JIT (Just-In-Time) management applied to staffing levels

[SunDazed, BSN, RN]

Administration is employing a new tool to manage staffing levels at our hospital, Just-In-Time. It is not a new tool of management. It is part of the Toyota Production System. In the business world it is considered one of the primary reasons that Toyota came to be such a streamlined, successful player in the manufacture of cars and trucks. I believe it is new to apply it to staffing levels on hospital units.

What is JIT inventory management? Basically, instead of having a lot of inventory on hand for manufacturing a product (like a car), there is a limited number of each little part. Parts are reordered more frequently when the supply of each runs low. Now the maker doesn't have lots of money tied up in inventory, doesn't have the expense of storing excess inventory, and doesn't get stuck with a lot of old inventory that won't fit the next model.

How is administration at my hospital employing JIT when staffing for the next shift? The staffing supervisors are being encouraged to put nurses and nursing assistants on call for an hour or two at the beginning of a shift. The staff is put on call even when new patients are expected to admit to the unit within the first two hours of the shift, boosting the unit census to a level that calls for additional staff. "Trim every hour you can" is the new staffing motto.

The number crunchers are saying we all have to give a little, or they threaten that something drastic will have to take place. The last drastic measure was the laying off of dozens of nurses and other support staff without notice. Each time this type of threat is made by administration, the employees grow more stressed and more resentful. Threats are not a positive way to motivate.

I get that the census is not predictable. I get that there are times when I will be on call and times when I will work extra shifts. What I don't get is why it has suddenly become the nurses (and NAs and clerks) who must bear the burden of all the variability. In the past we used the slow hour to read the emails from the supervisor, catch up on new competency mandates, clean the unit, and do our annual ethics compliance trainings. Nurses clean the unit? Yep. Housekeeping only cleans rooms when patients have discharged, or when paged to clean up a spill; and housekeeping cleans the hallways and lobbies where patients and visitors walk. No one is cleaning out the dust bunnies under the supply servers, the spills on the wall by the trash, or the countertops in the nurses' station. We are back to the basics here Miss Nightingale.

Many of the units now get to start the day with no unit clerk. What? Yep. That busy time of the morning when the doctors are writing a lot of new orders... the nurse who is doing morning assessments, passing morning meds, giving morning updates to the family, checking morning blood sugars and helping set patients up for breakfast, aka the morning meal, must also now enter all her own orders, oh, and answer the unit phone.

The problem is that the number crunchers don't seem to understand that there is a rhythm to each shift. I would much rather have an extra staff person (nurse, NA, unit clerk) during those rushed first hours than three hours into the morning. Let us take turns having 60 or 90-minute lunch breaks instead. I'll go work out or run errands. The best time of day to shave hours isn't at the beginning or the end, unless there are dramatic changes in the census. It seems like administrators are sinking to a new level of shadiness when they start applying tools for managing inventory to managing staffing levels for hospital units. I am sure in some industries this tool is applicable to managing "human resources", probably not in this situation though.

If they are going to employ manufacturing philosophies to manage hospital staff, then don't forget a couple more of Toyota's philosophies (you can find more at http://en.wikipedia.org/wiki/Toyota_Production_System):

1.Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals. Right now administration at my hospital is managing month-by-month, and quarter-by-quarter. There is a definite lack of interest from above in building real relationships with nursing staff. We are not parts. We are people.

2.Go and see for yourself to thoroughly understand the situation. Ever seen an administrator in the hallway outside of an inspection? Nope. Not in a slow time, certainly not when it is busy.

3.Level out the workload. (Work like the tortoise, not the hare.) Don't make your nurses frantic, it increases chance of errors and can threaten patient safety. When you know a newly admitted patient is on the way, why wait to call in the nurse? It puts added stress on everyone, including the patient. If the nurse is doing the admitting orders because there is no clerk, who is taking care of the patient?

[tokmom, BSN, RN]

Ai YI YI.. I feel for you.

How can you manage a hospital like a automotive factory? I have yet to see a car cry, whine, pee or poop. They sit on a factory line and don't move! Geez....

