“Who is this Stan fellow, Curmudge?”
“He is one of the reasons that we are going to talk about patient safety, Jaded Julie. Another reason is that we have recently been discussing standard work, and improved patient safety is one of the main benefits of standard work in a hospital.”
“I’m listening, Curmudge. Tell me about Stan.”
“Shortly after his retirement, Stan, a very close friend from my college days, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. Stan, always a gentle giant, now cannot speak a coherent sentence. Although he is cared for by his devoted wife, this is not the way Stan planned to spend his ‘golden years.’
Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.
While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.
When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.
The final outcome is as I described at the beginning of our conversation. Stan’s wife is his constant caregiver. Stan recognizes me but not the names or anything about many of our close college friends. He can say ‘hello’ and ‘good-by,’ but his long sentences are quite incomprehensible. We try to see Stan and his wife whenever we visit the far away city where they live, but reminiscing about our college days is pretty difficult.”
“Curmudge, that is so sad. And it appears to have been preventable. I guess that explains why you are a patient safety zealot.”
“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”
Affinity’s Kaizen Curmudgeon
Thursday, October 30, 2008
Thursday, October 23, 2008
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
“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
Thursday, October 16, 2008
More Work on Standard Work
“Curmudge, at the end of our conversation a week ago, my mind had become boggled by the magnitude of the whole standardization issue. To help me get my head on straight, please tell me where we are ‘at’ and why we are here.”
“Jaded Julie, Masaaki Imai has answered your ‘why are we here?’ question most clearly in his book, Gemba Kaizen: ‘Where there is no standard, there can be no improvement.’ If Generic General Hospital wants to improve—and especially to develop a Lean culture—they must have standards.”
“Now I recall where we stopped last time. We were talking about the requirements of documented procedures for standard work. We had discussed established and documented and were ready to tackle implemented, or as specified by JCAHO, accessible to nursing staff. These are the requirements for implemented: ‘All pertinent staff must be made aware of the procedure, trained in its use, and then use it. Training, proof of competency, and use of the procedure must be documented in appropriate records.’”
“The documentation requirements are pretty onerous; but if I were to be the subject of a procedure, I would want the nurse to be trained and able to demonstrate her competence. Another aspect of implemented is that standard work needs to be managed to assure compliance with the standard. However, as Mark Graban suggests in Lean Hospitals, the manager who observes a deviation should always ask ‘why?’ There may be a perfectly valid reason for the deviation, and it might lead to an improvement in the method. Another way to gain compliance with a standard method is for it to have been written by the people who use it. Compliance is undoubtedly proportional to one’s sense of ownership.”
“Curmudge, are you ready for the fourth requirement, maintained? This means that the procedure must be approved, reviewed on a defined schedule, and promptly revised when improvements are developed.”
“JCAHO requires review every three years, but that’s a long time for people to wait to learn about an improvement. If it’s difficult to create a standard and gain its approval, it’s probably going to be difficult to revise it. The hospital’s organization should facilitate rapid revision. One certainly doesn’t want a procedure to be done by a method that differs from an out-of-date standard, especially in front of an auditor. People should remember the old laboratory rule, ‘say (write) what you do, and do what you say.’”
“Curmudge, I surely hope that the people in Generic General Hospital know they don’t have to write all of their standards from scratch. They can adopt their standard work from lots of existing sources.”
“And that, Julie, is what we are going to talk about next week.”
Affinity’s Kaizen Curmudgeon
“Jaded Julie, Masaaki Imai has answered your ‘why are we here?’ question most clearly in his book, Gemba Kaizen: ‘Where there is no standard, there can be no improvement.’ If Generic General Hospital wants to improve—and especially to develop a Lean culture—they must have standards.”
“Now I recall where we stopped last time. We were talking about the requirements of documented procedures for standard work. We had discussed established and documented and were ready to tackle implemented, or as specified by JCAHO, accessible to nursing staff. These are the requirements for implemented: ‘All pertinent staff must be made aware of the procedure, trained in its use, and then use it. Training, proof of competency, and use of the procedure must be documented in appropriate records.’”
