One of the principles of Lean Healthcare is that value is defined by the customer.  Strange as it may seem, we are not always clear who the customer is, let alone what they value.  Not too long ago we even had a great deal of discomfort using the term “customer” at all in healthcare.  Additionally, the professional dynamics between clinical disciplines has left us resistant to thinking of other clinicians as our customers.   Recently working with several clients (my current customers), I had the opportunity to explore this customer-value proposition at a micro level.


My Mom

It has always been helpful to me to be clear about why I do this work to improve healthcare – it is simply about the patient.  Ultimately every process in our work is in service of the patient or at the very least the community.  For me it is personal — that patient becomes family. My mom often reminds me that when I was little, I would offer to make her tea when she was not feeling well.

The distance between the activities we carry out day to day and the patient can make it difficult to see the ultimate customer.   Our work is complex and requires many people and handoffs to meet the patient’s needs.  Steven Spear’s  Decoding the DNA of the Toyota Production System is often referred to as the “4 Rules in Use”.  Let’s look at a simple example focusing on Rule 2, Connections:

When a patient’s condition changes, nurses often need to inform a physician of the change and request a change in the treatment plan.  It seems pretty straightforward; the activity includes a few customer-supplier connections and generally is seamless.   Not always, though.





No big deal right?  This supposed simple pathway of three steps has three connections, each fraught with waiting, defects, ambiguity and opportunity for additional connections and missteps.   Patient safety advocates will know that because these types of connections are often ambiguous we teach our clinicians to communicate using SBAR.  The first connection includes the information (situation and background) supplied to the physician, the second connection includes the nurse’s request (assessment and request). The third connection actually meets the patient’s need for value.  SBAR relies on standard work to prevent the wastes of frustration with missing information and unclear requests.  Our connections are improved when we pre-specify our hand-offs directly to the “next” customer, in a way that meets that “next” customer’s definition of value in a timeframe that is pre-specified so we can recognize abnormal versus normal.

Lean Healthcare teaches us to think about our work with the end in mind of meeting the patient’s need as well as respecting the value needed by each customer connection required to deliver that care.

How has thinking about your internal customers changed the way you work?

Maureen Sullivan, Senior Manager for Lean Healthcare and Process Improvement at HPPToday’s blog was written by Maureen Sullivan, senior manager at HPP.

Maureen has nearly 30 years of healthcare experience in clinical nursing, management and quality leadership.  As a registered nurse, Maureen’s clinical experience is in medical-surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels.

Maureen has a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from the National Association for Healthcare Quality as a certified professional in healthcare quality (CPHQ).


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