An ICU “of Love”... and of Lean!
Planning, structuring and carrying out efficient work management is an increasingly crucial element in the Intensive Care Units (ICUs) of large hospitals. It directly affects patient safety, quality of care, staff well-being and operating costs.
In this context, Hospital de Amor (HA), better known as Hospital de Câncer de Barretos, in the interior of São Paulo state, recently implemented concepts and practices of the lean system to bring about significant improvements in work management in the institution's ICUs. The lean initiative was carried out to reverse problems caused by a recent restructuring of the work teams.
HA currently has two ICUs, each with 10 beds. The structure has a team of five technicians and up to two nurses per ICU. Recently, with the aim of reducing costs, the work schedules in this unit were changed to eight-hour shifts. Previously, they ranged from 6 to 12 hours. The breaks were also changed. They now last one hour; before, they were 15 minutes.
This new reality put the ICU on a new footing in which, in each 8-hour shift, the care structure was at times insufficient to meet needs, with a staffing shortfall of up to 62% relative to ideal capacity, compromising the continuity and effectiveness of the care provided.
This has created a series of challenges: higher operating costs, lower quality of care, a greater incidence of adverse events, more healthcare-associated infections (HAIs), as well as widespread dissatisfaction among the staff, including an increase in sick leave, through medical certificates, due to health problems among the professionals.
In this context, the purpose of implementing the lean system was to understand these problems, investigate their root causes and propose countermeasures, based on lean concepts and practices. The objectives and targets set were therefore to improve the stability of care processes and staff satisfaction, reducing HAI notifications by 30% and sick leave through medical certificates by 50%.
Investigating the contexts, problems and root causes
The analysis of the “current state”, one of the foundations of the lean system, revealed a multifaceted scenario in which the change in working hours directly affected operational results. In 2024, HA's ICUs had an occupancy rate of close to 90%. And patients were classified by severity category as low (25,23%), intermediate (25,43%), high (20,79%) and very high (28,54%). In this context, it became important to deepen our knowledge of the activities of nursing technicians in the ICU.
The first step was to go to the gemba and apply a “Process Study Sheet”. With it, we identified the variation in the time spent on each activity, its degree of complexity and whether the activity was routine or occasional. This confirmed that the time and complexity of the activities demand attention, discipline and experience, characteristics that are indispensable to ensure continuity and safety in the process.
After identifying the processes and the time spent by each professional, an analysis was made of the “spaghetti flow” – the product of the technique also known as the “Spaghetti Diagram”, which is, in short, a graphic representation that maps the flow of movement of people, processes, information and products – which revealed a critical operational challenge in the ICU, especially during the nursing technicians' rest periods. When one of the technicians goes on break, the others must immediately take over coverage of the patients assigned to him or her. This redistribution causes intense internal movement, directly affecting both the work dynamics and the safety of care.
In practical terms, two critical moments were identified over the course of the day. During a two-hour period, the ICU operates with only three technicians to care for 10 patients, which corresponds to 60% of ideal operating capacity. This sharp reduction not only reveals a gap in coverage, but also increases the overload on the remaining professionals, who must move around constantly to ensure patients are cared for, increasing the likelihood of delays and failures in the care process. In the same 8-hour shift, another moment, when the situation is somewhat less critical, occurs during a 1-hour period in which the team has 4 technicians, reducing care capacity to 80%.
It is worth remembering that, even in the previous scenario, with 6- and 12-hour shifts and with 5 technicians and 2 nurses for every 10 ICU beds, this was still below the ideal for an ICU, which deals with high complexity, exposing the team to persistent risks and increasing the pressure on the professionals.
This complexity can be assessed by the NAS (Nursing Activities Score), which measures the nursing workload. In 2022 and 2024, our NAS were 95% and 89%, respectively, confirming the high complexity (between 80 and 100%).