“The documentation requirements are pretty onerous; but if I were to be the subject of a procedure, I would want the nurse to be trained and able to demonstrate her competence. Another aspect of implemented is that standard work needs to be managed to assure compliance with the standard. However, as Mark Graban suggests in Lean Hospitals, the manager who observes a deviation should always ask ‘why?’ There may be a perfectly valid reason for the deviation, and it might lead to an improvement in the method. Another way to gain compliance with a standard method is for it to have been written by the people who use it. Compliance is undoubtedly proportional to one’s sense of ownership.”
“Curmudge, are you ready for the fourth requirement, maintained? This means that the procedure must be approved, reviewed on a defined schedule, and promptly revised when improvements are developed.”
“JCAHO requires review every three years, but that’s a long time for people to wait to learn about an improvement. If it’s difficult to create a standard and gain its approval, it’s probably going to be difficult to revise it. The hospital’s organization should facilitate rapid revision. One certainly doesn’t want a procedure to be done by a method that differs from an out-of-date standard, especially in front of an auditor. People should remember the old laboratory rule, ‘say (write) what you do, and do what you say.’”
“Curmudge, I surely hope that the people in Generic General Hospital know they don’t have to write all of their standards from scratch. They can adopt their standard work from lots of existing sources.”
“And that, Julie, is what we are going to talk about next week.”
Affinity’s Kaizen Curmudgeon
Thursday, October 9, 2008
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
“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
Thursday, October 2, 2008
Standard Work--Countermeasures
“So, Curmudge, after our discussion of obstacles last week, what solutions… countermeasures…did you come up with?”
“Lean.”
“Lean? That’s all? Just Lean? No details?”
“Details are above my pay grade.”
“Curmudge, everything is above your pay grade. You don’t even have a pay grade.”
“True, Jaded Julie. But I still think that’s a great default answer for a volunteer. So back to the problem at hand. Ultimately the folks at Generic General Hospital will need to develop a Lean culture, which as we know, includes continuous improvement of their processes. To improve a process it must be standardized, and to be standardized it must be documented.”
“I’ve got it, Curmudge. A Lean culture is the countermeasure for non-standardized work and documentation problems. So how do they acquire the Lean culture?”
“Julie, people can learn a Lean culture—and any other culture for that matter—by doing it until it is hardwired.”
“Of course, just as we have been discussing for the past year.”
“So GenGen needs to hire a sensei; train their Lean Team, their leaders, and the people in gemba; and get going on kaizen events. Their efforts will be prioritized according to corporate goals and strategies as developed via hoshin kanri planning. As hoshins are completed, leaders will realize that further progress is being held back by the lack of standard work and documentation. Hopefully, management will elevate standard work and documentation to the top of the priority list and develop organizational frameworks to support them. This should mitigate the obstacles we discussed last week.”
“Mark Graban suggests that the Lean technical tools will allow us to turn Lean philosophy and concepts into action. Might the reverse also be true? Could the repeated use of Lean tools help instill Lean philosophy and concepts in the people?”
“It may be defying the law of gravity, Julie, but perhaps Lean can pull itself up by the bootstraps. If that’s possible for an inanimate object like a computer, it should be feasible for a living concept like Lean.”
Affinity’s Kaizen Curmudgeon
“Lean.”
“Lean? That’s all? Just Lean? No details?”
“Details are above my pay grade.”
“Curmudge, everything is above your pay grade. You don’t even have a pay grade.”
“True, Jaded Julie. But I still think that’s a great default answer for a volunteer. So back to the problem at hand. Ultimately the folks at Generic General Hospital will need to develop a Lean culture, which as we know, includes continuous improvement of their processes. To improve a process it must be standardized, and to be standardized it must be documented.”
“I’ve got it, Curmudge. A Lean culture is the countermeasure for non-standardized work and documentation problems. So how do they acquire the Lean culture?”
“Julie, people can learn a Lean culture—and any other culture for that matter—by doing it until it is hardwired.”
“Of course, just as we have been discussing for the past year.”
“So GenGen needs to hire a sensei; train their Lean Team, their leaders, and the people in gemba; and get going on kaizen events. Their efforts will be prioritized according to corporate goals and strategies as developed via hoshin kanri planning. As hoshins are completed, leaders will realize that further progress is being held back by the lack of standard work and documentation. Hopefully, management will elevate standard work and documentation to the top of the priority list and develop organizational frameworks to support them. This should mitigate the obstacles we discussed last week.”
