As hospitals around the world increasingly face pressure to improve efficiency, "Lean" process improvement has become a popular approach to improving patient flow. In this article, we examine nurses' perspectives on the implementation of Lean redesigns to the inpatient discharge process.

The researchers found that nurses experienced competing demands and tensions related to their time and professional roles and responsibilities because of Lean.

Four main themes included

1.  Addressing the needs of individual patients, while still maintaining overall patient flow; 

2. Meeting discharge efficiency targets while also achieving high patient satisfaction scores;

3. "Wasting time" to save time, and

4. The "real" work of providing clinical care versus the "Lean" work of process improvement.

Our findings highlight the importance of applying hospital nurses' perspectives when implementing Lean process improvements to improve efficiency and patient flow. Scholars have identified a positive publication bias for studies of Lean implementation and outcomes, particularly in the United States.

In contrast, this study shows how, in some cases, efforts to improve efficiency and hospital-wide patient flow using Lean methods may adversely impact frontline nursing staff, including the creation of tensions between dual responsibilities to patients and the organization.

These tensions are important to address, particularly when trying to understand nurses’ engagement with efforts to improve efficiency and patient flow. Further ethnographic research is needed to explore the effects and unintended consequences of Lean on hospital nursing.

Hospital quality improvement

The study has some limitations largely influenced by the qualitative methodology and sample from one privately owned acute care hospital in Northern California, which may limit the generalizability of our findings.

Sample selection may have also contributed to potential bias in our results, as nurses who were more positive about Lean may have chosen not to participate. However, the benefits of thematic analysis lend valuable insights that might be transferable to other settings implementing Lean process improvement.

They also experienced known challenges of recruiting acute care nurses such as time and workload constraints, logistical challenges around scheduling, and potentially a lack of interest in the research topic or ambivalence about the value and applicability of the research. To address these barriers, future research could be approached using Participatory Action Research or similar model.

The engagement of nurses is crucial for the success of hospital quality improvement initiatives. They used the voices of nurses to gain insight into the effects of Lean redesigns to streamline patient flow and improve the inpatient discharge process.

This study highlights how a Lean-based process redesign effort implemented in a community hospital in the United States created tensions for frontline staff nurses, placing competing demands on their time and professional roles and responsibilities.