the administration from announcing plans to end the team. The rationale? Other hospitals don’t have one.

Most hospitals now use computers to set staffing. You enter the number of patients on the unit today, and the software spits out how many nurses and nursing assistants are needed. Employers claim they factor in the severity of patients’ conditions—but “virtually none of them do,” Borsos said.

Of course, the employer sets up the software—and decides whether to “staff like you’re the Waldorf Astoria” or “like you’re a Motel 6,” as Borsos put it. Guess which most hospitals choose.

Standardization goes beyond staffing formulas, as hospitals try to script the conversations staff have with patients. The script goes something like, “I’m very glad you’ve come here for care. Do you have any questions? I have time to answer them. Put a number on your pain,” McEwen said.

“It’s a form of time management that is insulting to professionals, and actually increases the risk of harm.”

JUST-IN-TIME STAFFING

Like employers in other industries, hospitals are pushing for schedules that maximize “flexibility”—theirs, not yours.

“They can’t bear for people to have downtime,” Sheridan-Gonzalez said.

Some float staff from one unit to another, especially at night. Others send workers home mid-shift.

Lean restructures may include staggered schedules where one person starts at 6 a.m., the next at 6:30, and so on. Borsos called it “pseudoscience, to try to fit everything into a nice, neat, easily measured box.”

The Holy Grail of flexibility, of course, is keeping staff on call, with no set schedule and no guaranteed hours. A growing share of cafeteria workers at St. Charles in Oregon are “float,” meaning they could work as a day-shift cook one day and a swing-shift room service attendant the next—and be paid less than either.

“Traditionally in hospitals the number of on-call or per diem staff is somewhere between, say, 10 and 15 percent,” Borsos said. “The newest trend is allowing hospitals to take more and more benefited positions and make them flexible and contingent.”

JOIN THE TEAM?

Part of the lean ethos is getting workers to participate in their own exploitation. Some hospitals offer nurses a boost of pay and status for championing a lean project.

“Hospitals are very often successful at co-opting natural leaders,” McEwen said.

What can the union do? First is to educate members to see through management’s hype—what labor educator Charley Richardson called the “tricks and traps” designed to lull you into believing you and management have the same concerns at heart. These include joint brainstorming, win-win rhetoric, and trust exercises.

One strategy is to try to get your people onto the lean team—but they probably won’t be picked, and it’s a “slippery slope,” Sheridan-Gonzalez said. Union members on joint committees should treat every meeting as if it were a bargaining session, with two opposing sides.

They can say, “We don’t accept your framing. We see this as a potential for harm,” McEwen recommends.

And the usual union tactics can be used against lean, too: petitions, forms that document unsafe staffing, button/sticker days, and marches on the boss to resist speed-up.

Labor Notes’ book Working Smart offers a thorough analysis of lean and how to fight it. Download Charley Richardson’s manual “Employee Involvement: Watching Out for the Tricks and Traps.”

A version of this article appeared in Labor Notes #412, July 2013. Don't miss an issue, subscribe today.
Alexandra Bradbury is co-editor of Labor Notes.al@labornotes.org

Comments

TrippBabbitt | 08/19/13

W. Edwards Deming had nothing to do with lean - facts are stubborn things.

Additionally, with Dr. Deming there is no optimum. Best practices and one-best way that accompanies standardization are Taylor's concepts, not Deming.

The evidence contained in this article would indicate that the intentions are misguided. The ideas for improvement should be developed from those that understand the system - which in this case are the nurses with the help of management. Applying tools without knowledge or forcing a worker to comply is certainly characteristic of Taylor or Neo-Taylor thinking. It is unfortunate that blind faith in tools and standardization is embraced.

This can change, however, when decision-making is put in the hands of the people who understand and do work. This is respect for people. Checklists can only be useful if the workers are pulling for their use, otherwise you stand to fall back into the "why are we being forced to do this again?" mode. This leads to reversion back or coercion to keep doing (through inspection). No perspectives are changed and sustainability is lost.

