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

Nemawashi--An Essential Element of A3

“Just yesterday, Julie, I was paging through Liker’s The Toyota Way and I encountered a slightly familiar but little-used term, nemawashi. It’s part of Principle 13 of The Fourteen Principles of the Toyota Way. Liker defines nemawashi as ‘the process of discussing problems and potential solutions with all of those affected, to collect their ideas and get agreement on a path forward.’ (1)”

“I know why it was slightly familiar, Curmudge; we wrote about it in Kaizen Curmudgeon four years ago. We introduced the concept in our February 18, 2008 posting and discussed it further on February 25. With your age-depleted memory, I’m amazed that you had any recollection of nemawashi at all. I suspect that even people who are young and productive have forgotten about nemawashi. That tends to occur with concepts that are described with long Japanese words.”

“Then it’s time for a refresher. We hear every day about A3 Problem Solving, but people may tackle a problem with that technique without getting input from all affected, i.e., nemawashi.”

“And it’s even less Lean-like if problems are ‘resolved’ by command-and-control without using nemawashi or A3.”

“As blog postings go, Julie, our discussions of nemawashi four years ago were pretty comprehensive. Since we needn’t duplicate them, it may be most practical to touch upon their high points and emphasize their link to A3s.”

“How about starting with the basics, Curmudge, and Dr. Deming’s advice to ‘drive out fear.’ An organization’s practice of nemawashi engenders trust among individuals and between individuals and the organization. If practiced rigorously, nemawashi requires openness and transparency. As mentioned four years ago, there will not be undiscussable issues.”

“So now let’s link nemawashi with A3 Problem Solving. We typically view an A3 as a team activity with team members selected to provide the broadest input, hopefully from everyone affected (nemawashi). An enlarged A3 sheet drawn on a whiteboard is used to record the team’s deliberations for all to see (transparency). The desired outcome is for the team members to be in general accord (consensus) on the future state, countermeasures, and path forward.”

“I’ve got it, Curmudge. One needs to start with nemawashi in order to do the A3 process right.”

“That’s our lesson, Jaded Julie. So what have we gained in the four years and 180 Kaizen Curmudgeon blog postings since we last discussed nemawashi?”

“Well, we’ve both learned a lot, but you have forgotten quite a bit of it. I guess I’m more knowledgeable, and you’re older.”

“They say that wine is the only thing that gets better with age. But that’s only good wine that I can’t afford.”

“Hang in there, Curmudge.”

“Keep up the good work, Julie.”

Kaizen Curmudgeon

(1) Liker, J.K. The Toyota Way, p. 40 (2004, McGraw-Hill).