This frequent movement of technicians to cover temporary absences directly affects the efficiency and quality of care. The time spent moving around, the need to adapt quickly to different demands and the physical and mental overload compromise the unit's ability to respond. In addition, forced rotation can break the continuity of care, hindering communication between professionals and, consequently, patient safety.
Based on the analysis of the eight months before (January to August 2022) and the seven months after (September 2022 to March 2023) the change in working hours, a striking picture reflects the impact of this change on operational indicators and on employees' perceptions (through the results of the climate survey).
The labor database, for example, showed a 600% increase in the issuing of medical certificates when the six-hour shift is compared with the eight-hour shift. According to Almeida & Rodrigues (2013), the average cost of absenteeism ranges from 2% to 6% of payroll. Projecting for 2022, the costs associated with medical certificates rose from R$ 54.202,43 to R$ 325.214,58. This significant jump indicates not only an increase in the absenteeism rate, but also a significant financial impact for the institution.
Another relevant figure showed a 380% increase in requests by ICU professionals to transfer to other units. This high turnover affects team stability and creates a cascade effect: exhausting work leads people to seek to move, resulting in the arrival of inexperienced staff, which in turn places an even greater burden on the more experienced professionals.
A third worrying point was a 450% increase in “Near Miss” notifications. In hospitals, this expression, also called "Near Adverse Event" or "Near Error") refers to an incident that did not harm the patient because it was detected and corrected before reaching the patient, signaling a failure in the process that could have caused an adverse event. Notifying and analyzing these incidents is crucial to identify risks, implement improvements in processes and thus prevent future harm and accidents.
This is a critical indicator, as it reflects a higher incidence of possible failures and implies a significant average cost per event. Based on the study by Zhan and other authors, a single adverse event can cost, on average, US$ 8.750,00. Projecting this 450% increase, one arrives at a significant figure of US$ 39.375,00, or approximately R$ 220.500,00, depending on the exchange rate used.
An analysis from 2022 to one year after the change in working hours revealed worrying data: increases of 320% in the annual incidence density of Urinary Tract Infection (UTI), of 54% in Primary Bloodstream Infection (PBSI) and of 61% in Ventilator-Associated Pneumonia (VAP). This rise indicates that failures in the implementation and execution of prevention protocols are affecting several areas of care.
The significant increases in sick leave and transfer requests by professionals and in “near miss” notifications indicate that the change in working hours affected not only operational efficiency and safety, but also the organizational climate. These results point to an overload of professionals and to the deterioration of working conditions, which may compromise, in the long term, both the quality of care and the financial sustainability of the ICU.
Lean countermeasures implemented
The first measure adopted was to draw up a map of the desired state. To do this, it was indispensable to map the critical points in the gemba and build a consistent and realistic action plan, covering different strategies.
In this context, the first countermeasure considered was the restructuring of Shifts and Hiring. The proposal called for alternating 6-hour day shifts and 12-hour night shifts, with the aim of reducing overload levels. This plan provided for hiring new professionals: it was estimated that 15 technicians and 4 nurses were needed to balance demand and improve the quality of care.
We also began implementing Visual Management, aimed at modernizing manual processes, such as recording vital signs and controlling the inflow and outflow of medications. The objective was to reduce work overload and errors resulting from lost information. Visual management tools for monitoring inventories and flows, such as tracking days of hospitalization and invasive devices, will enable fast and effective corrective actions.
Safety rounds, or safety huddles, were also scheduled: quick, structured meetings, held preferably at the start of the afternoon shift, in which the nurse, physical therapist, physician and nutritionist get together to discuss the day's critical points, review safety indicators and identify potential risks in advance. With this, we expect to reduce notifications and care failures.
Investing in regular training and in holding daily meetings was also essential to raise awareness of good care practices and the prevention of adverse events. This approach seeks to create an environment of continuous learning, increasing adherence to protocols and reducing the incidence of errors, with a focus on the quality of patient care and on the safety of professionals.
One of the training programs developed was the formation of the “ICU Rapid Response Team”. This is a multiprofessional team trained to recognize early signs of patient deterioration and take immediate action to stabilize the patient.
