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

2. 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 CH 5 Standardized Work 4/17

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

4. 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 CH 5 Standardized Work 4/17

5. 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 CH 5 Standardized Work 4/17

6. 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 CH 5 Standardized Work 4/17

7. 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 CH 5 Standardized Work 4/17

8. “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 CH 5 Standardized Work 4/17

9. “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 CH 5 Standardized Work 4/17

10. “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 CH 5 Standardized Work 4/17

11. 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 CH 5 Standardized Work 4/17

12. 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 CH 5 Standardized Work 4/17

13. 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 CH 5 Standardized Work 4/17

14. 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 CH 5 Standardized Work 4/17

15. 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 CH 5 Standardized Work 4/17