A Deming influenced Lean system would have workers not complaining about blue masking tape or consultants designing their system for them. Being in denial won't enable this to happen.

So Cal RN | 08/19/13

Lean is not Taylorism. W. Edwards Deming’s developed lean and his work really focused on respect of the front line worker to develop continuous improvement. What happens is that mangers say they implement lean, but don’t change their own behaviors. Managers may have the information, but that does not mean they the knowledge of how to optimize. Lean is not the problem but managers who do not want to be proactive and engage their employees. Lean tools are something that union healthcare workers should not only educate themselves about, but master. Nurses are trained to look at statistics, evidence based practice & think in terms of systems. We have already used tools like standardization to help us deliver care to more patients in line with our scope of practice. Checklists are saving lives every day. “Stop the Line” safety checks & speaking up is teaching people that safety is giving workers a voice to speak up for the patient & themselves. These are all lean tools, but because managers don’t understand systems they will often blame the worker or give up on the process. Deming was a believer that “If you destroy the people of a company, you do not have much left.” As someone else posted, do some research. The truth is employees can do the god so well with lean, they will need less management!

NancyEJ | 08/16/13

I just have to add a response to this

--“Hospitals are very often successful at co-opting natural leaders,” McEwen said.

What can the union do? First is to educate members to see through management’s hype—what labor educator Charley Richardson called the “tricks and traps” designed to lull you into believing you and management have the same concerns at heart. These include joint brainstorming, win-win rhetoric, and trust exercises.

One strategy is to try to get your people onto the lean team—but they probably won’t be picked, and it’s a “slippery slope,” Sheridan-Gonzalez said. Union members on joint committees should treat every meeting as if it were a bargaining session, with two opposing sides.--

It's exactly this sort of divisiveness and demonization that makes unions a very BAD idea in a healthcare setting. No matter how hard a company works to build a better workplace and involve their employees in problem solving some union is going to come around and sow ugliness and suspicion around that effort. Why? Because when healthcare providers work cooperatively together and break down the barriers between management and staff, unions have a tougher time selling their snake oil.

The solution to these sorts of problems is not a clunky collective bargaining model that's getting close to 100 years old and failing workers in every sector. The solution is educating and motivating management and staff to work together with greater understanding and cooperation, not less.

This sort of one-dimensional boss bashing is so outdated, counter-productive and futile. When is Labor Notes going to start really getting out ahead and act like a thought leader to help to solve workplace issues instead of a tool of Big Union working to preserve the corpse of a dying dinosaur?

I guess when Big Union stops funding Labor Notes!

NancyEJ | 08/16/13

Thank you. I'll take a look at it but I wouldn't take anything from IWJ on face value as it's a union funded front organization. I realize it's member organizations are churches but they are not really driving the campaigns or the research. It's like the Economic Policy Institute -- the funding stream is all union and there to support nothing but a big labor agenda.
I'm a big advocate of workers self organizing to address worksite issues. I just despise the conduct of Big Labor. No sector of society had done more to hold working people back than organized labor today, especially SEIU.

NancyEJ | 08/16/13

wow. I want to say this is the stupidest article I've ever read, but then I've been a longtime reader here. First of all -- has the author heard at all about the explosive growth in healthcare costs? It's been in the news quite a bit.

Oh, I know, I know, it's all about the evil 1% and the CEO's salary blah blah blah. No. Healthcare costs are crippling all of us -- union lovers and haters all -- and there's no quick fix. So yes, a hospital (or other business) will hire a consultant because they couldn't afford and don't need that level of expertise in a full time employee (with benefits). Most consultants are remarkable at what they do or they aren't consultants for long. But yes, there will be the occasional dopey consultant, just like you have the occasional crooked union rep or really dumb labor journalist. It's not intrinsically a waste of money to hire a consultant. Guess what -- businesses, like hospitals -- don't stay in business long if they waste money, whether on consultants, administrators or CEOs. In every case, generally speaking, you get what you pay for.

