Why is standard work missing in healthcare?

Updated 4/20/23: This article was originally published in 2015 in partnership with one of our healthcare subject matter experts and nurse of 27 years Ms. Susan Chewning that has since retired. The perspective and questions raised in the original post is still relevant, so we wanted to revisit this topic 8 years later.

In lean healthcare, it is amazing how often standardized work is missing. As a patient, we challenge you to observe the health care team members and note the variability of their work from one technician to the next, one nurse to the next or one doctor to the next. One shift does a task a certain way while the next shift is totally different. Is it really necessary to send in 12 different associates throughout the night when a patient is trying to rest and recover?

Variability in healthcare at times is seen as a badge of pride and honor. There are areas in healthcare where individuality can shine. However in many areas, if not most areas, standard work should be imperative. One simple example of process variability that creates millions of infections that a patient didn’t have when they came into a facility is the simple process of sterilization and decontamination.

Standardized work can come in various forms - checklists, video instructions, programming that is embedded into instrumentation or hung on the wall of examination rooms. We’re also seeing the emergence of technology that embeds AR (augmented reality) into glasses to allow workers to visually see step-by-step instructions as a layer over complex operations like automotive assembly, maintenance troubleshooting or even surgery.

Forget the robots and costly tech gadgets for a moment. Why can’t we get the simple things right in healthcare? Why don’t we see standardized, predictable and effective work steps being performed in critical processes like the proper cleaning, decontamination and use of medical instruments? Why do we rely on tribal knowledge that is only as good as the last training or shift hand-off? Imagine coming into a situation where you are a part of a cross-functional team that is gathered around a patient who has just been prepped for operation with assumptions about who’s going to do what, whether the instruments have been sterilized properly, or that the patient has provided all of the information needed to treat him or her as needed. There old saying… “assume” makes an “ass out of you and me”.

Work steps as simple as how to properly label blood vials could use a standard work. Do you circle the date or write the date? Does the collector put three initials or just two? I bet most would say that’s all common sense, but if you were able to walk the process as a coherent patient, or loved one, you would undoubtedly observe variation. With variation in the simple but important tasks like labeling vials, then we might also assumed variation exists at some magnitude for the more difficult tasks related to work steps involving decontamination, the timely and proper issuance of antibiotics or accounting for that gauze that was used to help control the travel of blood after an incision. “Oh no! Did we leave that in the patient that we just sewed up?” It happens more than you know.

9 Steps to Standardizing Work Effectively

Here are some tips on capturing best practices and documented these work steps as standardized work:

1. WHY this is important: Start with “the why”. Why is it important to create standardized work for the process at hand? What has gone wrong, or could go wrong, due to miscommunication, poor assumptions or process variation. Tie “the why” to something that the team knows about. Stories and emotional connections are really important before jumping into “the what”.

2. STUDY the current best practice: Pick a procedure that you believe represents the best within your organization. This might include the surgeons, nursing staff, technicians, tools and facilities. What are the key differences between the best practice and the others? Study not only the best practices but why variation is key element for the team.

3. DOCUMENT each process step in a flowchart or Swimlane diagram: What are the key steps? What are the primary roles, responsibilities and constraints for each team member? Where are there pause points for decisions to be made?

4. PLAN for the unexpected: What is the contingency plan if something does not go as planned? What is the back-up plan and escalation process? Have you tested these alternative plans to ensure you will be prepared?

5. REVIEW the documentation: Take the documentation that has been created and review it together as a team. We have found that projecting a standard work document creates a situation that challenges the entire team to poke holes in it and highlight changes needed.

6. STANDARDIZE the work: Create a standard checklist, SOP, job instruction or other document that captures the key steps, pause points, decisions, back-up plans and roles. Ensure that the those who are using this standard can understand it (i.e. legible, accessible, in a language they understand, etc.).

7. TRAIN the team: Train all users on their respective work tasks. Pay particular attention to work steps where decisions are made and where work is transferred from one role to another. Most mistakes happen during handoff steps. Ensure the training is effective by observing the trainee’s understanding and consistent work output.

8. POST the new document: Don’t hide a document on a shared network drive. It won’t get used. Make sure the standardized work document(s) is/are available at the point of use. Standard work is a tool that should be treated like any other piece of equipment or valued facilities. You do not want, “out of sight, out of mind.”

9. CHECK the process: Audit the process to ensure all team members are consistently following the document. Checking the document also presents an opportunity for improvement, highlighting new risks and other needs that may change as the organization and it’s process mature.

Include all members of the team in the development and deployment of your standardized work. Communicating “the why” is paramount when developing and sustaining best work practices. Minimizing process variability - which leads to process predictability, efficiency and the reduction of waste - is great for the team members, the provider as a whole and, most importantly, the customer.

Concentric Global has subject matter expertise in healthcare, so if you are looking for an assessment or training in lean in healthcare please feel free to reach out and see how we can help.