Lean Hospitals 3rd edition by Mark Graban CH 5: Standardized Work as a Foundation of Lean Presented by Brady Bradshaw

Need for Standardization From 171 forms to just six Rising costs Long waits Hospitals usually communicate task expectations informally This makes process changes very difficult When standardized work is not followed in this setting, risk is introduced for patients Bradshaw ETM 568 CH 5 Standardized Work 4/17

Toyota House Metaphor (page 95) Bradshaw ETM 568 CH 5 Standardized Work 4/17

Lean Foundations Standardized work is the method for developing best practices and methods Heijunka is Japanese word for ”level loading” or line balancing Kaizen is another Japanese word that means “continuous improvement” These foundations balance each other out Standardized work without Kaizen is stagnant workplace Kaizen without standardized work is a chaotic environment where people randomly try new methods Standardized work without heijunka leaves employees stressed out Bradshaw ETM 568 CH 5 Standardized Work 4/17

What is Standardized Work? Starts with a simple premise: people should analyze their work and define the best methods for completing a task For example, bed sores or ulcers – easily preventable but commonly occurring Require staff to reposition bedridden patients every two hours Instead of blaming employees, we need to look at a better way to document and manage the standard work to make sure it is followed consistently Formal definition: Standard Work is the current one best way to safely complete an activity with the proper outcome and highest quality, using the fewest resources possible Bradshaw ETM 568 CH 5 Standardized Work 4/17

Proper Outcome Toyota guidebooks talk about standard work with the end goal in mind ”Standardized work is a tool for maintaining productivity, quality, and safety at high levels.” Standardization must benefit patients, employees, physicians, and the hospital itself Quality should never be traded for speed. You shouldn't standardize for the sake of standardization Bradshaw ETM 568 CH 5 Standardized Work 4/17

Problems with Standardization Just because you standardize something doesn't always mean that it will be followed Hand washing standards can consist of using sanitizing gel or soap and water and how the process should be completed Some hospitals have reported compliance numbers as low as 50% for hand washing Even doctors who spend more time directly with patients have had 8.7% less hygiene compliance due to accumulated work demands This is the reason we need heijunka in the workplace as well Meant to be a helpful countermeasure to problems that matter Bradshaw ETM 568 CH 5 Standardized Work 4/17

“Safely Complete” Still focuses on outcomes and benefits of standardized work Safety practices should be considered nonnegotiable for patients and employees ThedaCare CEO says “If we cant do thing safely, why should we be doing them in the first place?” Safety should be part of a daily routine in any Lean hospital That’s why safety is so integral to Standardizing Work Bradshaw ETM 568 CH 5 Standardized Work 4/17

“One Best way” Is there one best way to do something? The importance of a task determines the level of specificity that the SOP (standard operating procedure) will include Petri dishes in microbiology labs that determine medical decisions – critical importance This would have pictures and examples If SOP are too specific, people may disregard them Which hand to swipe the petri dish with? Not crucial to right handed or left handed technicians Bradshaw ETM 568 CH 5 Standardized Work 4/17

“Fewest Possible Resources” The overall principle of Lean: minimizing waste In the long run, higher quality inputs and safety will decrease cost Limiting resources can drop morale and make improvements more difficult In the Lean approach, we first improve quality and productivity, then consider opportunities to reduce waste Retraining or redeploying employees is always more efficient that laying them off Bradshaw ETM 568 CH 5 Standardized Work 4/17

Standardized, Not Identical Identical work would be nearly impossible to achieve anywhere, let alone in a hospital Regardless of the task, employees like to have some autonomy to decide how best to complete the task But if employees are stuck in an activity that is too open ended, they are mentally drained from constantly trying to plan their next move Standardized work is the plan that frees us from have to make hundreds of small decisions There is almost always necessary variation in customer needs and the way tasks must be completed Bradshaw ETM 568 CH 5 Standardized Work 4/17

Other factors to consider Who knows the work best? The people who are doing it every day “Standards should not be forced down from above but rather set by the production workers themselves.” Taiichi Ohno Consider how long each task takes Hospitals include variation in activities, but don’t expect 10 hours of work to be done in an eight hour shift Bradshaw ETM 568 CH 5 Standardized Work 4/17

Asking Why when standardized work is not Followed How to respond: Is the standard work appropriate? Are the right tools, equipment, and materials in place and of appropriate quality? Is the person following the steps and sequence? Has the person had adequate practice in the operation? Does the system allow the person to meet the standard? Find issues in your own work before you immediately blame someone else Bradshaw ETM 568 CH 5 Standardized Work 4/17

Training with standardized Work Step 1: Prepare the employee – discuss need for SOP. Best done off duty Step 2: Demonstrate the job – let the employee follow along in the documentation. Emphasize key points and highlight quality and safety Step 3: Observe the job being done – coach and provide guidance “If the worker hasn’t learned, the instructor hasn’t taught” Step 4: Follow-up – check in periodically to ensure that standardized work is followed. Check for Kaizen ideas for improving the SOP Bradshaw ETM 568 CH 5 Standardized Work 4/17

Lean Lessons The foundations of Lean are standardized work, heijunka, and kaizen Practices that are more consistent lead to quality that is more consistent Standardize work should reflect an emphasis on quality and safety, not speed Standardized work is written by those who do the work Standardized work frees people to be creative problem solvers rather than robots Standardized work is not just a one-time documentation exercise. Neither is it permanent, it must be improved over time Bradshaw ETM 568 CH 5 Standardized Work 4/17