Consultants also don't come in to serve some evil agenda of the 1%, regardless of what your union president said in the newsletter. They come in with the expertise and objectivity (look it up) to ferret out the truth and offer the client solutions from a fresh perspective. So yes, you will occasionally have a consultant come in and agree with what some union was saying all along. But can you really expect employers to just take the union president's word on something? I mean if you want unions to be treated like workplace authorities by the employer then please get unions to lay off the asinine hyperbole and business bashing horse manure. (as illustrated so well in this piece)

All that said, the real claptrap in this article is the "Medical Waste" sidebar, written like the author knows as much about how to run a hospital as my dog does. And I'm sorry, but, if a hospital is for-profit, guess what? (you may want to sit down for this part) IT HAS TO MAKE A PROFIT OR GO OUT OF BUSINESS. That's how that works. That's how corporate governance is structured, that's their prime directive. (Sorry to offend your socialist sensibilities.) And if the people who work there don't care for the workload -- there are lots of not for profit hospitals out there. And not to worry. When a decision really starts impacting patient care it's going to overnight start showing up in that evil profit margin.

Containing healthcare costs is a complex issue that some simple-minded unionist rant is not going to illuminate. Example -- for-profit hospitals must advertise or in short order they start seeing empty beds. Really. It works that way. The same is true for "fancy new buildings" and the latest systems and technology. Funny thing is, paying patients (including Cadillac plan union members) like to have their surgeries done in fancy new buildings with state of the art everything. (studies have born that out, by the way)

And really? You want to blame the high cost of healthcare on consultants?? A consultant makes an RN's paycheck, but yeah, in a few days not two weeks. THEN THE CONSULTANT IS NO LONGER ON PAYROLL. Get it? And you might want to add the exponential growth of legacy costs, insurance premiums of all kinds (including the union H&W kind) and the burden of inflexible union work rules to your list...um...near the top.

Wow. Read a book.

JAS RN Professional | 08/16/13

Hi~NancyEJ | 08/16/13, You may want to look at and read, the article put out by the organization - Interfaith Workers Justice - from the press conference they held back in July 2010 held in downtown Detroit. The article was titled "Ascension Health a Fall from Grace". This is the USA largest non profit Catholic Health care system. You can also follow additional information on one of the cases sited in the article by going to the website; wwwdetroitnursewages.com. To the best of my research the total number of not for profit hospitals out there in the USA is more than likely less than 12 scattered across the country.

JAS RN Professional | 08/16/13

See above reply. Not for profit healthcare systems are operated by government. # 1 is Medicare run by Federal, #2 VA Hospitals.

NancyEJ | 08/18/13

Fair enough. I'll take your word for it. But the lack of alternative non-profit places of employment doesn't change the fact that for profit systems are required to make a profit. It's built into their corporate DNA. I guess the folks who don't like health systems making a profit could go ahead and try to get some law that limits profits or does away with profit making in healthcare -- good luck with that by the way.
I'm still waiting for unions and those that support them (like the Hollywood crowd) to pool their resources and open businesses that don't make a profit, where the CEO is modestly compensated, all the employees have top drawer benefits and are paid a "living wage", no job is ever outsourced, no money is wasted on advertising, new construction and consultants, and everyone belongs to a union. You'd think with a swell business plan like that soon enough the idea would catch on.

Oh, and a note to the author -- go ahead and peruse the SEIU International or 1199 LM-2 reports -- come back and tell us if you see unions paying consultants, you know, instead of just listening to their employees.

TrippBabbitt | 08/20/13

Their has to be a purpose for that profit. I believe the question we should be asking is "Why does an organization need profit?" There should be some good and a higher purpose involved in the answer.

Actually, there are many organizations that aspire to the greater good - one being Whole Foods. Not that every organization should copy them, but doing things to provide more jobs helps everyone.

By what method? are consultants teaching. This is the issue and not just consultants. This is the issue at hand.