Let's get to work on Standard Work.

“Curmudge, we’ve spent the past couple of weeks talking about problems that hospitals might have with non-standard work and how Lean should be the best source of countermeasures. Despite the fact that you don’t know diddly about running a hospital, is there any more guidance that we might share with the folks at Generic General?”

“At best, Jaded Julie, we might speculate on some of GenGen’s needs, but ways to satisfy those needs must be determined locally. That will require the combined insight of people from top management all the way down to gemba. To guide our thinking about the documented procedures necessary for standard work, let’s adopt ISO 9001’s definition: ‘…the procedure is established, documented, implemented, and maintained.’”

“I mentioned those criteria a couple of weeks ago, but we blew right by them. As I recall, Curmudge, you wrote about these two years ago, before you had my expert guidance.”

“Ah…right, Julie. In addition, here’s a requirement from JCAHO Standard NR.3.10 which should capture the attention of hospital people more firmly than ISO: ‘All nursing policies, procedures, and standards are defined, documented, and accessible to the nursing staff in written or electronic format.’ Notice how JCAHO’s wording correlates with ISO’s ‘established, documented, and implemented.’”

“Okay, now that we have done our homework, how are we going to apply this stuff to Generic General Hospital?”

“In my opinion, GenGen’s first need is to agree on the existence of a problem. Of course, this will require deliberation by a team representing management, information systems, the library, and all of the hospital’s affected gembas. If they can’t develop a consensus or path forward, they might as well break for lunch. My hope is that they will recognize that the issue of standard work and documentation is critical, especially if they have many of the problems that we discussed a couple of weeks ago. Then they should try to discern the most meaningful improvements that can be made before everybody in the room reaches retirement age.”

“If someone knows how another hospital solved these problems, GenGen just needs to steal and adapt the solution. But assuming there’s not a solution out there worth stealing, let’s go on to the first of the criteria of a procedure, established or defined. In health care this means that for every activity that is critical to a patient’s care and treatment, there must be a defined and accepted way of performing that activity. I presume, Curmudge, that you have thought about this one between naps.”

“Again, a representative team will be required. Because some procedures are so elementary and others are virtually all professional judgment, deciding what procedures should be standardized will not be easy. In addition, the team (or ad hoc sub-teams) will need to identify those steps that impact quality, outcome, and safety and as a result must be highly specified. Of course, the decision to simply adopt an evidence-based standard should be straightforward.”

“I presume, Curmudge, that administering an enema would be a good example of an elementary procedure. Most nurses learn that right out of Perry and Potter’s Clinical Nursing Skills & Techniques.”

“As long as they minimize patient discomfort, I don’t care where they learn it.”

“The next criterion is documented; that’s not going to be a slam-dunk either.”

“That’s for sure, Julie. But remember, GenGen has most likely had JCAHO surveys and found compliant with Standard NR.3.10, so they must have a documentation system acceptable to JCAHO. Generic General will undoubtedly try to use as much of their current documentation system as possible.”

“Curmudge, the problems in creating a unified system from a wide variety of documents in different media from all over the hospital seem mind-boggling.”

“I agree, Julie. The beauty of blogging is that when one’s mind becomes boggled, one can just log off the computer and continue the discussion next week. So that’s what we’ll do.”

Affinity’s Kaizen Curmudgeon