This 7th blog on organizational transformation again is under the rubric of process, standard work, and it is a key part of the Methodology of lean.
Standard work is the codified work sequence that comes about as a result of improvement activity. When a care process is changed the staff and physicians delivering that care act differently based on what the new process is telling them to do. These new processes are designed by front line nurses and doctors in an attempt to take waste out of an existing care process leading to better outcomes for staff and patients. Unfortunately standard work is sometimes derided by health professionals as "cookie cutter" medicine or "cookbook" medicine. It is seen as taking away the autonomy of the doctor.In reality it actually frees more time for critical thinking. Let's explore why.
When an improvement activity occurs their is a plan than must be developed.This plan is based on certain back round evidence which is collected before the experiment is designed to test a hypothesis. For example, the infection rate is twice as high in the inpatient surgery center at hospital A vs. hospital B. We first observe the better performing hospital by observing a large number of surgeons washing their hands.We observe the time spent, the process of cleaning each finger, and the variability in the process from surgeon to surgeon.We do the same thing at the poorer performing hospital. We find in the poorer performing hospital that many surgeons are washing their hands differently.The next step is to formulate a hypothesis: If all surgeons washed their hands the same way and washed them in accordance with the best evidence for hand washing technique would infection rates at Hospital A go down?
Now we are ready to test or actually do the experiment. A new hand washing process is established by having the surgical medical director take the existing evidence on hand washing and present that to the surgical committee get feedback from them and then create standard work for hand washing. The new standard work is then piloted with a few surgeons to determine if it is the appropriate process for all the surgeons. Now we study the consequences of this new protocol and find that all the pilot surgeons comply with the process and believe it is effective.
We now are ready to act on the new standard work for hand washing. The surgical committee recommends that the new process be established as the standard for all surgeons in the O.R. Of course, after the usual "you can't make me" the new process is implemented. The process up to this point has involved many surgeons who understand there is an infection problem in the O.R and are willing to help fix the problem even if they are not directly the surgeons having the infection problem.The key to success is buy-in of the surgical leadership and massive upfront communication on the issue with focus on the problem as a process problem not blaming any specific surgeon.In some cases unblinded data on each surgeon is used to assure compliance but only after all the above actions have been taken.
The new standard work is again studied over the next 3 months. The study is focused on two things: Compliance to standard and outcomes. Compliance to standard can be accomplished in several ways.In one case we installed video cameras which only showed hands not faces. This way we could show non-compliance in a non blaming way to the committee. The other way is to directly observe which is more intimidating but successful if surgeons buy in to it.
At the end of three months infection rates had dropped by half and compliance to hand washing standard work was at 100%. The study showed the plan was working. The auditing and measurement part of this experiment continues as part of the managers standard work. As long as outcomes and compliance to standard work remain at the appropriate target a new pdsa cycle is not necessary.
Now, how does this standard work process for hand washing (cookbook medicine) help the surgeon spend time on more important things?It should be fairly obvious that if he doesn't have to take care of all the infected patients he has more time to treat patients that need his help.He also gets dragged in to fewer meetings regarding reducing infections and the most important point is his patients have better outcomes.
Standard work is a critical component to creating reliability of patient outcomes. Although this is a simple example the concept can be applied to all specialties and all processes in a hospital or clinic.The error I see most often with standard work implementation is lack of a process owner for auditing compliance to standard work.As soon as auditing is discontinued the process spins out of control and variation returns.
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