“Mark Graban suggests that the Lean technical tools will allow us to turn Lean philosophy and concepts into action. Might the reverse also be true? Could the repeated use of Lean tools help instill Lean philosophy and concepts in the people?”
“It may be defying the law of gravity, Julie, but perhaps Lean can pull itself up by the bootstraps. If that’s possible for an inanimate object like a computer, it should be feasible for a living concept like Lean.”
Affinity’s Kaizen Curmudgeon
Thursday, September 25, 2008
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
“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
Friday, September 19, 2008
More Problem Solving
“I liked A3 Problem Solving, Curmudge, but it was a bit of a stretch to envision all of that information on an 11- by 17-inch piece of paper. Are we going to cover all of the problem-solving techniques used in Lean in that much detail? My brain is filled up.”
“No way, Jaded Julie. I recall several years ago when President Ronald Reagan said, ‘If I have to learn any more names, I’m going to forget some that I already know.’ I don’t want you to forget the really important stuff that we have already covered. Besides, one can google most of the common problem-solving tools and find good discussions of them in Wikipedia. We’ll discuss only those topics that are the most important, the most fun to write about, and those that don’t require us to squeeze a lot of figures into the blog.”
“Okay, Curmudge, but why shouldn’t everyone ignore the blog and just google everything?”
“Hey, you’re pretty negative today. The answer is that Curmudgeon gives readers an old guy, a feisty nurse, your couch-potato husband, and health care examples. If no one were to read Curmudgeon, we’d be unemployed.”
“You’re already unemployed, Curmudge. So what other than idle chit-chat are we going to do today?”
“Let’s begin by listing some of the common problem-solving tools and how they might be used. We most likely won’t devote further blog space to these:
Bar chart—A chart with rectangular bars of lengths proportional to the value that they represent. Used to summarize attribute (categorical or discrete) data. Improves the data’s visual impact.
Histogram—A bar chart showing the frequency distribution of quantitative values with the values, not time, on the x-axis. A common example is the number of students (y-axis) who achieved test scores within certain intervals [e.g., 61-70, 71-80, 81-90, 91-100] (x-axis). This is the basis for the familiar academic practice of ‘grading on a curve.’
Pareto chart—A special type of bar chart where the values being plotted are arranged in descending order. Use this for displaying the probable reasons for an unfavorable outcome, such as poor patient satisfaction scores. Tackle the reason with the tallest bar first.
Fishbone (Ishikawa or cause-and-effect) diagram—A diagram that shows the possible causes of a certain event. Use this to visualize the many possible factors contributing to a problem. Data are often organized into six categories: material, assessment, people, method, equipment, and environment.
Scatter diagram—A graph of pairs of numerical data, with one variable on each axis, to look for a relationship between them. Data grouped closely about a line suggest that the variables are related. Of course, this does not prove that the relationship is cause-and-effect.
Run chart—A line graph showing values (y-axis) plotted against time (x-axis). Can be used for most any data collected in time-order sequence.
Control chart—A run chart with control limits to differentiate between common cause variation and special cause variation (signifying a problem). Seeks to determine if a sequence of data can be used to predict the future. Sometimes used to look back in time to demonstrate compliance with a standard.”
“Curmudge, I’m not really turned on by variables and axes. But if I really need to use some of these tools, is there someplace on our intranet where an Affinity employee can go for more information?”
“Sure thing, Julie. From the home page, click on the Affinity Learning Center, then Lean, Lean Tools, and finally Problem Solving. In addition, templates for many of the tools are in the right bucket (margin). Finally, there was a course presented at Affinity ten years ago called Sailin’ Thru Statistics; many Affinity veterans should have a copy of the course notebook that you might borrow.”
“It looks to me as if the techniques you listed are more for finding problems than for solving them.”
“You’re right, Julie, but identifying the problem is pretty important. That’s the reason we introduced The Five Whys and root cause analysis last January. As Albert Einstein said, ‘The formulation of a problem is often more essential than its solution.’”
“Thanks for the info, Curmudge. So what are we going to talk about next week?”
“Next week I hope we can talk about standard work.”
“You hope! Don’t you know for sure?”
“Julie, a senior citizen can never say ‘for sure’ when looking into the future. That’s why I have to pre-pay when I order a three-minute egg.”
Affinity’s Kaizen Curmudgeon
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