[martymoose, BSN, RN]

This is ABSOLUTELY rediculous. I worked for GM when we did implementt JIT( we called it bullJIT , lol)But that was when we had predictable production- like a schedule of so many parts /day, based on what moved out the week before and the predictions of sales. And guess what- how many manufacturing jobs are left in the US????? not too many. IT FAILED. Because in that case parts could be made for pennies less by foreign competition- all the JIT in the world wouldn't have helped.

So now, the health care industry is going to this? People are now the manufactured product. But its no skin off managemnets back when we get inundated and caught behind because "production" suddenly tripled- for example gosh, ed was empty last night , but now we have people waiting in the hallways. If management thinks we are going to work on call like that, they can stick it up you know where.Some people will have rediculous OT, while others will be losing hours based on the "flavor of the day"They arent going to care that now all of a sudden we are inundated- do you know anyone who would work on call like that? I know I sure as bleep won't. I might as well go find another factory job and not have to worry about losing my license or getting sued if i "goof up a part" OMG this makes me steaming mad.Its like they think we are standing around twiddling our thumbs - are you serious- most of us can't even get our work done in the 8 or 12 hour shift!!!

Maybe it will be ok if my place goes to this- cause it will be the straw that breaks the came'ls back, and I would rather live in a cardboard box than to ever put up with that horsebleep.

[N.U.R.S.E.]

You know I feel the same way I am starting to question if I want to be anurse bcz where I work nobody seems to think that there is nothing wrong with assigning one nurse 30 pts and 50to 60 during 11to 7 hours I did not go to school to have a factory job but sad to saynurse is nothing more than a glorified. Factorthe sad part at the peril of the pt and the nursey worker production production production

[SweetOldWorld, BSN, RN]

It seems to me Toyota has been in the news in recent months for an entirely different reason. Hmmm, maybe cutting things too closely doesn't always work out so well.

[whichone'spink, BSN, RN]

It seems to me Toyota has been in the news in recent months for an entirely different reason. Hmmm, maybe cutting things too closely doesn't always work out so well.

And can lead to injury and death, just like with those faulty pedals. Even more of a chance of that happening in a hospital.

[SummitRN, BSN, RN]

The amount of on-call required to treat people like commodities would probably cut your guaranteed days off down to none. You might only work 2 days a week, but you better not have plans on the other 5 just in case.

[martymoose, BSN, RN]

this absolutely burns my britches.

can't the hospitals do things the way they used to be?

first it was the studor-disney land concept, now this?

how bout the hospital do what they are supposed to do- treat patients, instead of paying some GD CEO billions of dollars? Money hungry bas^%#

this is what happens when you have upper management in a hospital that has NO practical experience in health care

[drmorton2b]

Union? If there is one its weak.

[jrbl77, RN]

I read this article with great interest, having just finished a terrible day at work. Our census is low, so we have bare bone staff, but that doesn't take into account the level of illness of the pts. Thsi is also very interesting in that this is supposed to be nurse's week- not much to celebrate from my point of view. makes me wonder what has happedned to nursing as I have known it in the past. Although I really know and it involves the almighty dollar. i find it hard to put a dollar value on patients and the care they deserve and what they actually get. I often go home feeling like a bad nurse as I know that my pts don't get the mouth care, bath care and turning and walking they need and deserve. But I can only do so much in my one shift. I graduated from nsg school 34 yrs ago this coming weekend. I have worked what I consider hard for all these past years, I don't really know how much longer I can continue doing nursing as it isn;t what it used to be. Maybe this too shall pass, I'll have to see. I have always felt that money isn't everyting, but is sure does help!

[belgarion]

I have a LOT of experience with JIT and I can tell you it only works when you also have an effective MRP (Materials Resource Planning) system in place. This requires an accurate production production schedule which requires accurate planning from marketing which requires timely updates from sales, which requires actual planning on the part of the customers.

I guess JIT could work in the hospital setting if those pesky, inconsiderate patients would just have the courtesy to give advance notice of the time and date they intend to have their heart attacks or run their cars into a tree.

[RNTOBE_1970]

I am sorry, but that whole Lean Six Sigma is a bunch of crap. Its just another thing that unusually large amount of executives at my facility do to fill their calendar. The front line worker never has any input...