Insights from a Nurse Lean Leader

The 2022 Lean Healthcare Transformation Summit featured the first ever Nurse Leader Panel bringing voices from those at the front line in Nursing leadership.  Throughout the interview-style conversation, panelists detailed how they used a management system to support their teams and manage through COVID and other nursing related crises, as well as advised attendees on how to improve quality and make processes easier for those on the front line. While discussion was thoughtful and detailed, we recognized that we were not able to answer all the questions submitted. Instead, we reach out to one of these nurse leaders to provide responses to some of these questions that had gone unanswered.  Included below are some thoughts from Stephanie Guareño, Senior Nurse Process Improvement Manager from the Mount Sinai Health System in New York.  Stephanie’s sound advice provides helpful insight for organizations as they navigate and establish relationships within nursing teams to move their transformation forward. 

Have you been able to break down some of the traditional clinical hierarchy of doctors and nurses (or other roles) to promote more teamwork and collaboration in daily care?

Each unit has a leadership dyad - a nurse manager and medical director partner - to improve patient outcomes and both the staff and patient experience. This has helped take the burden of the patient’s experience off nursing alone and helps involve the providers. In our exemplar units, the medical director rounds on the patients with the nurse manager at a specified cadence (in some cases, daily). The director is also involved in the unit process improvement projects and huddles; they will even attend some staff meetings so that the staff really see them as part of the team and a resource for them. It has helped to create a culture of safety that empowers them to escalate issues to their medical director as well.

What is your nursing organization structure to support these initiatives?  Are there roles or positions that support unit managers to implement and sustain improvements?

At our Lean hospital campus, we have a small Lean team, currently made up of three team members that support our 50+ areas that have Daily Management Boards. They meet with the leaders of each of these areas to coach them through their process improvement projects. Our role is in giving the knowledge and tools to the leaders so that they can help develop an army of problem solvers on their units that feel empowered to not only surface problems in real time but problem-solve them as well.  We also have a Continuous Improvement course series that we have recently started piloting across our entire system. The first of the series is available online but the other courses are taught live. This helps teach the didactic piece of continuous improvement. That, coupled with our coaching has helped leaders implement improvements and, in some areas, sustain them. We have different areas at different parts in the CI journey, varying from novice to exemplar.

Describe your experiences with violence in the workplace. What are you learning/doing to reduce team member injuries?

We have had a Workplace Violence (WPV) committee for several years that has done great work related to reducing injuries/abusive behavior. However, post-COVID, we have seen a very large uptick in the number of WPV incidents. We have recently taken a fresh look at our work on workplace violence. Traditionally, the lean team was not part of the WPV committee; now we are. The WPV committee started looking at all the reported WPV incidents to look for patterns – units, day/time, etc. We are also taking a deeper look into how and when these incidents are reported and looking at the handoff of these patients. We are still in the gap phase of our process but there is a lot we are learning about the lack of flagging of these patients in our EMR, the ineffectiveness of how we’re currently reporting them as well as how we follow up after the incidents.

What are your best practices for engaging the frontline nurses in continuous improvement

What has worked for us is having all employees take our continuous improvement academy basics level course upon orientation. This is offered through our electronic education module site. They get a taste of what CI is and it helps give everyone a common language. Then, when they’re on the units, they get oriented to our Daily Management System by the manager as well as their preceptor.

We also allow the staff to choose the improvement projects they want to work on, encouraging them to start small. We will usually have unit champions that are volunteering to kick this off. Once the others see the success they’ve had, they will usually follow suit.

The daily management work is also being integrated with the unit practice councils. The UPC members will discuss unit challenges/problems and sometimes start the improvement process during that protected UPC time.

Thank you to Stephanie for sharing your thoughts and great work as you and your team support the organization on the journey of continuous improvement. 

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Lean Management System Modular Program

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