In view of the increase in HAIs, a project was implemented in January 2025 focused on training the multidisciplinary team and raising its awareness regarding Ventilator-Associated Pneumonia (VAP). The project has the active participation of nursing technicians, physicians, physical therapists, nurses, dentists and the Hospital Infection Control Service (SCIH) team, reinforcing the integrated approach to promoting patient safety. In the initial phase, the focus was on raising awareness of VAP, highlighting its risks and impacts on the quality of care. In a second stage, there were structured presentations for the whole team, once a quarter, at the meeting called “Coffee without VAP”, which addressed the evidence-based prevention strategy, promoting adherence to the VAP bundle.
The educational sessions were designed to train and develop an open dialogue, as well as to encourage reflection and commitment among the professionals, ensuring the effective implementation of preventive measures in the hospital routine and keeping them informed of the whole evolution of the indicators. In addition to the training, cards were created that are applied to patients on mechanical ventilation for more than 24h.
It also proved essential to monitor quality and satisfaction indicators. And to closely follow the results, before and after the interventions. Monthly meetings and quarterly reports will make it possible to identify deviations and make agile adjustments, ensuring the continuous evolution of processes and transparency with the whole team.
Results of the lean actions
Incidence density of HAIs: the trend in the VAP incidence density rate has been rising in recent years. In 2024, this rate reached 9,1, revealing a significant challenge in care practice. However, the introduction of training focused on adherence to the VAP bundle and the expansion of awareness actions on HAIs, implemented at the beginning of 2025, brought about a significant change. After these interventions, the incidence rate fell to 6,9, a decrease of 32,3%.
Medical certificates and turnover: regarding sick leave through medical certificates, 168 certificates were recorded in 2023. In 2024, there was a significant reduction, with the rate falling to 36,7, which represents a significant improvement of approximately 78%. As for turnover, in 2023, after the shift change, 38 transfer requests were recorded, showing a significant impact on employee behavior. In 2024, the annual rate recorded an average of 31 requests, indicating a reduction of approximately 18,4% compared with the increase observed right after the change. This decrease possibly reflects employees' expectations regarding the proposed return to the old schedule, as indicated by the information gathered from the team.
Standardized mortality ratio (SMR): to deepen the analysis of the quality of care, an assessment was made of the standardized mortality ratio, defined as the ratio between observed mortality and expected mortality, according to SAPS 3. In 2024, this ratio was 1,11, which indicates that observed mortality was 11% above the expected value. With the improvement initiatives implemented, the period from January to April 2025 recorded an SMR of 0,85, representing a reduction of approximately 23,4%.
Initial and promising results
The results achieved, such as the 32,3% reduction in the incidence density of HAIs, the significant 78% decrease in the number of medical certificates, the 18,4% drop in transfer requests and the 23,4% reduction in the standardized mortality ratio, reflect significant progress in care practices and in the safety of care in the ICU.
These gains demonstrate the importance of systematic and integrated approaches to continuous improvement, such as those advocated by lean. By acting directly to eliminate waste, strengthen teamwork and keep a constant focus on the quality and safety of care processes, lean offers a structured path to turn critical challenges into opportunities for sustainable growth. In this way, a culture of operational excellence, respect for people and, above all, safety for patients and professionals is consolidated.
This lean implementation is all the more important because HA is a philanthropic institution, maintained by the Fundação Pio XII. It was founded in the 1960s, in the heart of the city of Barretos (SP). At that time, the population of the region faced enormous challenges in accessing medical treatment in the state capital. And the hospital, which initially operated as a general center, soon saw the need to offer specialized care to meet the growing demand for cancer treatment.
In tribute to the emotional bond built over its history and to the philosophy of care that values not only technical excellence but also the humane treatment of each patient, the lean system will fortunately be able, more and more, to explore and resolve possible bottlenecks that may limit the hospital's capacity, improving the safety, the care and the professionals of what is one of the most important healthcare institutions in Brazil.
