Efficient, repeatable processes are integral to patient care and health care operations. When done well, patients receive more consistent, quality care, and if an error occurs, it avoids the blame game and becomes an opportunity to improve the process. This is the principle of standard work, a concept within Lean methodologies, that provides a structure for teams to assess their processes and develop standards (hence, the name) for how processes will be completed.
“Leaders often approach improvement through top-down initiatives that may or may not be the right solutions based on the actual problems that are hindering good performance,” said David Munch, MD, senior principal at Vizient. “What they need to understand is that the closer you are to the problem, the more you know about it. Most of that insight and wisdom lies on the front lines. Managers must involve staff members in the design of standard work. To maintain its effectiveness over time, a standard work design also needs to be supported by regular assessment and adjustment that facilitates its ongoing improvement.”
For example, a Tennessee hospital’s surgery center was faced with excessive patient wait times in the pre-op holding area. By engaging front-line staff in redesigning their pre-op processes to create standard work, wait times decreased by more than 30 minutes per patient, facilitating more efficient case admissions. Employee engagement increased ownership of how current processes could be improved. In the long term, these behaviors can promote a culture of servant leadership, an important component in health care today.
“Results gleaned from Lean initiatives show that better outcomes generally arise when decisions are made by those closest to the work,” Munch said. “When the staff agrees on and implements standard work processes, they can respond more quickly to changes, increasing satisfaction for patients and staff.”
Standard ≠ rigidity
At first, employees may hear the word ‘standard’ and think ‘rigidity’. They may not immediately see how structure actually promotes flexibility and facilitates changes.
“You can’t improve something that has high levels of variation. After all, which variation will you work on?” Munch said. “How will you know if something is just another variation or a true defect? You must control the process first, so that you can see the common problems, address them and improve. You go from one standard to a better standard, always asking the question, ‘How can we improve our standard work?’ The realization can be a breakthrough for a company.”
Input must be solicited from all relevant stakeholders, as well. A redesign of care delivery in nursing units, for example, would require input from nurses, physicians, clinicians and technicians. The workflow would involve diverse participants, whose roles intersect. Everyone involved would need a voice in standard work improvements, while the Lean method would facilitate orderly involvement from the team.
In a smaller-scale example, a review of how pharmacy technicians pull medications could reduce the number of steps taken daily and decrease time spent in dispensing medications. In this scenario, the pharmacist and technician(s) may be the only staff involved in the standard work redesign.
Overcoming opt-out and leveraging data
Redesigning work to align with Lean principles can be challenging. The larger the group, the greater the pushback may be. Organizations may face entrenched practices, both administrative and clinical, that supplant the improvement efforts of standard work. Reduce opt-out by securing support of clinicians and top-tier leadership, particularly the CEO.
“Gaining buy-in to standard work—and eliminating variation that impedes its effectiveness—is facilitated when processes are designed to not only identify the right work, but make the right work easier to do,” Munch explained.
In the emergency department of one Ohio hospital, co-pay collections were suffering from disorganized processes. Staff involvement and retraining in standard work led to more than a 1,000-percent increase in co-pays and cash collections.
Conformance to new processes will be made easier by demonstrating benefits such as greater convenience. The use of data and analytics, particularly leading and lagging indicators, offers quantified information that will be useful for work groups. Leading indicators show how well a process is working. Lagging indicators reveal the strength of outcomes.
“Introducing leading indicators, such as hygiene standards for environmental equipment, helps employees keep ‘score’ and use ongoing improvement measures to improve daily,” Munch said. “A lagging indicator, like hospital-acquired infections, is reviewed retrospectively. Staff should first identify specific actions that will encourage the desired outcome, and then audit those behaviors regularly.”
Less managing, more coaching
The use of Lean methodologies will shift managers’ roles over time to assume a greater role in coaching. Managers learn the most beneficial questions to ask, reversing the traditional, top-down flow of information. Questions as clear as, “did you have a good day?” and “how do you know?” can be answered through the daily monitoring of standard work activities. That employee, having access to leading and lagging data indicators, should be able to answer definitively.
Preparing managers for a new system of management means taking an intensive look at how they’re currently spending their time. Rather than being punitive, the overview should be used to eliminate inefficient activities, thus freeing time to learn new processes identified through standard work.
When implemented effectively, Lean methods encourage communication and problem-solving between front-line staff, clinicians, managers and executives.
Vizient offers members advice on training, coaching and developing techniques that can be shared with your colleagues as you begin a Lean transformation. You can also access case studies and articles on thought leadership to see how other Vizient members have undergone and navigated their own transformations.