Documents and Standards

“Curmudge, if we define a standard loosely as something in writing that tells ‘how to do it,’ most hospitals have an overabundance of standards. (I could have said ‘plethora,’ but that would have been too sophisticated for me.—JJ)"

“That’s for sure, Jaded Julie. Those documents serve a useful purpose, but many don’t meet all of the criteria we have been discussing (established, documented, implemented, and maintained). Perhaps we can call these quasi standards. Things like guidelines, job aides, operating instructions for medical devices and instruments, and all sorts of different lists. Also, there are de facto standards such as evidence-based procedures, policies and procedures to demonstrate JCAHO compliance, algorithms, and bundles.”

“Whoa, Curmudge! I know you wrote about this stuff before I came on board, but I need some help understanding algorithms and bundles.”

“No problem, Julie. An algorithm is a step-by-step protocol, often in the form of a decision tree. Using a series of questions, it guides you to do the right thing based on the patient’s symptoms, test results, and responses. The questions are usually ‘yes/no’; a ‘yes’ answer sends you out one branch, and a ‘no’ sends you in a different direction.”

“And what about bundles?”

“The Institute for Healthcare Improvement (IHI) has been a strong proponent of bundles for several specific processes. A bundle consists of ‘a small, straightforward set of practices—generally three to five—that, when performed collectively and reliably, have been proven to improve patient outcomes.’* Each practice in the bundle is evidence-based, but they all must be used in order to achieve the bundle’s improved outcome. Bundles have been used to minimize central line blood stream infections and ventilator-associated pneumonia and to treat severe sepsis.”

“That’s a ‘bundle’ of information, Curmudge. So all of these kinds of documents can be made into standards?”

“Sometimes it’s just a matter of adding the ‘boilerplate’ (dates, authors, approvals, etc.) necessary to meet the hospital’s formatting requirements. In other cases, long policies and procedures must be broken up to make them user- and learner-friendly. For some institutions, the biggest challenge will be putting all of their standards in a searchable database.”

“This sounds like a lot of work, Curmudge. Where is the gain?”

“There’s no free lunch, Julie. We apply Lean to nursing to reduce waste, ambiguity, and workarounds, and to increase efficiency and patient safety. These require standard work and documentation. We are depending on the gains’ outweighing the work that went into developing the standards.”

“Curmudge, do you recall the nurses in Hôpital Nord 92 in France that we discussed a few weeks ago?”

“Of course I do. They prepared—and complied with—lists of the essential steps in several of their basic nursing processes. The authors of the paper considered it to be a major accomplishment.”

“Do you know, Curmudge, whether in France they have an accrediting body like our Joint Commission? If they don’t, the nurses in Nord 92 might have been starting at square one with their documentation.”

“I haven’t the foggiest, Julie, but I think I know what you are getting at. Because of regulatory requirements here in the U.S., we have documentation virtually ‘coming out of the woodwork.’ In France they may need to create documents, while our greatest need in the U.S. is to manage effectively the documentation that we already have.”

“So how are these documents to be managed?...Wait, Curmudge! I have the answer. The leaders teach the folks in gemba about Lean principles and guide them in the use of Lean tools. Like your favorite Peter Drucker quote, ‘It’s all about the people.’”

“Julie, I think you’ve got it.”

Affinity’s Kaizen Curmudgeon

*http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm