Standardized Clinical Processes

“Curmudge, we’ve talked about standard work and its antithesis, autonomy, in July 2008 and in January 2011. Why are we doing it again? Do you suspect that people have forgotten these concepts?”

“It’s possible, Julie. That’s why we discussed nemawashi a week ago. Today’s discussion will be revised and focused on clinical processes.”

“Clinical processes! Won’t we be trespassing on physician territory? Docs can be fierce defenders of their autonomy, and they sometimes refer to checklists and standard work as ‘cookbook medicine.’ Might they be upset when they read this blog?”

“Don’t worry. Docs seldom read anything written by a person without an M. D. after his name. And if they read this, they will note that we are quoting Brent James MD.”

“As we have discussed earlier, Curmudge, a physician will be reluctant to follow a procedure written by someone else and plopped on his desk. Doc Mack has told me what he would think of something created by some ‘nurse in an office,’ and in the Army she might be a lieutenant colonel.”

“Dr. James described a team’s study of a specific treatment that they designed based on the literature. ‘Physicians were instructed to vary from the protocol if they judged it to be in the best interest of a patient. Each time this happened, the case would be discussed among the group. Over time the protocol was modified when there was a scientific basis for doing so, and over time variation from the protocol diminished.’ “

“That sounds like developing standard work the hard way, but it’s the best way to gain the support of clinicians.”

“Here, Julie, are the five steps comprising James’s process:

1. ‘Select a high priority clinical process;

2. Create evidence-based best practice guidelines;

3. Build the guidelines into the flow of clinical work;

4. Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;

5. Meanwhile, learn from and (over time) eliminate variation arising from professionals, while retain variation arising from patients.’ “

“Step 5 is the main process goal to be attained from evidence-based medicine, ‘Eliminate variation arising from the professionals while retaining variation arising from the patients.’ Should I go out and shout that from the top of the parking ramp?”

“Only if the weather is good, Julie. Note that James also says, ‘This is very different from the free form of patient care that exists generally in medicine.’ The title of James’s presentation, ‘Don’t Wait for Washington,’ suggests that if clinicians don’t make their processes more efficient, ‘Washington’ may do it for them.”

“That’s a bit intimidating, Curmudge. Now let’s run up the steps to the top of the parking ramp.”

Kaizen Curmudgeon