Standard Work

“Standard work” is a lean concept. In short, it refers to standardization of the work that one will perform. Once it is established, it allows all future improvements to be made upon the standard, therefore improving all work in that area at once and building a sustained method of process improvement. Although it is one of the most powerful tools in lean implementation, it is also one of the most difficult to put into practice.

In medicine, there is no shortage of protocols and guidelines attempting to create standard work. There is also no shortage of personnel speaking out against standardization, the loss of autonomy, and the lack of “personalized” “patient based” care. Some suggest that standardizing medicine creates an impersonal, withdrawn healthcare automaton who simply orders diagnostics and medication based on complaint without using their brain. Others note that standard work impinges on their freedom to practice medicine and is limiting. I disagree.

If you look upon your training in medicine, you will see a healthcare standard that was adjusted over hundreds of years of medical care, incorporating advances in science and research, new medications, and new technology. As the field advances, so does the minimum standard taught in nursing and medical schools. After graduation, the continuous process of assimilating best practices and new therapies continues. However, the approach is not as organized. Much is left up to the provider to absorb and digest before implementation. This kind of approach leaves considerable variability in the standard care provided regionally, nationally, and even locally within the same practice. Though this can be labeled autonomy, it is in fact merely a lack of a minimum standard. We find ourselves frustrated by such a lack of standard work in many other fields, why would it be different in medicine ? Take for example the lack of a standard in these non-medical cases: comparing two similar used cars at different locations, or comparing meals with the same name at different restaurants, or differences in the meaning of “luxury” when referring to cars, apartments, and hotels. In all these cases, frustration occurs when attempting to find some common ground or “standard” as a frame of reference.

Patient presentations are difficult, varied, and complex. Building standard work is difficult, time consuming, and requires constant adjustment. But it should not be viewed as an impediment to autonomous practice. It should be viewed as removing barriers to higher thinking, reducing distractions and allowing focus on the more complex aspects of medicine, and off loafing cognitive load to ease the mental work of medicine.

Think of it this way. If you typically ask 15 questions to stratify a chest pain patient and you must constantly remind yourself to ask them, you use up mental capacity that could be devoted to the subtleties within the answers instead. If you had the questions prompted or even answered before you spoke with the patient, you would have more time to discuss treatment options based on risk. You would also have more time to discuss other things with your patient that typically get pushed aside in order to answer the critical first 15 questions. Perhaps you would drive home the effects of smoking, or obesity, or discuss underlying anxiety or depression. In this case, standard work builds an approach and expectation for what is done before you, during your time, and after you are done, leaving you more cognitive space to catch the unusual.

Standardization does not imply that you may never deviate from the expected work , but it does require an explanation of the deviation. This is where some of us get stuck. The perception is that a standard of care is developed and any deviation is unacceptable. However, there is already a minimum standard of care in medicine. It may vary depending on where you practice, but it most certainly exists. If you chose to deviate from it, you typically document your rationale. If the standard of care for evaluating a patient with chest pain is to obtain an ecg and cardiac enzymes and you chose to obtain none of these but follow a pulmonary embolism pathway instead, you would be expected to document that rationale. However, if you had a very busy shift and forgot to ask the few questions regarding pulmonary embolism, you might not pick up on the subtitles of the chest pain. That would lead you down the wrong pathway. If instead the standard work already included prompting you to ask the questions, or provided you with the answers before engaging the patient, you would correctly identify the underlying cause more often and spend less time trying to remember the questions.

The work is not easy. Anyone who has attempted to build a pathway, protocol, or guideline knows the variability in approaches to patient complaints. But, the value of defining the standard is great. It not only sets expectations for the healthcare provider, it also defines the necessary information the provider requires, the methods of obtaining it, and all the expected steps to be completed prior to engaging the provider. The next time you are faced with building a protocol, expand the scope by asking this question: “Once we define this standard, are we going to define the steps prior to it and after it as well?” Standardization of the processes beginning to end will result in significant gains in efficiency, improvement in patient safety, and long term improvement in job satisfaction.

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