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Mark Graban

Health Care

Thinking and Adapting in the Context of Standardized Work

Don’t be afraid to use your brains.

Published: Tuesday, February 16, 2010 - 09:15

When I was in Sweden recently, we had a lot of good discussion about the lean concept of “standardized work.”

There was much agreement from different presenters at the lean laboratories conference, and from the hospital people we visited, concerning standardized work—that it isn’t a robotic form of cookbook medicine or cookbook processes. Standardized work isn’t “mindless conformity” as Bill Marriott writes about in regard to the hotel chain.

We found an interesting example of a situation where thinking is required.

Let’s say that according to a process for phlebotomy (drawing blood from a patient) it’s preferable to draw blood from the patient’s left arm. Having a standardized process doesn’t mean we always draw from the left arm.

Somebody asked about an extreme situation. “What if the patient is an amputee and they don’t have a left arm?” Clearly, the phlebotomist must be empowered to make a decision—draw from the right arm. Even if the patient just expresses a preference to using the right arm (because they are left-handed and don’t want that arm to hurt), the phlebotomist could be allowed to make a judgment call, even if the standardized work doesn’t spell out this choice.

As I’ve heard in other contexts, the role of an employee is to:
1.  Follow the standardized work—unless there’s a good reason not to.
2.  Make contributions to improve the letter and the spirit of the standardized work (because the standardized work is defined by those doing the work, not the bosses).

“Standardized work is not what top management says; It’s what staff says,” notes Dr. Göran Ornung, cardiologist and emergency physician, concerning point No. 2.

If people are afraid to use their judgment and make decisions, maybe the standardized work document (and more important, the training) should specify that you are not leaving your brain at the door.

Final thought—there’s a difference between not following the standardized work for a justifiable reason and not following it because you didn’t feel like it. See the article, “A Bid for Better Care, Surgery With a Warranty,” by Reed Abelson, in the May 17, 2007 issue of The New York Times, defining standardized work and their guidelines about choosing not to follow it.

What do you do in your training or management to make sure standardized work doesn’t mean “mindless conformity?”

Many of these same ideas are expressed in Dr. Atul Gawande’s book The Checklist Manifesto: How to Get Things Right (Metropolitan Books, 2009). More on that later, when I write a full review of the outstanding book.


About The Author

Mark Graban’s picture

Mark Graban

Mark Graban is an author, educator, and speaker in lean health care, through his company Constancy Inc. He is a faculty member for the Lean Enterprise Institute (LEI) and vice president of improvement and innovation services at KaiNexus, a technology company that helps organizations spread continuous improvement. He is founder of the Lean Blog and is author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition (Productivity Press, 2011) and, with Joseph E. Swartz, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements (Productivity Press, 2012), both recipients of the Shingo Professional Publication and Research Award.


Standardized work in Healthcare

Truly this shows if we look hard and long enough we can find an example to support our theories. Most healthcare applications do not have this little variety.

Tripp Babbitt