What do we mean by standardized work, or standardized operations? I define standardized work as the current best way to safely achieve the highest valued outcome. It is important that standardized work always be designed to achieve the expected outcome. This procedure must be reliable. It should also be designed to increase value by improving the quality and reducing the cost. Value equals quality divided by cost of the process. It should improve quality by applying proven methods to enhance the health and well being of each patient. Many subspecialists have created evidence based guidelines and these should be followed whenever possible. And finally standardized work should improve efficiency by using the fewest resources possible including time there by lowering costs. One of the most important benefits of standardized work is consistency. When something is done the same way each time there is less likelihood of errors that could cause harm to patients. To quote the founder of Toyota Production System, Taichi Ohno, without standards, there can be no improvement. It is impossible to improve a random process. Do you want to improve efficiency, quality, and safety of patient care? If you aspire to these goals a key tool will be the creation of standardized work. What do physicians say about standardized work? Standardized work is cookie cutter medicine. This approach leaves me with no freedom to be me. This criticism reflects the history of medicine. Medicine was a cottage industry, requiring apprenticeship, and consisting of individual practitioners. Autonomy was highly valued, and many chose this profession, because they valued individual autonomy. They liked working alone. No one should tell me what to do I am the captain of the ship. Let's view this approach in terms of a well-known team sport, European football, or as Americans call it, soccer. What happens when a player fails to follow the play? A form of standardized work. The playbook depicted as dash lines and arrows shows the center dribbling down the center of the field and within 50 meters of the goal he is expected to pass to the left wing. The left wing then moves toward the goal and as the defensive player approaches he passes to the right wing. The right wing is uncovered by the defense, and kicks the ball in the goal. Instead of following the playbook, the center decides to go it alone. And keeps the ball, as he approaches the goal, he is double teamed, and looses the ball. In team sports, the failure to follow the playbook often results in loss of the game. In healthcare, the stakes are far higher. When communication protocols and other standardized procedures are not followed, the care of the patient can be delayed. An error may occur and the worst case scenario the patient is harmed. How do patients see solo practitioner model? Each doctor is telling me something different. Who is in charge? My nurse doesn't seem to know what is going on. No one seems to be listening. Do the doctors and nurses ever talk? My friend had the same problem as I have and his care was completely different than mine. Why? As I described in week three of our basic course, structure or standardization can be thought of as an egg. If the eggshell is too thin, the shell will break prematurely, and the embryo will die. Similarly when there is insufficient structure or standardization, the efforts of people caring for each parent are not coordinated, and the care is less efficient and less effective. The ability the improve the health and wellbeing of patients is compromised. On the other hand, if the shell is too thick the embryo is unable to break out of the shell and dies. When there's too much structure or too detailed standardization, innovation and creativity are stifled. Those required to follow overly rigid standards have no sense of control or autonomy, resulting in low job satisfaction. When physicians hear about standard work, they fear access structure. But ideal standardized work is flexible, allowing front line workers to continually adjust and improve their playbook. Standardized work encourages the integration of multiple caregivers and the coordination of care. Everyone has a defined role, and this creates predictability and consistency and it encourages effective teamwork. Because everyone in the front line is encouraged to improve the standardized work protocol. This forces a new kind of autonomy. My ideas matter, I am listened to standardized work provides the team with playbooks and a game plan. Work is called standardized, not standard, because it should always be improving. And, those in the front lines are guiding these improvements. What are some of the other advantages of standardized work? This approach creates the fundamental operating procedures that free the brain to perform higher level functions. Providing more time to focus on differential diagnosis, creating more sophisticated management plans, coordination of care with other providers, consultants, nurses, physical therapist, case managers and family members. Implementation is hard initially it requires slow thinking. You need to consistently review each step in your brain. However, with time this procedures become habits, fast thinking and can be managed in the background. Standardized work requires adaptive change. A change in a way things are done. Adaptive change creates a sense of loss and causes anxiety and emotional disequilibrium. Implementation requires adaptive leadership as described in our second course, creating a culture of safety, week four, adaptive leaders need to be innovative empathic. Tolerant of uncertainty and able to manage disequilibrium, maintaining it within the productive zone. Standardized work lies at the heart of lean improvement. Without standardized work, there cannot be significant improvement. Remember as discussed in fixing health care delivery basics week four, when automobile manufacturers adopted standardized work lemons disappeared. If we adopt standardized work week two can eliminate our lemons. Preventable deaths and permanent injuries standardized work saves lives. Thank you.
