Enteral Warming and Lean Six Sigma

Evi Dewhurst

How can the managerial techniques of Lean Six Sigma make your NICU more efficient and allow your clinicians more time for their patients? In this blog, I will use the task of enteral warming to demonstrate Lean Six Sigma and how it can provide these results.

A common practice in the neonatal intensive care unit is to warm an enteral feed prior to delivery. As health professionals know, this is done for several reasons: to mimic the natural body temperature of breast milk, to assist with reducing residuals and to also benefit digestion or even avoid negatively impacting a fragile neonate’s body temperature. While some facilities do not warm an enteral feed, most do, and clinicians are required to complete specific tasks to warm enteral nutrition to proper temperature. Ideally, the milk temperature would be at or near body temperature (ninety-eight degrees).

What is Lean Six Sigma and how does it relate to warming?

While the sound of “Lean Six Sigma” might bring to mind a Greek organization, it is actually not in reference to a college campus social group. Lean Six Sigma is defined as a managerial concept that aims to eliminate eight types of waste in the work place: defects, overproduction, waiting, non-utilized talent, transportation, inventory, motion, and extra-processing. The goal of adopting this concept is to reduce wasted resources and increase efficiency. It is applicable to everything from manufacturing processes to corporate structure. Today, Lean Six Sigma techniques are widely used across various organizations, such as health care, finance and beyond. So, how exactly does it relate to a simple task such as warming an enteral feed? Keep in mind we are looking at ways to reduce waste and increase efficiency. How can we do this using a Lean Six Sigma technique?

The Value Stream Map: The good, the bad and the inefficient

Value stream mapping is a principle common to lean management. A value stream map tool maps out an entire specific procedure from start to finish in real time. Let’s return to the question of how to warm an enteral feed from a Lean Six Sigma perspective. A common way to warm enteral nutrition uses a cup and water method. This heats milk from refrigerator temperatures to around ninety-eight degrees using hot tap water in a cup. Sounds pretty simple, right? However, using a value stream map, we can see this warming process typically takes over twenty steps to complete and more than seventeen minutes to finish. It brings to the forefront all the good, bad or inefficient steps for clear understanding of how the process can be improved.

Inefficiencies such as steps requiring repetition if an unplanned event occurs show as a clear drain on resources (waiting, motion and extra-processing). Using a map such as this, can you think of other ways to remove waste and increase efficiency? As a clinician, what steps can you take to improve such a process?

A Lean Six Sigma Integration

While I have used the process of enteral warming as an example for Lean Six Sigma techniques and the value stream map tool to demonstrate inefficiencies, you can apply these techniques and tool to any process in your unit, from small to large. The goal is to identify where a waste of resource(s) occurs and eliminate the waste for better efficiency in your unit, which can only benefit your patients, your processes and your health care team. While commonly used from a managerial perspective, lean concepts can be applied by just about anyone. A great exercise is to pull members of your team and encourage them to think about their daily process in terms of resources and how they would conserve, save or utilize them better. You might hear many good ideas! Good luck, and enjoy the process of Lean Six Sigma integration within your clinical environment.

References (Learn more about Lean Six Sigma and lean practices here):


The Medela Guardian Warmer was designed to deliver a warm neonatal enteral feed while increasing clinical staff efficiency.
Learn more about the Guardian.