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Mark Graban

Six Sigma

Will Health Care Professionals Accept the Lean Concept of ‘Standardized Work?’

Staff must have a say in defining standardized work

Published: Monday, July 9, 2012 - 10:06

When I was a guest on Quality Digest Live, co-host Dirk Dusharme asked me about hesitations that some health care professionals might have about the lean concept of “standardized work.” As you can see in the show’s archived recording, I talked about how the increased standardization of core processes can have great benefits to patients, clinicians, staff, and the hospital. Those benefits should be the focus. They are why we need to have more standardized processes, rather than standardizing for the sake of standardizing, or because it’s the “lean thing to do.”

“Standardized,” in the lean approach, doesn’t mean that a process becomes inflexible, or that we want people to check their brains at the door. As the Joint Commission is recommending, having a standardized shift hand-off communication protocol reduces errors that can harm or kill patients. Standardized is a spectrum—making something more standardized doesn’t mean that everything is done in a completely identical way.

Having a standardized structure for hand-off communication doesn’t mean that health care professionals are just robotically reading a script. Standardized work, especially when supplemented with checklists in this context, provides structure that helps ensure that an important step in the hand-off process doesn’t get skipped. There are still many opportunities for staff to use clinical judgment and to vary their approach based on the needs of a specific patient when medically necessary. Standardized work is only limiting and inflexible if we allow it to be—and we shouldn’t.

Additionally, standardized work is neither static nor permanent. That’s where the concept of kaizen comes in. An internal Toyota publication from a few years ago says standardized work is “the basis for kaizen,” and that kaizen is “the lifeblood of standardized work.” The two concepts are intertwined in a chicken-and-egg sort of way. Today’s standardized work is just that—today’s way of doing things. We should be improving the way we do our work in small ways nearly every week. That’s what Joseph Swartz’s and my book, Healthcare Kaizen (Productivity Press, 2012), is all about—engaging everybody in workplace improvement.

Another key point about standardized work that I didn’t have time to address on the show is an idea that traces back to Toyota and Taiichi Ohno: That standardized work should be created by the people who do the work. When people “resist” (a term I don’t like because it blames the “resistor”) standardized work, it’s often for a good reason: The standardized work is being dictated to them by a manager or an outside expert. That’s why I am a little concerned about the Joint Commission’s standardized communication framework: Will it be poorly received because (even if it’s correct) it’s dictated by an outside body? Will there be room for customization and improvement over time?

Looking at operating room checklists as a form of standardized work, I have an airline pilot friend whose consulting firm teaches hospital staff a method for creating their own checklists. A competing firm basically just sells a hospital a ready-made checklist. Which do you think is more likely to be accepted by the staff, to really be put into use in a meaningful way? Which is most likely to be sustained and improved upon over time?

People generally have a strong sense of ownership for what they create. Involving people in the process, allowing them to define their standardized work, eliminates those complaints about standardized work. When people are allowed to define processes that support their important patient-care work, it’s viewed as a positive.

Considering standardized work as related to a surgical process, having a better-defined standardized approach can have many benefits:
• A standardized method for scheduling surgeries prevents miscommunications or problems that would delay a procedure (such as a lack of insurance approval).
• More standardized methods for processing instruments and prepping the operating room leads to fewer delays and interruptions due to missing instruments or instruments not being properly sterilized.
• Standardized work related to presurgical prep can help improve patient flow and prevent delays, while preventing mistakes that might harm the patient.

There are dozens of processes that can be standardized to better support the surgeon, staff, and patient—without telling the surgeon how to do her “value adding” work for the patient. We can’t dictate standardized work to the surgeons—nor should we. The same idea (and respect) should apply to others in the extended surgical team.

That said, I have a friend in Dallas who is a highly regarded cosmetic surgeon. He has diligently applied lean principles to improve his work and his patients’ results. He has videotaped his own work, looking for wasted surgical motion so he can reduce the length of surgeries and prevent internal bleeding and bruising. The surgeon benefits because he is more efficient, but the patients benefit because recovery times are faster, and they have fewer complications. Now, since he defined his own standardized work, he owns what he created. It wasn’t dictated to him. Creating individual standardized work is less complex than getting a team of surgeons to agree... but it is possible when we allow them to define their own standardized work, answering three key questions:
• What do we standardize?
• How much do we standardize it?
• How do we improve it over time?

That’s the key to standardized work and kaizen. Back to Dusharme’s question about hesitations regarding “standardized work,” when we take this approach, I’ve found people are enthusiastic, not resistant, because standardized work and kaizen help improve patient care.


About The Author

Mark Graban’s picture

Mark Graban

Mark Graban is an author, educator, podcaster, and speaker in lean and continuous improvement strategies through his company Constancy Inc. He is a senior advisor to the technology company KaiNexus, the founder of LeanBlog.org, and the author of Lean Hospitals, Healthcare Kaizen (with Joseph E. Swartz), both recipients of the Shingo Publication Award. Mark’s most recent books are Measures of Success and The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.


Virginia Mason

Here's a great blog post on standardized work from Virginia Mason - one of the many examples of standardized work benefitting patients (preventing falls):