Standard Work—Obstacles and (A Few) Solutions

“Solutions to problems in standard work? Curmudge, you must be dreaming.”

“Solutions are ultimate goals that we’re unlikely to attain anytime soon, Jaded Julie; ‘countermeasures’ is a more realistic term. And as for dreaming, the Book of Acts says that’s what I’m supposed to be doing. ’Your young men shall see visions, and your old men shall dream dreams.’”

“Okay Old Man, wake up and tell me about standard work.”

“My off-the-top-of-my-head definition of standard work is ‘everybody doing the same work does it the same way.’ The ‘same way’ is, of course, the best way we know to do that job. The ‘way’ is described in a simple-as-possible document, readily available to all doing the job, which can be promptly revised when a better ‘way’ is found. However, I admit that my statement about everybody doing the same work the same way is probably too rigid for nurses in a hospital.”

“I agree, Curmudge. I’ve been reading your copy of Mark Graban’s Lean Hospitals, and he favors the term standardized rather than standard. Standardized implies that only those actions that impact quality, outcome, and patient safety need to be highly specified; adherence to other details in a procedure may be more flexible. Graban also regards standardized work to include consideration of what tasks are done by which people.”

“Another issue for nurses is professional judgment. There may be instances when a nurse might decide to overrule a standard and invoke her professional judgment in order to achieve a better outcome. And a related problem is that no one, especially a professional, likes to be told what to do. We should minimize that and help everyone gain a sense of ownership by having the people who do the work write—or at least approve—the standard.”

“Could this be a path forward, Curmudge? Just have the folks in gemba develop standards that are established, documented, implemented, and maintained, as you wrote a couple of years ago.”

“That’s the right idea, Julie, but doing it is not as easy as writing it. A hospital is a veritable black hole for efforts at standardization. As Graban states, ‘Trying to standardize all of our methods would seem like an overwhelming challenge.’ Let’s begin at the beginning and think about some of the obstacles to standardization that probably exist in most hospitals. Then, hopefully, we can devise ways by which they can be overcome.”

“Are we going to discuss our hospital, Curmudge?”

“I can’t, Julie. If I tried, I’d get at least half of the facts wrong. There are thousands of hospitals in the U.S. They range from those with Magnet status for nurses down to some that are a hazard to patients and a dead end for employees. Let’s pick one in the middle and call it Generic General or GenGen for short. In your long career you’ve probably worked in a place like GenGen and have seen a variety of standard work and documentation situations.”

“That’s for sure. My GenGen had more silos than the whole state of Wisconsin, and each one had its own methods and documents.”

“That sounds pretty tough for pool nurses who worked in several units.”

“Right. And some units’ methods were electronic—on a server somewhere—while others used hard copies in big loose-leaf notebooks. And believe it or not, some units depended on sticky notes and nurses with long memories.”

“It sounds as if ambiguity could have been rampant at Generic General. How did they train new nurses?”

“GenGen had dedicated mentors, but a lot of what they taught was by word-of-mouth. I believe you call those ‘oral traditions’.”

“’Oral traditions’ aren’t good, Julie, unless you are an aboriginal tribe somewhere in the jungle.”

“Finally, Curmudge, Generic General had a totally top-down organization. No one seemed to have thought about a nurse using professional judgment, although they probably did anyway. New procedures were written by someone in an office, and it was hard for nurses to change things. If they did, only nurses in their own unit found out about it. There was no way for others in the hospital to learn about the improvements that were made.”

“There’s no question, Julie, that any hospital resembling Generic General has a bedpan full of problems.”

“So what solutions…er, countermeasures…do you propose?”

“None, Julie. I haven’t thought of them yet. You’ll have to wait until next week.”

“Next week! Curmudge, you’ll have to conjure up some visions in a hurry, unless of course you plan to spend the week dreaming.”

“Don’t worry. They will be visions; they keep me young.”

Affinity’s Kaizen Curmudgeon